The new Chronic Pain program

at CHEO Mental Health Series, June 14th, 2017

Christine Lamontagne, MDCM, FRCPC

Medical Director of Chronic Pain Services

Children’s hospital of Eastern Ontario

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Declaration of Conflict

Speaker has nothing to disclose with regard to commercial support.

Speaker does not plan to discuss unlabeled/ investigational uses of commercial product.

Partner Presentation

CHEO and the Royal work closely and actively with many community agencies and health care providers.

This presentation is brought to you by one of our local partners. The information and views presented today represents that of our partner organization.

Objectives

1) Define pediatric chronic pain. 2) Define the prevalence of pediatric chronic pain in The

Greater Ottawa Area 3) Define the impact of chronic pain in children 4) Explain the role of the Ontario Pediatric Chronic Pain

Network 5) Why the 3 P approach to pediatric chronic pain

management? 6) Describe CHEO’s new interdisciplinary chronic pain

program 1) Referral criteria 2) Priority ranking and wait times 3) Types of conditions seen 4) Proposed interdisciplinary model of care 5) Discharge criteria and Transition to adult care

Acute vs Chronic Pain

Acute Pain

(Less than 3

months)

Chronic Pain

(More than 3 months)

Cause Usually single

obvious cause

(tissue damage)

May be associated with disease, but cause is

often unclear; can be a disease in its own

right

Mechanism Usually nociceptive

(triggers sympathetic

response)

Often neuropathic

( may cause autonomic dysfunction)

Purpose PROTECTIVE NOT PROTECTIVE

Pain

Intensity

Proportionate to

tissue injury

Often out of proportion to physical findings

Treatment Treatment of

underlying cause

usually alleviates the

pain

More difficult to treat, requiring

multidisciplinary, multi-modal treatment

approach (3’P’s)

Prevalence of chronic pain in children and

adolescents. The epidemiology of chronic pain in children and adolescents

revisited: A systematic review. King , Chambers, Huguet, MacNevin, McGrath, Parker,

MacDonald. PAIN 152 (2011) 2729–2738

• Chronic and recurrent pain is prevalent in children

and adolescents, with girls generally experiencing

more pain than boys and prevalence rates increasing

with age.

• Psychosocial variables impacting pain prevalence:

anxiety, depression, low self-esteem, other chronic

health problems, and low SES.

Pain type Prevalence

range

Age

difference

Sex

difference

Factors associated

with increased

prevalence

Headache 8–82.9% Older > younger Girls > boys Presence of anxiety and

depression; low self-

esteem; positive family

history of headache; low

SES

Abdominal

pain 3.8–53.4% Younger > older Girls > boys SES ; emotional

symptoms; school stress

Back pain 13.5–24% Older > younger Girls > boys Emotional symptoms

MSK/ limb pain 3.9–40% Older > younger Girls > boys Feeling sad

Multiple pains 3.6–48.8% Unclear Girls > boys Chronic health problems;

frequent change of

residence; frequent

television watching; poor

school performance;

fewer interactions with

peers

generalized

pain 5–88% Unclear Girls > boys Poor self-rated health;

feeling low or irritable;

bad temper; feeling

nervous

Prevalence of debilitating pediatric chronic

pain in Greater Ottawa Area • 2-8% of children have pain symptoms that can be

severe enough to interrupt sleep, restrict physical activity and prevent them from attending school. ( Finley, Chorney & Campbell, 2014)

• From Statistics Canada: children population (0-19 yo) in Ottawa/Gatineau area from 2016 census : 306 740

• Estimate of number of children with severe delibitating chronic pain in Greater Ottawa Area:

2% of 306 740 = 6134 patients

8% of 306 740 = 24 539 patients Reference: http://ottawa.ca/en/long-range-financial-plans/economy-and-

demographics/population, www.Canadian painsociety.ca

When Pain Persists

• Fallout of Chronic

Pain …

– Anxiety

– Depression

– Poor sleep

– Poor Quality of Life

– Suicide

– Chronic pain in

adulthood

Family dynamic

Friends

School

absenteeism

Extracurricular

activities

Family’s Finances

Rest, passive

coping

Chronic Pain Risk Factors: neuropathic pain component, central sensitization

predisposition, intensity of acute pain,

psychosocial vulnerability 1

Perceived

tissue damage

Limited activities

Weak tight muscles

Withdrawal from social

and physical activities

Anxiety, depression,

anger

Pain-

centered

life

Tissue

damage

THE CHRONIC PAIN SPIRAL: EVOLUTION FROM ACUTE TO CHRONIC PAIN

ABéland MD 2012 | Abeland@Live.ca P Lavand’homme. The progression from acute to chronic pain. Current Opinion in Anesthesiology 2011;24:545–550. Adapted from: http://prc.canadianpaincoalition.ca/fr/chronic_pain_and_disability.html

Physical and

psychosocial

deconditioning

This working group will focus on: Flow of Patients Through System Core Staffing Requirements Requirements of Registry & Portal Process Standards

This working group will focus on: Training development Development and delivery of training and education programs, including outreach to primary care providers.

