Integrative Pain and Symptom Management

1. Integrative Pain and Symptom Management William Zempsky, MD, FAAP Timothy Culbert, MD, FAAP Sessions S131 and S169

2. Faculty Disclosures In the past 12 months, we have not had a significant financial interest or other relationship with the manufacturer(s) of the product(s) or provider(s) of the service(s) that will be discussed in my presentation. This presentation will include discussion of pharmaceuticals or devices that have not been approved by the FDA or if you will be discussing unapproved or “off-label” uses of pharmaceuticals or devices.

3. Overview of Presentation • Introduction: Integrative Pediatrics • Introduction: Pain and Symptom Management • Description of Programs • CAM Therapies in Pediatric Pain • Clinical Applications • Headache • Insomnia • Experiential • Audience Q and A

5. Integrative Medicine Vs. CAM 1 • CAM-complementary and alternative medicine • Specific therapies/modalities • Not typically taught, used or reimbursed in USA hospitals • A group of diverse practices not presently considered part of conventional medicine • 5 domains defined by NIH-NCCAM • Mind/Body • Biological • Manipulative/Body- based • Alternative Systems • Energetic

6. Integrative Medicine Vs. CAM 2 • Integrative Medicine-A system of care that emphasizes wellness and healing • Principles • Mind/body/spirit • Patient –provider as collaborative partners • Natural, less invasive approaches when possible • Facilitating the body’s natural healing capacities • Need for provider self-care • Conventional and CAM in balance • Customized to patient need and preference • Balance of evidence and safety considerations • Note-over 20 Pediatric CAM Programs in USA

7. Kids and CAM • 2%-30% in primary care settings • 30%-70 % of kids with chronic illness • 1999-2000 Children’s Hospitals and Clinics of Minnesota Data • Simpson, 1998 Ambul Child Health • Ernst, 1999 Eur J Pediatrics • Davis, 2003 Arch Peds Adol Med • Grootenhuis, 1998, Cancer Nurs • Stern, 1992, J Adol Health

8. CAM Use at Children’s Minnesota-52% Overall • 59% of Oncology Patients • 51% Pulmonary Patients • 32% General Pediatrics • 62% Pediatric Epilepsy • 47% Pediatric Sickle Cell

9. Types of CAM Used

10. Doctors and CAM • Pediatricians in Michigan • >50% would refer for CAM • >50% used CAM themselves • Sikand, 1998, Arch Ped Adol Med • Pediatricians National Survey • 66% believed CAM could be helpful • Kemper & O’connor, 2004, Ambul Peds • Pediatricians in Ohio and Minnesota • 97% would refer kids with chronic pain for CAM if more was known about efficacy • 73% of female peds and 58% of male peds surveyed classified themselves as “believers” • Charmond, Banez, Culbert, 2006 Submission in process • **All-expressed need for more CAM education

11. CAM and Pain Management • Most common reason for CAM usage in adults surveys is chronic pain –particularly musculoskeletal pain • For many children with chronic pain-conventional options –psychotropic meds and PT-are not working • Increasing evidence that CAM is quite useful and also safe (particularly non-drug options) • Personal use of Cam by physicians pedicts likelihood of patient referral for CAM

12. CAM & Kids:Legal & Ethical Aspects • Complex issues at boundary of medicine, law and public policy • Cohen et al, 2005, Pediatrics • Clinical Risks • Parents abandon effective care in life-threatening situation? • Does CAM divert from or delay necessary treatment? • Evidence for CAM treatment –known to unsafe or ineffective? • Consent of proper parties? • Is risk/benefit ratio acceptable? • Your knowledge of CAM provider you are referring the patient to • Cohen and Kemper, 2005, Pediatrics

13. Evidence: Safety vs. Efficacy SafeYesSafe No effectiveYesRecommendMonitor closely effective NoTolerate Advise against Weiger et al, 2002, Annals Int Med Cohen, Pediatrics, 2005

14. Chronic Pain: Diagnosis • Study of general academic pediatricians-investigated opinions of children presenting with unexplained chronic pain • 134 patients, 8-18 y.o.-chart review –3 M.D.’s • 60% had psychiatric co-morbidity (kids not docs) • Did not agree on cause of pain for 57% of pts • Did not agree on appropriate diagnostic workup for 37% of patients • Konijnenberg et al, 2004, Pediatrics

