MERCY PAIN CENTER. Multidisciplinary Pain Treatment and Rehabilitation. Using a Team-Based Approach to Treat Chronic Pain

Transcription

1 MERCY PAIN CENTER Multidisciplinary Pain Treatment and Rehabilitation Using a Team-Based Approach to Treat Chronic Pain

2 Speaking in Maine Chronic Pain Management

3 History Interventional Pain Management OR Medical Pain Management

4 History Interventional Pain Management AND Medical Pain Management

5 History Interventional Pain Management AND Medical Pain Management AND Interdisciplinary Biopsychosocial Pain Rehabilitation Program

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7 There is no evidence from randomized controlled trials to support the popular assertion that the benefits of long term opioid therapy outweigh the risks.

8 There is no evidence from randomized controlled trials to support the popular assertion that the benefits of long term opioid therapy outweigh the risks. We must be very cautious in using lack of evidence as a strict guideline as to how to practice medicine.

9 There is no evidence from randomized controlled trials to support the popular assertion that the benefits of long term opioid therapy outweigh the risks. Open label extension trials and epidemiologic studies demonstrate that chronic pain patients on opioids have worse pain, worse depression, worse function, and worse quality of life.

10 There is no evidence from randomized controlled trials to support the popular assertion that the benefits of long term opioid therapy outweigh the risks. Open label extension trials and epidemiologic studies demonstrate that chronic pain patients on opioids have worse pain, worse depression, worse function, and worse quality of life. What is the cause and what is the effect?

11 There is no evidence from randomized controlled trials to support the popular assertion that the benefits of long term opioid therapy outweigh the risks. Open label extension trials and epidemiologic studies demonstrate that chronic pain patients on opioids have worse pain, worse depression, worse function, and worse quality of life. Medical management withdrawal from opioid improves pain and function.

12 Transitioning a Pain Program Away From Chronic Opioid Prescribing

13 Multidisciplinary rehabilitation for chronic low back pain: systematic review Twelve randomized comparisons of multidisciplinary treatment and a control condition. Guzmán et.al., BMJ Jun 23;322(7301):1511-6

14 Multidisciplinary rehabilitation for chronic low back pain: systematic review Twelve randomized comparisons of multidisciplinary treatment and a control condition. Strong evidence that intensive multidisciplinary biopsychosocial rehabilitation with functional restoration improves function when compared with inpatient or outpatient non-multidisciplinary treatments. Guzmán et.al., BMJ Jun 23;322(7301):1511-6

15 Multidisciplinary rehabilitation for chronic low back pain: systematic review Twelve randomized comparisons of multidisciplinary treatment and a control condition. Strong evidence that intensive multidisciplinary biopsychosocial rehabilitation with functional restoration improves function when compared with inpatient or outpatient non-multidisciplinary treatments. Moderate evidence that intensive multidisciplinary biopsychosocial rehabilitation with functional restoration reduces pain. Guzmán et.al., BMJ Jun 23;322(7301):1511-6

16 Interdisciplinary Biopsychosocial Pain Rehabilitation

17 Twelve week group based program Twice weekly for 2 ½ hours

18 NEGATIVE SELLING

19 Twelve week group based program Twice weekly for 2 ½ hours Pain physiology education

20 Twelve week group based program Twice weekly for 2 ½ hours Neurophysiology education Nociception does not equal Pain

21 Pain is an output of the brain, the end result of the brain interpreting information from inside the body (nociception) and from the outside world as threat, a very motivating output designed to protect you.

22 Twelve week group based program Twice weekly for 2 ½ hours Neurophysiology education Nociception does not equal Pain Hurt does not equal Harm

23 Twelve week group based program Twice weekly for 2 ½ hours Neurophysiology education Nociception does not equal Pain Hurt does not equal Harm Cognitive behavioral treatment Acceptance and Commitment Therapy

24 Twelve week group based program Twice weekly for 2 ½ hours Neurophysiology education Nociception does not equal Pain Hurt does not equal Harm Cognitive behavioral treatment Acceptance and Commitment Therapy Mindfulness Training

25 Twelve week group based program Twice weekly for 2 ½ hours Neurophysiology education Nociception does not equal Pain Hurt does not equal Harm Cognitive behavioral treatment Acceptance and Commitment Therapy Mindfulness Training Change Avoidance to Willingness to Risk Pain