This working group will focus on: Development of Measures for Program Evaluation & Performance Risk Identification & Mitigation Research Program identification & development Research dissemination Registry Development

This working group will focus on: Clinical Standards Treatment Algorithms Clinical Operations

14

Organizational Structure

Paediatric Chronic Pain Network

Ontario Chronic Pain Network

Pediatric Chronic Pain Network

Advisory Board

Education and Training

Research and Evaluation

Patient Care

Strategy

Adult Chronic Pain Network

Advisory Board Co-chairs – Salisbury, LaMontagne, Campbell

Ontario Pediatric Chronic Pain Network

(PCPN)

• CHEO’s involvement: Co-chair and Leadership representation at Advisory Board and multiple chronic pain team members involved in subcommittees, patient care, research and education and training

• Sites funded for outpatient interdisciplinary pain programs/ clinics: Toronto , London, Hamilton and Ottawa

• Sites funded for intensive pain rehabilitation program: – Holland Bloorview Rehabilitation (Toronto) now accepting

patients for inpatient (2 weeks)/outpatient( 2-3 weeks( rehab treatment based on 3 P, referrals coming from individual pain clinics only

Managing Pain & Dysfunction: the 3 P

approach

Physical/Rehabilitative

Medical

-Pharmacological - Interventional (nerve

blocks, IV lidocaine infusions)

Psychosocial

Self

Management

Active coping

Self Management

Skills

Increased

activity

Improved

Social

Functioning

↓Anxiety, depression,

anger

Function

centered

Life

CHANGING THE CHRONIC PAIN SPIRAL: FUNCTION- CENTERED LIFE

ABéland MD 2012 | Abeland@Live.ca Adapted from: http://prc.canadianpaincoalition.ca/en/self_management.html

Physical

reconditioning

Pain- centered

life Analgesia

Education

Treatment of

neuropathic/chronic pain

First Line

•TCA (amitriptyline,nortriptyline)

•Gabapentin or Pregabalin •SNRI (duloxetine, venlafaxine)

Second Line

• Tramadol

Other Opioids *

Third Line

• Cannabinoids*

Fourth Line

•Carbamazepine, valproic acid, topiramate, lamotrigine

•Topical Lidocaine (5% gel or cream); Lidocaine patch N/A •SSRI •Methadone

Add additional agents sequentially

if partial but inadequate pain relief;

Attention to synergistic/additive side effects

Pharmacological management of chronic neuropathic pain: Revised consensus

statement from Canadian pain Society. Pain Res Manag. December 2014

Acetaminophen

NSAIDs

Anticonvulsant drugs

Opioids

Local anesthetics

ASCENDING PATHWAYS

DESCENDING PATHWAYS

Enhancement of pain modulation by descending pathways1,3-5

Tricyclic antidepressants

Serotonin/ norepinephrine reuptake inhibitors

Anticonvulsant drugs

Opioids

Inhibition of pain signal transmission in ascending pathways1,2,4,6

MECHANISMS OF ACTION OF SELECTED ANALGESICS

1. Vanderah TW. Med Clin North Am. 2007;91(1):1-12. 2. Becker DE, Reed KL. Anesth Progr. 2006;53:98-109. 3. Tanabe M et al. Brit J Pharmacol. 2005;144(5):703-714. 4. Knotkova H,

Pappagallo M. Med Clin North Am. 2007;91(1):113-124 . 5. Benarroch EE. Neurology. 2008;71:217-221.6. Carver A. In: ACP Medicine. New York, NY: WebMD; 2005:section 11,

chap 14.

Mental health disorders in pediatric

chronic pain population Vinall, Jillian et al “Mental Health comorbidities in pediatric chronic pain: A Narrative

review of Epidemiology, models, neurobiological mechanisms and treatment”. Children

3.4 (2016):40

• High co-occurrence of PTSD, anxiety, depression,

somatization and conversion disorder, ODD(boys), ADHD(boys)

in 30-50% of pediatric chronic pain patients

• Shared neurobiology (cortisol, serotonin, BDNF, inflammatory

markers)

• Common predisposing affective, cognitive and behavioral

factors

• High risk of developing mental health disorders in adulthood

even when pain has resolved. Anxiety (OR 1.33), depression

(OR 1.38)

• Temporality? Anxiety seems to precede pain

Environmental factors

• Co occurrence of Parental mental health diagnosis

and pediatric chronic pain (anxiety, depression,

somatization)

• Peer victimization

• Social isolation

What are the chronic pain services currently

offered at CHEO?