15. Chronic Pain: Treatment • Feasiblity and acceptability of integrative treatment package for pediatric chronic pain (hypnosis and acupuncture) • 33 kids chronic pain clinic, 6-18 years • 6 weekly sessions • Highly acceptable >90% completed treatment, no adverse effects • Zeltzer et al, 2002,J Pain Symptom Manage

16. Chronic Pain Book • Conquering Your Child’s Chronic Pain • Lonnie Zeltzer, MD

18. Children in Pain • Long history of undertreatment of pain in children • Perioperative pain • Newborn pain • Pain of Chronic Disease • Problems persist • Emergency department • Common pain problems • Sickle Cell pain

19. Do children feel pain? • Pain fibers present at end of 2nd trimester • Increased heel sensitivity post heel sticks • Crying increases for days post circumcision • 6 month olds-anticipate and avoid pain

20. Pain Memory • 3 groups • Uncircumcised • Circumcised with EMLA • Circumcised with placebo • Pain scores at 4 and 6 mos shots • Circumcised infants had higher pain response Taddio et al. Lancet, 1997

21. Children involved in a placebo trial of transmucosal fentanyl • Subsequent study all children received opiates • Patients in original placebo group had higher pain scores with subsequent procedures • Inadequate analgesia effects future pain response Weisman et al, Arch Pediatr Adol Med, 1998.

22. What symptoms do we need to consider? • Pain • Nausea • Insomnia • Anxiety • Depression

23. Pain Acupuncture Massage Relaxation Herbal Remedies Arnica Nausea Acupuncture Aromatherapy Herbal Remedies Anxiety Acupuncture Relaxation Acute Symptoms

24. Chronic Symptom Management • Patients and families often looking for something else • Change the paradigm from a treatment of last resort • Make integrative approach the norm

25. Behavioral Therapy Herbal therapy Biofeedback Physical Therapy Osteopathic Manipulation Craniosacral Therapy Acupuncture Massage Yoga Reiki Chronic Pain Management

26. 16 yo with CRPS • Sprained ankle 2 months ago • Placed in a boot • PE • Pain • Allodynia • Cool • Swoolen • Blue

27. Visit 1 PT program Tens Unit Aquatic Therapy Desensitization Behavioral Therapy Coping Meditation Melatonin for sleep Subsequent visits Acupuncture Anxiety Pain Yoga Massage area with arnica gel

29. Children’s Minnesota Integrative Medicine Program: Overview • Clinical, Research and Educational Activities • Inpatient and Outpatient Services • Collaborative Model with other disciplines • System-Wide activities • Are integrating services with new Pain and Palliative Care Team

30. Children’s Minnesota Integrative Medicine Program: Staffing • MD-trained as developmental/behavioral pediatrician (1.0 FTE) • PhD-Pediatric Psychologist (2.0 FTE) • APRN-research and education background (1-2 FTE) • Massage therapists (2-3 FTE) • MD acupuncturist (0.2 FTE) • Support Staff (3.0 FTE)

31. Integrative Medicine Clinical Services • Inpatient • Volumes • Massage 2005 –1,453 2006-2,460 • IM Consults 2005-378 2006-536 • Massage Up 69% IM Consults Up 41.7% • Outpatient • Volumes • Massage 2005-93 2006-303 • Massage Up 212% • Medical 2005- 1063 2006-1188 • Medical Visits Up 11.7% • Psychology 2005-506 2006-749 • Psychology Visits Up 48%

32. Children’s Minnesota Integrative Medicine Program: Therapies • Mind/Body Skills • Hypnosis, biofeedback, relaxation, groups • Massage and Bodywork • Energy Therapies • Acupuncture/Acupressure • Clinical Aromatherapy • Exercise Physiology and Nutrition • Herbals and supplements • Conventional (psychopharm and psychotherapy)

