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THE PAIN DECADE AND THE PUBLIC HEALTH

THE PAIN DECADE AND THE PUBLIC HEALTH. Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania School of Medicine Director of Pain Management, Philadelphia VA Medical Center

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THE PAIN DECADE AND THE PUBLIC HEALTH

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  1. THE PAIN DECADE AND THE PUBLIC HEALTH Rollin M. Gallagher, MD, MPH Clinical Professor, Departments of Anesthesiology and Psychiatry University of Pennsylvania School of Medicine Director of Pain Management, Philadelphia VA Medical Center National Pain Management Coordinating Committee, Veteran Affairs Health System Editor in Chief, Pain Medicine Board of Directors: American Academy of Pain Medicine and National Pain Foundation Immediate Past President, American Board of Pain Medicine

  2. The Pain Decade and the Public Health • History • Conceptualization – Lippe, Saper, Ashburn et al, 1999 • Matriculation – SB 3163 • Enrollment – October 28, 2000 • Life span – 2001 - 2010

  3. “Pain is a more terrible lord of mankind than even death itself.” Albert S. Schweitzer, 1931 On the Edge of the Primeval Forest. New York: Macmillan, 1931:652

  4. Pain MedicineHistory • Epochs • Antiquity to 19th Century • Pain a symptom treated by purgation • Dichotomy of pain – Descartes and Byron • Physical pain • Mental pain

  5. Pain MedicineHistory • Epochs • Late 19th Century to 1980’s: Age of medical science and technology • Spine surgery and back pain disability • Psychogenic pain, compensation neurosis and behavioral medicine • John Bonica and IASP • Gate Theory of Pain (Wall and Melzack) • Hospice and the treatment of suffering

  6. Pain Medicine History • Epochs • Late 20th Century to 2007 • Rise of epidemiology • Failed spine surgery syndrome • Geographic variation in surgical rates • National variation in opioid analgesia • The myth of “psychogenic pain” and psychiatric co-morbidity • Pain diseases versus chronic pain • Multi-factorial bio-psycho-social causation

  7. DIAGNOSIS There Are Many Painful Diseases and Pain Diseases Inflammatory / Immunological Mediation Nociceptive pain Caused by activity inneural pathways inresponse to potentiallytissue-damaging stimuli Neuropathic pain Initiated or caused by a primary lesion or dysfunction in the nervous system CANCER PAIN, LBP, CHRONIC FACIAL PAIN (mixed pain states) Peripheralneuropathy CRPS* Postoperativepain SENSITIZATION Arthritis Postherpeticneuralgia Trigeminalneuralgia Sickle cellcrisis Mechanicallow back pain Neuropathic low back pain Central post-stroke pain Diabeticneuropathy Sports/Exerciseinjuries Phantom tooth pain *Complex regional pain syndrome.

  8. Phenomenological Model of Pain Disease: Post Herpetic Neuralgia Factors reducing risk for PHN: Early anti-viral treatment, Early amitriptylene, Good pain control. BPS OUTCOMES Chicken Pox with Infection, with invasion of dorsal root ganglion & spinal nerves in childhood “Shingles” Activation of virus and disease of acute herpes zoster Exposure to Varicella Virus Post-herpetic Neuralgia Successful Pain Control * * Initial exposure Risk factors for chronic pain: Severity and duration of acute rash, Pain severity, Anxiety severity. Factors enhancing good outcome: Access to appropriate pain treatment Access to rehabilitation. Precipitating Factors: Acute illness, Stress, Age, Immuno- Suppression, Cancer. Predisposing Condition

  9. Quality of life Physical functioning Ability to perform activities of daily living (ADLs) Work Social consequences Marital/family relations Intimacy/sexual activity Social role and friendships Psychological morbidity Fear, anger, suffering Sleep disturbances Loss of self-esteem Medical comorbidites & consequences Accidents Medication effects Immune function Clinical depression Mismanaged chronic pain is often a personal catastrophe! ….and is a huge public health problem. Established effects (by research)of chronic pain • Societal consequences • - Health care costs • - Disability • - Lost workdays • - Business failures • - Higher taxes Pain causes these problems. These problems reduce the effectiveness of pain treatment. They must be managed to obtain good treatment outcomes

