Alchemy: Allopathy to Repatriation - Internal Medicine | ACP · 1 Alchemy: Allopathy to...
Transcript of Alchemy: Allopathy to Repatriation - Internal Medicine | ACP · 1 Alchemy: Allopathy to...
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Alchemy: Allopathy to Repatriation
Palmer MacKie
Integrative Pain Program
Eskenazi Health
Dept. of Medicine, IUSOM
Objectives
1. View Pain as complex social entity, not nociception
2. Identify and address the 3 pain domains
3. Polymodal Therapy is optimal:
– Education(mind), participation(body),creative(spirit)
4. Yoga, CBT, Hypnosis, Acupuncture and oral CAM all
have evidence and their place but nothing trumps….
5. Therapeutic Relationship allows:
– Education, expectation and engagement
What is Pain?
• A complex experience embracing physical,
mental, social, and behavioral processes,
compromising the life of many individuals.
SSI Commission For Evaluation of Pain
Willing, motivated Partner
Clin J Pain Vol. 24, No.4, May 2008
Accept reports
of pain with
belief and
compassion.
Then find the
meaning(s).
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Philosophy and Goals:
Pain is unavoidable, suffering is modifiable
• Primary Goals are Two:
– Reduce pain and suffering
– Increase functioning
• Employ poly-modal approach
• Feelings, beliefs, thoughts and actions
– We possess ability to use these to create
negative feedback loops that entrench pain
and suffering. Thankfully, the reverse is true.
NeuroImage 23 (2004) 392–401
Sensory
Evaluative Affective
Components of Persistent Pain Break this Cycle
“I feel like my son spent his first year of
life in his crib in a darkened room”
• TM a 41 “married mother” of two with debilitating
headaches. Onset at 26 and worse after children…
• Quit work as photographer, quit hobbies, etc…
• Headache calendar = 25 days per month
• Had seen a number of doctors with marginal successes
• Opioids, TADs, beta-blockers, Bio-feedback
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Be occupied, then, with what you really value and
let the thief take something else
Rumi
That’s out of my price range. Do you have
anything that’s free?”
Sensory
Evaluative Affective
Components Pain Treatment
Control not Cure
Treatment Options
• EDUCATION
• Progressive Exercise
– Aerobic
– Strength
– Range of motion
• Rehabilitation Medicine
• Massage
• Acupuncture
• Psychological
• Heat, TENS, ice
• Co-analgesics
• Relaxation Response
• C B T & Mindfulness
• Non-opioid medicine
• Chiropractic
• Cranio-sacral
• Nutrition
• Yoga /Tai Chi/Qi qong
• Hypnosis / biofeedback
• EDUCATION
Only need to exercise on days you eat
Breaking the Cycle Lumbar instrumented fusion compared with cognitive
intervention and exercises in patients with chronic back pain
A prospective randomized controlled study
• For patients with chronic low back pain after previous
surgery for disc herniation
• The success rate was 50% in the fusion group and 48%
in the cognitive intervention/exercise group
– lumbar fusion failed to show any benefit over
cognitive intervention and exercises.
J.I. Brox et al. Pain 122 (2006) 145–155
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Spinal fusion vs. Comprehensive Program
• Randomized and controlled, N=349
• 24 mo f/u: Oswestry and SF-36 (short)
• Both groups improved
• surgery not superior to CPP
• Cost analysis
• Surgery $14,400
• CPP $8,323
Is Acupuncture a Punitive Placebo?
Brinkhaus, B. et al. Arch Intern Med 2006;166:450-457.
Low back pain in the 3 treatment groups
NeuroImage 47 (2009) 1077–1085
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Acupuncture, Fibromyalgia and Brain
• Those receiving true acupuncture had
– Short-term increase in mor binding potential (BP)
• Cingulate, insula, thalamus, caudate, amygdala
– Long-term increase in mor binding
• Cingulate cortex, and amygdala
– Long-term increase in mor BP was associated with
greater pain reductions
• Those receiving sham acupuncture had
– No long term increase in mor BP and little analgesia
Improvement in function and pain compared with
credible sham Ann. Intern Med. 2004;141:901-910
Compared with a sham control, acupuncture provided
clinically irrelevant short-term improvements in pain
Ann Intern Med. 2007;146:868-877.(Meta-analysis)
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Wk
4 P
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4 F
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8 P
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8 F
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14 P
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14 F
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26 P
Wk
26 F
Verum Acu
Sham Acu
PAIN 147 (2009) 60–66
Sham Lacked Efficacy?