• New Assessments: on average 9-11 new patients per month.

• Follow ups: outcome measures gathered at 3, 6 ,9, 12, etc

months. Patients are usually followed for 1-2 years

• Patient-Reported Outcomes Measurement Information System

(PROMIS) for the provincial registry which includes both

pediatric self-report and parent proxy measures on • demographic information

• pain description

• school and learning details

• family dynamics

• health care utilization

• past physical, psychological/ psychosocial and pharmacological treatments

• a sleep questionnaire

• a pain catastrophizing scale, anxiety and depression screening

Realistic Goals with medications or

interventions

• 30-50% pain reduction is realistic

• Total pain relief is an unrealistic goal

• Ideal: improve function with minimal side effects,

reduce pain

- Function -Pain Relief

- Adverse Effects

NNT in order to get 50% pain reduction

NNT = Numbers needed to treat; from Finnerup et al. (2005) Pain 118: 289-305

Opioids in pediatric chronic pain

• Used or indicated only in selected patients ( tramadol,

morphine, hydromorphone)

• Has to be used as a tool in the setting of a 3 P approach to pain

management.

• If not helpful in maintaining or increasing function, then should

be discontinued

• Most patients report feeling more depressed when taking

opioids with minimal benefit for their pain (concepts of tolerance

and hyperalgesia)

• Teenagers are at Higher risk for opioid addiction, diversion or

misuse. Opioid contract and frank discussion is a must.

• Contraindicated in chronic headaches

What are the outpatient pain services

currently offered at CHEO?

• APS/ transition pain clinic: for persistent postop

pain and pain less than 3 months. Patients seen by

NP and physician only. Goals: manage pain

medications and initiate referrals for physio or

psychology, help prevent chronic pain and disability.

• Chronic pain clinic: interdisciplinary assessment

and follow ups of patients with pain lasting greater

than 3 months

• What about for inpatients? Acute Pain

Service(APS), PSMT (palliative) and Chronic pain

Service (CPS)

What are the chronic pain services currently

offered at CHEO?

• New Assessments: on average 9 new patients per month.

• Follow ups: outcome measures gathered at 3, 6 ,9, 12, etc

months. Patients are usually followed for 1-2 years

• Patient-Reported Outcomes Measurement Information System

(PROMIS) for the provincial registry which includes both

pediatric self-report and parent proxy measures on • demographic information

• pain description

• school and learning details

• family dynamics

• health care utilization

• past physical, psychological/ psychosocial and pharmacological treatments

• a sleep questionnaire

• a pain catastrophizing scale

Main goals of the chronic pain program

• Improve Function first then decrease pain. It is NOT

about elimination of pain or finding an organic cause

for the pain

• Develop a virtual pain tool box where child/youth

incorporates and learns strategies to manage pain:

pharmacological, physical and psychological

• Provide support and education for parents to help

manage their child’s pain with this 3 P approach.

• Very important that patients have been appropriately worked up

by referring physicians or PCP so that they are ready to engage

in rehabilitation model of care and not searching for a cause.

Patient Groups/Conditions seen at CHEO

• Post concussion pain syndrome

• Chronic headaches, not responding to prophylactic therapy

• Neuropathic pain: CRPS type 1 and type 2, post

traumatic nerve injury, post surgical pain

• Recurrent Abdominal Pain: IBS, abdominal wall pain,

post surgical, IBD…

• MSK: fibromyalgia, post viral myofascial pain

syndromes, JIA

• Congenital disorders: EDS, mitochondrial disorder,

etc

The interdisciplinary team at CHEO

• Anesthesiologist/ pain physician(0.5 FTE)

• Nurse coordinator(FTE: 1.0)

• Physiotherapist (FTE: 2.2)

• Social worker (FTE:1.0)

• Occupational therapist (FTE:0.4)

• Psychologist (FTE:2.0)

• Pharmacist (FTE:0.4)

• Administrative staff (FTE:1.0)

• Nurse Practitioner( FTE:0.8)

• Psychiatrist (FTE:0.5) still looking for

What are the Referral criteria for Chronic

Pain Services?

• Pain as primary issue lasting greater than 3 months

• Ages 0-17.5 years old

• Six months or less from 18 years old :

– Assessment only and referral back to PCP or referring physician

for pain management

– Education sessions will be provided if possible

– Referral to adult pain clinic will be initiated by PCP.