  10. Depression and Pain Comorbidity Pain, A condition or symptom that causes or activates depression Pain Remission Recovery Response Relapse Recurrence Relapse “Normalcy” Progression to disorder Symptoms Syndrome Acute Continuation Maintenance Treatment Phases Gallagher & Verma, Prog Pain Res Man 2004, Adapted from Kupfer DJ. J Clin Psychiatry.; 1991;52(suppl):28-34. Dohrenwend BP, et al. Pain. 1999;83(2):183-192. Raphael et al Pain 2004

  11. Pain MedicineHistory • Epochs • Late 20th Century to 2007 • Rise of Neuroscience and Biotechnology • Gate theory • Molecular biology and neurotransmitters • Psychopharmacology • Neuropharmacology • Neuromodulation • disease

  12. Pain in our wounded warriors(2002-2007) • 686,306 OIF-OEF veterans • 229,015 using VA services (33.4%) • 43 % have musculoskeletal diseases (all cause pain by definition) - back pain most common • 37% have mental health disorders Kang et al. Paper presented at War-Related Illness and Injury Study Center, 2007.

  13. The Polytrauma Challenge • 65% of OEF/OIF combat injuries are caused by improvised explosive devices (IEDs), landmines, shrapnel, and other blast phenomena. • multiple visible injuries (tissue wounds) • hidden injuries [bone and soft tissue damage, including nerves] • 60% with symptoms of traumatic brain injury (TBI) : hearing, vision, cognition, emotional control • Over 95% have chronic pain

  14. Neuro- plasticity Ectopic discharge Central sensitization Ectopic discharge Alteration of modulatory systems Phenotypical Changes ANS activation <<< Stress <<< Pain<<< BRAIN PROCESSING Spinal cord Damage Nerve injury +++ C fiber Abeta fiber Limb trauma Adapted from Woolf & Mannion, Lancet 1999 Attal & Bouhassira, Acta Neurol Scand 1999

  15. Does early intervention make a difference? Castillo et al. Pain 124 (2006): 321-329 • 567 severe single extremity trauma patients at 7 years • Predictors of poor outcome before injury include: • Alcohol abuse 1 month before injury • Older age, lower education, low self efficacy (Gallagher Pain1989) • Predictors of poor outcome at 3 months post-injury: • Acute pain intensity, anxiety, depression and sleep disturbance

  16. Opioid protective effect • Patients treated with opioids for pain at three months post-discharge were protected against chronic pain.. • despite the fact that these patients had higher pain intensity levels and were thus at higher risk for chronic pain • lending support to the theory that… ..early aggressive pain treatment may protect patients from central sensitization and chronic pain.”

  17. Early, Continuous, and Restorative Pain Management in Injured Soldiers: The Challenge Ahead Rollin M. Gallagher, MD, MPH Rosemary Polomano, PhD, RN Pain Medicine 2006;7(4):284-286 John Farrar, MD, PhD David Oslin, MD Wensheng Guo, PhD Chester Buckenmaier, MD Geselle McKnight, CRNP Alexander Stojadinovic, MD

  18. THE END: CPRS Pain Cycle • Pathology: • Muscle atrophy, • weakness; • Bone • demineralization; • -Depression • Pathophysiology of Maintenance: • Radiculopathy • Neuroma traction • Myofascial sensitization • Brain pathology (loss, reorganization) • Psychopathology • of maintenance: • Encoded anxiety • dysregulation • - PTSD • -Emotional • allodynia • -Mood disorder Central sensitization Acute injury and pain Disability Less active Kinesophobia Decreased motivation Increased isolation Role loss Peripheral Sensitization: Na+ channels Lower threshold Neurogenic Inflammation: - Glial activation - Pro-inflammatory cytokines - blood-nerve barrier dysruption

  19. Mechanism Targets For Neuropathic Pain Pharmacotherapy (Adapted from Beydoun 2001) BRAIN Modulation by Norepinephrine Serotonin Endogenous opiates Tricyclics, SSRIs, SNRIs (Venlafaxine, Duloxetine), Tramadol, Opiates Voltage gated Ca channels (L & PQ presynaptic): Gabapentin, Pregabalin Anti-inflammatory NSAID, Cox 2 Spinal cord NMDA antagonists: Ketamine, Dextromethorphan PNS NA channels Lidocaine Patch 5% CarbamazepineOxycarbazine Tricyclics Topiramate 2 agonists Tizanidine Clonidine

  20. Pain MedicineHistory • Epochs • Late 20th Century to 2007 • Emergence of the specialty of Pain Medicine • Evolving organizational models of care • Sequential care model • Multidisciplinary pain center model • Managed care model • Pain medicine and primary care community rehabilitation model

  21. The tertiary, sequential care model 1 1 INJURY/SYMPTOM Emergency Services TIME 1 Primary Care 2 2 (5) 4 Specialty Office #1 (6) 3 TREATMENT FAILURES Specialty Office #2 3 4 ALTERNATIVE TREATMENTS Specialty Office #3 3 5 CHASING THE SYMPTOM THROUGH A REDUCTIONISTIC, BIOMEDICAL MODEL Specialty Office #4 4 Gallagher RM. MedClin N Am 83(5): 555-585, 1999.