GERAC
Chronic LBP
Haake, M. et al. Arch Intern Med 2007;167:1892-1898
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Musculoskeletal Pain:
Sham vs. Verum Acupuncture
Linde et al Arch Intern Med 2012
Acupuncture: What’s the Point?
• Study data & practices too heterogeneous
• Analgesia consistent in short-term
– Electroacupuncture > manual
– 25 – 30 min.
– 3 – 5 treatments over 14 – 21 days
– Often better than conventional care
• Specific and nonspecific effects
– Amygdala, insula and hypothalamus
– Dorsolateral Prefrontal and ACC
– Expectation influences effect
– Genetic component: “responders”
Acupuncture Safety
• Relative Contraindications
– Pacemaker
– Emphysema
– Coagulopathy/Coumadin
• Side-effects
– PnTx, infection, needle shock,
– cardiac tamponade, pain, hematoma
– symptom aggravation , forgotten needle
Mind-Body Therapies for
Common Conditions
Condition % who used
in the last
year
% who found
MBT “very
helpful”
Est. of folk
using MBT
Anxiety 34 47 6.3
Depression 26.5 29.3 3.8
Ch. Pain 19.5 55 3.2
Headache 18.5 40.7 2.8
Back/neck 18 40.3 11.2
Trends in Cognitive Sciences. 8(5):193-4, 2004
“The human reward system has been shown to be
activated by a wide range of reinforcers, including food,
money, sex, drugs, and beauty. Now, a recent fMRI
study has found mesolimbic reward activation
associated with humorous cartoons, providing a
neurobiological link between theories of humour and
hedonic processes in the brain.”
Anatomy of an Illness
A cheerful heart doeth good like a medicine l
Proverbs 17:22
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Effect of Depression on Pain:
1. Magnifies medical/somatic symptoms
• Increases pain intensity and disability
• 40 % Symptom related visits are for Pain
• Depression co-morbid with Pain 30-50 %
2. Elevation of Cost
• Increases treatment non-adherence
• Increases medical utilization
3. Diminishes treatment success for both
• less symptom reduction / worse outcomes
• Less satisfaction & meaningful recovery
Diagnose & treat depression early & aggressively
Stepped Care for Affective disorders and
Musculoskeletal Pain (SCAMP)
• Randomized Controlled Trial
• Intervention : 12 wk plus 12 wk
– Optimize depression then 6 Pain self-management
• Outcomes: determined at 12 months
– Hopkins Symptom Check list-20
– Pain Severity
– Global Improvement in Pain
– Pain Interference
JAMA 2009;301(20):2099-2110
SCAMP results
1. > 50 % reduction in depression
– 37% vs. 16% RR 2.3
2. > 30% reduction in pain
– 41% vs. 17% RR 2.4
3. Global Improvement in Pain
– 47% vs. 12% RR 3.7
4. Double success: Depression and Pain
– 26% vs. 8% RR 3.3
Hypnosis
• Neurophysiologic imaging and pain tested
• Thalamus, Anterior Cingulate Cortex, SI,
Prefrontal Cortex
• Not for everyone, requires practice, effect size
often not huge.