33. Children’s Minnesota Integrative Medicine Program: Diagnoses • Chronic Pain • Functional GI Disorders • Headaches (TT, Migraine, Chronic Daily) • CRPS, Myofascial pain, somatoform • Holistic Mental Health • Depression, anxiety, adhd, autism • BioBehavioral Problems • Enuresis, encopresis, sleep disorders, habits • Chronic Illness Related Problems • Adjustment issues, fatigue, other symptom management

34. Children’s Minnesota Integrative Medicine -Other Activities • Inpatient Consultation Services • Massage • Non-drug symptom management • Nausea, pain, insomnia, anxiety • Integrative Nurse Training • 3 full cohorts of day surgery nurses • 3 more to come • 8 hour basic curriculum expanding to 40 hr AHNA model • Research • Mind/body interventions for pediatric pain • CAM and pediatric oncology • Clinical Aromatherapy • Massage, stress and cancer

35. Children’s Minnesota Integrative Medicine: What Works? • We complement and work closely with all subspecialties-value added • Work with difficult cases that are “stuck” –conventional approaches not getting it done • Psychologist and MD work very closely-assessment and treatment • More willingness from patients and families to consider mind/body approaches without “stigma” associated with “mental health” • Carefully considered therapy mix and political milieux • Great support from leadership team –we bring in philanthropic dollars, great PR and academic notice (talks and publications)-even though we don’t make big $$-we have controlled revenue and expenses very well

37. Value of Pain Service* • 23 hospitals, 5837 patients • half anesthesia pain service, half control • Decreased pain intensity, decreased nausea, decreased itching, decreased sedation in pain service group • Less pain than patient expected; more likely to receive education; quicker discharge *Miaskowski, Pain 199:80:23-29

38. Surveys of Adequacy of Pain Relief • Cummings et al. 1996 • Survey of all children in children’s hospital • Clinically significant pain was present in 21% of population • Pain intensity not related to age, diagnosis • Children offered less meds than prescribed • “No one” identified as helping with pain

39. For nearly thirty years I have studied the reasons for inadequate management of pain, and they remain the same….inadequate or improper application of available information and therapies is certainly the most important reason for inadequate postoperative pain relief John Bonica, 1990

40. We realized a traditional Pain Service only helps those patients with whom it interacts

41. Action plan which emphasizes CCMC’s fundamental commitment to pain control which suffuses through all disciplines and departments • Basic premise is that pain control and comfort measures will be a part of all patient encounters and that barriers to pain relief will be identified and removed. Affects the quality of life of all children in hospital and its community; not select few with complex pain

42. Mission • Provision of high quality clinical care in the area of pain control • Direct care to inpatients and outpatients with pain • Helping other disciplines treat pain problems more effectively • Creating an atmosphere throughout CCMC where pain treatment is viewed as important • Establishing a tradition of education and scholarship in the area of pain management

43. Pain Relief Program at CCMC • Specific Aspects of Pain Program • Acute Pain Consultation Service • Chronic Pain Program • Comfort Central

44. Patient Population(Acute) • Chronic Medical Illness • Heme/Onc, Developmental Disabilities • Complicated postoperative pain care • Weaning and dose escalation • Alternative medications • Sleep, anxiety • Pain out of proportion to illness • NICU pain problems • Sedation questions

45. Inpatient Complementary Programs • Acupuncture • Hypnosis • Biofeedback • Yoga

46. Chronic Pain Clinic • Multidisciplinary Approach • MD, Psychologist, PT, Nursing, MD-Acupuncturist, Biofeedbacker, Yoga Therapist, Meditator • Focus on function • Emphasize behavioral cognitive and physical and complementary therapies

47. Patient Population(Chronic) • Referrals primarily from Rheumatology, Neurology, GI, Orthopedics, private practice • Frequently referred problems: • CRPS • Widespread pain and fatigue (fibromyalgia, CFS) • Headache • Abdominal pain • Pain associated with genetic disorders (Stickler’s syndrome, Ehlers-Danlos) • Pain associated disability syndrome • Prolonged postoperative pain

48. Complementary Programs • Acupuncture • Biofeedback • Meditation • Yoga • Massage

49. Comfort Central • Protocol Development • Phlebotomy Lab Project • Topical Anesthetic Trials • Injection Protection Project