  22. The multi-disciplinary, biobehavioralpain center model INJURY/SYMPTOM time 1 Emergency Services 1 Primary Care 1 5 3 Specialty Offices, Alternative Care Treatment Failure Treatment Success 2 2 Multidisciplinary Pain Center: MD, PT, OT, Behav Med, Voc Rehab 4

  23. The managed primary care model DOES NOT WORK FOR PATIENTS OR POPULATIONS time INJURY/SYMPTOM Emergency Services Primary Care Office 1 1 (4) 3 2 JUST SAY NO!! Specialty Offices Treatment Failures (3) 6 2 5 INSURANCE LOSS JOB LOSS Gallagher RM. MedClin N Am 83(5): 555-585, 1999.

  24. Cost vs. Quality (From W. Brose, MD) Resource Excess care Best practice Quality of care (outcomes)

  25. The pain medicine and primary care community rehabilitation model A “systems” model for pain management that is based on three core principles: 1) empowerment by education of and support for primary care provider, patient and community 2) outcomes focus: evidence based, quality improvement approach 3) shared responsibility for outcomes amongst, patient, providers, health care system, and payers 4) Easy access for early intervention 5) Evidence-based rational polypharmacy imbedded in goal-oriented, stepped, selectively multi-modal treatment (e.g., PT, behavioral, social) ** ** Gallagher RM. Rational polypharmacy in integrated pain treatment. Am J Phys Med & Reh 2005(S);84(3):S64-76

  26. Pain medicine and primary care community rehabilitation model INJURY/SYMPTOM Multidisc- iplinary Pain Center 7 1 Emergency Services PrimaryCare: ClinicalAlgorithms Community Support & Services (PT, OT, Voc, behavioral, pharmacy) 2 Sub-specialty Eval. & mgmt. Recurrent or persistent pain impairing function (4) 3 5 Integrated Pain Medicine Eval & Services: Med. trials, PT, Blocks, Behavioral mgmt. 6 3 Treatment Failure 6 Gallagher RM. MedClin N Am 83(5): 555-585, 1999. .

  27. Algorithm for Medication Selection in Chronic Pain With and Without Comorbid Depression Neuropathicpain Nociceptivepain Pain condition +depression Secondary depression Primary D. Secondary sleepdisturbance Evaluate risks Persists afteradequateanalgesia Evaluate risks Persists afteradequateanalgesia NSAIDs,Cox-IIs,opioids, lidocaine p.? doxepin cr.? SSRI trial Evaluate risks Evaluate risks Lidocaine patch;gabapentin & other AED (Ca+ & Na+ channels); alpha 2 agonists (tizanidine, clonidine);opioids SNRIs: venlafaxine, duloxetine Antihistamine,zolpidem,etc. Trazodone Low-doseTCA Titrate TCAs (Na+ channels and SNRI) : desipramine, nortriptyline, Adapted from Gallagher RM, Verma S. Semin Clin Neurosurgery. 2004. This information concerns uses that have not been approved by the US FDA.

  28. The Opioid Renewal Clinic: A structured approach to managing opioids for pain in primary care Wiedemer N, et al Pain Medicine 2007Bair M, Pain Medicine 2007Aberrant Behavior Categories over one year

  29. OUR CONUNDRUM Growing societal awareness of: 1. the prevalence of inadequately treated chronic pain 2. its impact on society 3. the need for access to effective pain treatment vs Growing societal awareness of: 1. The rapidly increasing rate of use of opioid prescriptions 2. The increasing rate of prescription drug abuse 3. The increasing rate of prescription drug abuse deaths

  30. Balanced Pain Policy InitiativeCenter for Practical BioethicsKansas City, MO • American Academy of Pain Medicine • American Pain Society • American Society of Addiction Medicine • DEA • FSMB • National Association of Attorneys General • Wisconsin Pain Policy Center • Wisconsin Department of Regulation & Licensing