26 Bypassing the traps of language with experiential practice Room full of duct tape Say it in another language Mindful walking Hooligans on the Bus Crossing the swamp

27 Twelve week group based program Twice weekly for 2 ½ hours Neurophysiology education Nociception does not equal Pain Hurt does not equal Harm Cognitive behavioral treatment Acceptance and Commitment Therapy Mindfulness Training Change Avoidance to Willingness to Risk Pain

28 Twelve week group based program Twice weekly for 2 ½ hours Neurophysiology education Nociception does not equal Pain Hurt does not equal Harm Cognitive behavioral treatment Acceptance and Commitment Therapy Mindfulness Training Change Avoidance to Willingness to Risk Pain Graded group and individual exercise

29 Twelve week group based program Twice weekly for 2 ½ hours Neurophysiology education Nociception does not equal Pain Hurt does not equal Harm Cognitive behavioral treatment Acceptance and Commitment Therapy Mindfulness Training Change Avoidance to Willingness to Risk Pain Graded group and individual exercise Medical management withdrawal

30 Twelve week group based program Twice weekly for 2 ½ hours Neurophysiology education Nociception does not equal Pain Hurt does not equal Harm Cognitive behavioral treatment Acceptance and Commitment Therapy Mindfulness Training Change Avoidance to Willingness to Risk Pain Graded group and individual exercise Medical management withdrawal Alumni group

31 Admission (Exclusion) Criteria Non-Acute (Chronic) Pain Symptom reduction options exhausted?

32 Admission (Exclusion) Criteria Non-Acute (Chronic) Pain Symptom reduction options exhausted? Medical contraindications to exercise

33 Admission (Exclusion) Criteria Non-Acute (Chronic) Pain Symptom reduction options exhausted? Medical contraindications to exercise Significant cognitive impairment

34 Admission (Exclusion) Criteria Non-Acute (Chronic) Pain Symptom reduction options exhausted? Medical contraindications to exercise Significant cognitive impairment Inability to work in a group Social phobia or agoraphobia History of disruptive behavior

35 Treatment Team Physician Physiatrist, Algiatrist Psychologist Physical Therapy Assistant Clerical Support - Coordinator Appropriate Space (CBT and Exercise)

36 Treatment Team Physician - Interested Medical Provider Exercise Director Behavioral Therapist Clerical Support - Coordinator Appropriate Space (CBT and Exercise) Scalable to Any Community of Pain Patients

37 Gotta Have a Margin Psychologist - Bills a group therapy charge Physician - Bills an office visit charge Physical Therapy Assistant - no charge Break even is at 3 paying patients Cost is $5,000 - $7,000

38 Physical Measures Affective Measures PHQ-9 GAD-7 Functional Measures Outcome Chronic Pain Acceptance Questionnaire (CPAQ) Treatment Outcomes of Pain Survey, Short (S- TOPS) Medical Outcomes Study Sleep Scale Oswestry and Neck Disability Indices

39 LIVING LIFE WELL PROGRAM Outcomes to date Physical measures: 26% improvement

40 LIVING LIFE WELL PROGRAM Outcomes to date Physical measures: 26% improvement Activity engagement: 55% improvement

41 LIVING LIFE WELL PROGRAM Outcomes to date Physical measures: 26% improvement Activity engagement: 55% improvement Pain willingness: 95% improvement

42 LIVING LIFE WELL PROGRAM Outcomes to date Physical measures: 26% improvement Activity engagement: 55% improvement Pain willingness: 95% improvement Satisfaction with care: 26% improvement

43 LIVING LIFE WELL PROGRAM Outcomes to date Physical measures: 26% improvement Activity engagement: 55% improvement Pain willingness: 95% improvement Satisfaction with care: 26% improvement Pain severity: 14% improvement

44 Mindfulness Resources Websites: Neurophysiology Resources Book: Explain Pain by David Butler and Lorimer Moseley Blog: Listserve: YouTube Video: Lorimer Moseley TED Talk Understanding Pain: What to do about it in less than 5 minutes

45 Thanks Stephen Z. Hull, M.D. (Steve)