• Pain ( interference, unpleasantness & intensity)
sleep, psychological metrics improvements
• Empowering, portable & possible targeting
PAIN 146 (2009) 235–237
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We are what we think. All that we are arises with our
thoughts. With our thoughts, we make the world Fibromyalgia: Behavioral Therapy
Cognitive BT
• Alter negative feelings,
beliefs from dysfunctional
thinking
• Identify harmful/incorrect
thoughts disrupting progress
• Connect these with negative
consequences
• Provide alternative coping
and action strategies
• Internal nidus of control for
helplessness
Cognitive BT • 6-24 months
• 50 % reduction in 40-55 %
in study
• Responders: affective
distress, low adaptive
coping, less catastrophizing,
low pain behaviors
• Cut MD visits, Hospital
days, lowers cost
• Dose response
• 4 trials showed no response
Yoga Interventions: Pain and Disability
• Meta-analysis
• 12 randomized and 4 nonrandomized trials
• 6 trials for back pain
• 2 trials for headache/migraine
• Studies reported positive effect sizes
– SMD for Pain -.74
– SMD Overall Treatment -.79
Journal of Pain, 2012 Vol 13, No 1 : pp 1-9
Oral CAM & Headaches:
What one’s have evidence?
1. Magnesium
2. Butterbur (P. hybridus)
3. Feverfew (T. pathenium)
4. Co-Enz Q10
5. Chondroitin
6. Riboflavin
Headache Prevention: Where’s the Beef?
• Magnesium
• B2/ riboflavin
• Butterbur
• Feverfew
• CoE Q10
• Acupuncture
• Bio-feedback
• Trigger Avoidances • Clin J Pain Volume 25, Number 5, June 2009
• Cochrane Database of Systematic Reviews. (1):CD007587, 2009.
• Acupuncture for migraine prophylaxis: update of Cochrane Database Syst Rev
Life-style and pre-diabetic Neuropathy
• 12 month intervention with N=32
• Intraepidermal nerve fiber density (IENFD)
– Proximal and Distal
• Michigan Diabetic Neuropathy Score
• Results:
– Both IENFDs increased, proximal more
– Change in proximal correlated with lower
neuropathic pain and sural sensory amplitude
Diabetic Care 2012
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Glucosamine
RCT Glucosamine, Chondroitin and Celebrex,
N 1229 mild & 354 severe knee OA
• Primary outcome 20% decrease in pain
• Glucosamine 3.9 % > placebo
• Chondroitin 5.3
• Glucos.+ Chond. 6.5
• Celebrex 10
• Subgroup analysis: Combination may have worked in Mod.-Severe OA 25% (P=0.002)
NEJM Feb. 2006
Glucosamine and Chondroitn
JOURNAL OF ORTHOPAEDIC RESEARCH MAY 2012
Glucosamine Supplements as a Possible
Ocular Hypertensive Agent What is he treating? Preventing?
What is he treating? Preventing?
• Treating alopecia
• Preventing …promotion
• Making Wishard’s food palatable
• All of the above
• Why might medicine be going to Pot?
High Hopes
Medical Marijuana
• Neuropathic pain
• Glaucoma
• Nausea and low appetite
• Diabetes prevention
– Lower waist circumference
– Lower fasting insulin levels
– Lower insulin resistance
– Lower BMI
American J. of Medicine 2013Vol.126
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Life-style and pre-diabetic Neuropathy
• 12 month intervention with N=32
• Intraepidermal nerve fiber density (IENFD)
– Proximal and Distal
• Michigan Diabetic Neuropathy score
• Results:
– IENFD both increased
– Change in proximal correlated with lower
neuropathic pain and sural sensory amplitude
Diabetic Care 2012
Integrative Pain Program
7-Week Pain School
• Pain Education
• Establish community
• Expectations
• Exercise
• Relaxation response
• Sleep Education
• Mindfulness
• Goal setting
• CBT
• Nutrition/Life Style
• Making a change
• Peer Advocates
Integrative Pain Program
Pain School
% change in measure 10/12 1/13 3/13
• Fatigue - 28 -17 -24
• Pain -13 -14 -14
• Aerobic exercise >100 >100 >100
• Pain interfering -22 -46 -27
• Emotions interfering -22 -36 -28
• Non-Rx to control Sxs 31 13 24
Pain Care Paradox
Standard Approach, Individual Treatment
1) Tincture of Time
2) Informed and Involved
3) Polymodal diagnosis & treatment
4) Community: More than Par-a-docs
5) Improved outcomes
6) Fewer adverse events
“The world is full of
suffering…
It’s also full of
overcoming it”
Helen Keller
The End
Thank you
Pager 312-1667
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Neuroscience Letters 520 (2012) 156– 164