  31. Physicians Charged with Opioid Analgesic Prescribing Offenses Goldenbaum, Donald M., Ph.D.; Christopher, Myra; Gallagher, Rollin M., M.D., M.P.H.; Fishman, Scott, M.D; Payne, Richard, M.D.; Joranson, David, MSSW; Edmondson, Drew, J.D.; McKee, Judith, J.D.; Thexton, Arthur, J.D., M.A. Author Affiliations: • Center for Practical Bioethics (Goldenbaum and Christopher) • AAPM: Philadelphia V.A. Medical Center/University of Pennsylvania (Gallagher) • AAPM: U. California, Davis (Fishman) • Duke University Divinity School (Payne) • U. Wisconsin (Joranson) • Attorney General, State of Oklahoma (Edmondson) • National Association of Attorneys General (McKee) • Wisconsin Department of Regulation & Licensing (Thexton).

  32. PRINCIPLES OF TREATMENT:Summary Primary prevention: • avoid injuries and diseases Secondary prevention: • When injuries or diseases occur, prevent or minimize nociception or neural activation of pain pathways, improve coping and adaptation, and restore and maintain function • Risk management Tertiary prevention • manage perpetuating factors, control pain and restore function and quality of life

  33. Decade of Pain Control and Research • Goals: To Promote Pain Medicine • Research • Education • Clinical Practice • Advocacy & Policy Development • How are we doing after 6 years? • A snapshot

  34. Growth in the Number of Published Articles on Pain over the Past 30 years. (Source: June 10, 2003, Pub Med search with keyword pain) Fishman S, Gallagher RM, Carr D, Sullivan: Pain Med 2004

  35. Growth in the Number of Published Articles on Nociception over the Past 30 years. (Source: June 10, 2003, Plumbed search with keyword nociception) Fishman S, Gallagher RM, Carr D, Sullivan: Pain Med 2004

  36. Growth in the Number of Published Articles related to pain over the past 3.5 years.(Source: August 2, 2004, Plumbed search with keywords: pain, neuropathic, nociception) No. Published Articles ------------------------------------------- Search 1995-99 2000-04 Term (5 years) (3.5 years) % increase Pain 59,749 72,018 > 21%Neuropathic 1,527 2,481 > 62%Nociception 831 1,220 > 47%

  37. Journal proliferation • Concomitantly rapid rise in numbers of journals devoted to pain • 2 new academic journals started in 2000 indexed recently by the National Library of Medicine for MEDLINE, Index Medicus and Pub Med. - Pain Medicine indexed 2003; Imp F. 2.477 Increased to six issues yearly in 2005 Increased to eight issues in 2007 Increase to twelve issues in 2009 - Journal of Pain indexed in 2004 • Neuromodulation, likely to follow. • Growth of review pain journals (Pain Practice, Pain Physician, J Opioid) • Multiple special supplements to other specialty society journals (Family Practice, Neurology, Psychiatry, JAMA, Internal Medicine, Neurosurgery) • Multiple sponsored articles and “throw away” journals

  38. NIH Research Initiatives • Pain is much more prominent in RFAs from several institutes. Challenge: Capps-Rogers 2007: HR 2994 “The National Pain Care Policy Act 2007” • National Cancer Institute: Challenge: Will pain and palliative care become a pre-requisite in evaluating CA clinical trials?

  39. VA-military Initiatives Senator Akaka (D-HI) introduces bill to enhance VA and military pain care and research • Promoting Improvements in Treatment of Veterans Suffering from Chronic and Acute Pain • Provide research funding for studies of pain in military and in VA • October 15, 2007

  40. Transition to Community Care: MILITARY HOSPITAL, USA MILITARY BASE CLINIC, USA Pain Medicine and Mental Health Services COMMUNITY HEALTH SYSTEM VETERANS HEALTH SYSTEM COMMUNITY SUPPORT SYSTEM

  41. SOCIETAL INTEREST • Non-profit advocacy organizations: • American Chronic Pain Association • National Pain Foundation: • www.nationalpainfoundation.org • American Pain Foundation: • www.painfoundation.org

  42. The future? • Pain Medicine as a Specialty • Standardize training • Create qualified teachers of all doctors • Medical schools • Residencies • Pain Fellowships • Promote important research • Societal Awareness for Advocacy and Policy Change • Organization of health care • Performance-based medicine • Pain Medicine and Primary Care Community Rehabilitation Model • Integrated medical record • Risk management

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