• Chronic pain impacts function (school attendance, sleep, mood,

quality of life and/or family functioning)

What are the Referral criteria for Chronic

Pain Services?

• Other significant medical or mental health issues have either

already been addressed or are concurrently being addressed by

the appropriate professionals (e.g.active suicidality)

• Investigations to identify etiology of pain have been completed

• Pain refractory to attempted management strategies (ex:

commonly used analgesics, physical or psychological

therapies), or therapies not available in community despite best

efforts

• Primary provider/referring physician agrees to collaborate in

ongoing pain management follow-up including writing

medication prescriptions when indicated and transition planning

where possible

Referral process

• Referral accepted via epic or by fax

• Triaged according to information provided on referral

form and chart review

• Denial of referral if all criteria are not met.

Priority Ranking

• Urgent (2-3 months): painful severe condition with risk of duration or chronicity (e.g. new CRPS), neuropathic pain, Inability to function in ADLs

• Semi-urgent (3-6 months): severe or progressive pain and risk of increasing functional impairment. Patient is able to function but limited

• Elective (6-9 months): persistent long-term pain without significant progression. Patient is functioning but pain has impacted some areas of his/her life.

Our model of care

• Mild, moderate and severe disability

• Most patients( mild-moderate) go through an outpatient day care treatment : – less intensive than a day program

– Family education included

– 3P approach: pharmacological (medications, vitamins, nerve blocks, infusions) , physical (physiotherapy, OT, home exercises, community massage therapy, acupuncture) , psychology (CBT, psychoeducation on pain, mindfulness, SW intervention with parents and family as needed)

– Outreach/consultation to schools by social worker

– Periodic follow-up with interdisciplinary team at 3,6 ,12 months and as needed

Intensive outpatient program: Rise Above

pain (RAP)

• Pilot project of group intervention (7 patients)

• 8 weeks, 3 hours sessions for patients and parents

• Psychoeducation on pain, introduction to CBT,

mindfulness, sleep hygiene concepts, lifestyle

balance, info on pharmacotherapy, pool session,

stretching, concepts of pacing and gradual return to

functioning

• Results: 1 dropout, 2 discharges, increase

functioning and lower pain scores

• Excellent satisfaction scores from patients and

parents

Intensive outpatient program: Rise Above

Pain (RAP)

• Pilot project of group intervention (7 patients)

• 8 weeks, 2-3 hours sessions, youth & parent groups

• Content

– Psychosocial: Psychoeducation on pain, MI, CBT, sleep hygiene concepts,

occupational balance, principles of ACT, emotion education, relaxation &

mindfulness, pain and the family, pain behaviours & communication, stress & coping

– Physical: pool session, stretching, goal setting, concepts of pacing and gradual return

to functioning

– Pharmacology : info on pharmacotherapy, golden rules of taking prescribed

medication, individual medication consults

– Pain flare management using the 3 “P” approach & graduation

• Results

– 1 dropout, 2 discharges, increase functioning and lower pain scores

– Excellent satisfaction scores from patients and parents

Our model of care

• Patients who are more debilitated or fail to improve

with the outpatient treatment program will be referred

to an intensive rehabilitation program (3-4 weeks):

– Based on the 3 P approach: pharmacological, physical

and psychological

– Holland Bloorview Rehabilitation Center

– Referral to US chronic pain rehab. centers( Cleveland,

Boston, Philadelphia) only if not eligible for Holland

Bloorview

Systematic Review on Intensive

Interdisciplinary Pain Treatment of

Children With Chronic Pain Tanja Hechler,, Marie Kanstrup, Amy Lewandowski Holley, Laura E. Simons,

Rikard Wicksell, Gerrit Hirschfeld, Boris Zernikow,, Pediatrics,2015;136;115

• 1 RCT and 9 nonrandomized treatment studies identified

• Studies included if :(1) treatment coordinated by 3 health

professionals, (2) inpatient/day hospital setting(mean 16 days)

(3) age < 22 yo (4) debilitating chronic pain. Most had parental

education (minimize response to pain behaviors, encourage functional

behaviors)

• 5 outcome domains (pain intensity, disability, school functioning,

anxiety, depressive symptoms) at baseline,posttreatment, and

follow-up.

• Post treatment: large improvements for disability, pain intensity

and pain catastrophizing , small to moderate improvement for

depressive symptoms. Positive effects maintained at 3-12

months

• Large heterogeneity in outcome measures used

What are the benefits noticed since

implementing an interdisciplinary chronic

pain team at CHEO?

• From patient’s perspective: increase in functioning,

decrease in pain and depression. Most patients have

higher functional scores and lesser pain scores on

discharge. Less opioid use, less medication use

• From parental perspective: less anxiety, less

catastrophizing, less miscarried helping

• From a hospital perspective: less ER visits, less

hospital admissions, shortened admission time,

decrease in multiple health care providers being

involved

+ Chronic Pain outpatient Groups

Comfort Ability

Young Adult Group

PT/OT Education Session

Transition Group

Pain Flare Group

Chronic Pain Info Session

The Psychosocial P

• High co-occurrence of patients with Chronic Pain and mental health difficulties (e.g. mood, anxiety, acceptance of pain), as well as difficulties with social and family functioning

• Psychosocial P offers the following services:

– Psychoeducation about pain and emotions

– Brief, short term individual psychotherapy therapy & occupational therapy

– Group therapy (The Comfort Ability; Young Adults transition group; R.A.P. intensive day program)

– Parent support (individual & groups)

– Consultation with community providers & schools

The Comfort Ability

• Brief Intervention designed for 10-17 year olds with chronic pain

• Rooted in Principles of Cognitive Behavioural Therapy

– Motivational interviewing, psychoeducation about pain, biobehavioural strategies,

cognitive strategies, active/passive coping, anxiety & depression, communication

strategies, individual comfort plan

• Developed by:

– Dr. Rachael Coakley, PhD , Psychologist

Associate Director, Pain Treatment Service

Boston Children’s Hospital (BCH)

Assistant Professor, Harvard Medical School

• Separate, simultaneous youth and parent session

The Comfort Ability at CHEO

• Runs every 6-8 weeks on Sundays

• Target Audience

• Youth aged 10-17 years and their parents

• CHEO patients who have been seen in the Chronic Pain

Interdisciplinary clinic

• Various pain presentations, various levels of disability

• 1 day workshop (6 hours)

• Provide foundation of skills as early as possible in their

rehabilitative process

• Currently collecting data to evaluate effectiveness at CHEO

Preliminary Data from BCH (Coakley, 2015)

– Online self-report questionnaires for parent and child administered

pre-treatment, 1-week, 1-month, and 3-month follow up

– N=136

– Ages 10-17

– Various pain problems (headache, abdominal pain, neuropathic

pain, wide-spread body pain)

– At least one participating parent (but collected data from two if

possible)

– Families received $30 gift card for participation

Preliminary Data from BCH: PARENT group (Coakley, 2015)

• More adaptive parenting practices (e.g., fewer responses to child’s symptoms)

• Reduced catastrophizing of their child’s pain

• Increased confidence that their child can better manage his/her own pain

• Reduced healthcare utilization ( e.g., admissions, emergency visits, calls to

health care providers)

• Increasing gains through 3-months post-treatment

• Very high rates of patient satisfaction

Preliminary Data from BCH: YOUTH group (Coakley, 2015)

• Improved pain self-efficacy (e.g. feeling as though they can make it

through a day of school with pain)

• Reduced catastrophizing of symptoms

• Improved function (e.g. fewer naps during the day)

• Reduced pain

• Improving gains through 3-months post-treatment

The Physical P

• People with chronic pain tend to demonstrate: – Poor flexibility

– Decreased strength

– Poor endurance

• Many people who experience pain have a poor occupational balance: – Their function is decreased in the areas of self-care, leisure

and/or productivity.

– Participation in activities that are meaningful can be limited

What the team offers (Physical P):

• Entry point to individual PT and OT services = PT/OT Education Class – Group format for education and goal-setting using the Canadian Occupational

Performance Measure (COPM)

• Individual PT/OT sessions may then be initiated or recommendations may be made to start or continue therapy with community providers, depending on the goals identified through the COPM

• Treatment may include: Education, pacing, specific exercise programs, myofascial release, mirror therapy and/or recommendations for adjunctive therapies (eg. massage, acupuncture)

• Goals are around optimizing function (assist with return to sports, school, leisure activities)

Discharge criteria

• Youth and family fail to engage in proposed treatment

despite efforts by the team to address patient/family’s

concerns

• Patient, family and pain team feel that pain is well

managed and under control and support a transition

back to primary care provider.

• Age (18 yo)

Transition to adult care

• Youth transition group workshops: lead by our clinical

psychologists with aim to teach patients how to

advocate for self and develop comfort ability plan

going into the adult health care scene.

• Transition back to PCP for medication management

• Availability of econsult : Tool to help manage patients

on wait list and help PCP to manage patients once

discharged from our program

• Soon to restart: combined clinics with TOH pain clinic

for patients still needing more support

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