INTERDISCIPLINARY PAIN MANAGEMENT & FUNCTIONAL RESTORATION

1. INTERDISCIPLINARY PAIN MANAGEMENT & FUNCTIONAL RESTORATION JAMES W. ATCHISON, DO Medical Director, Center for Pain Management Professor of PM&R Northwestern Feinberg School of Medicine

2. Disclosures Principle Investigator for RIC participation in multicenter research project for Paraxel/Pfizer. Principle Investigator for RIC participation in multicenter research project for INC/Grunenthal. Advisory Board for Mallinkrodft Advisory Board for Janssen

3. REVIEW OF CASE ISSUES • CONTINUED PAIN w/ POOR SLEEP • SPREADING PAIN PATTERN • INCREASED DEPRESSION AND ANXIETY • FAILED MULTIPLE PROCEDURES • MEDICATIONS INEFFECTIVE • LONG ACTING OPIOID – OXYCONTIN 40 MG TID • 180 MEQ MS PER DAY • SHORT ACTING OPIOID – NORCO 10/325, 8 PER DAY • 80 MEQ MS PER DAY • BENZODIAZEPINE – TID (2 AT NIGHT) • ?MUSCLE RELAXANT AND SSRI?

4. The Triad: Pain, Sleep, and Mood Pain Functional impairment Depression /anxiety Sleep disturbances

5. PSYCHOSOCIAL “Yellow Flags” New Zealand Accident Comp Corp. 1997;23-66. Cairns MC, Spine 2003; 28(9):953-59. • Expectations and pain behavior • Heightened emotional activity • Reinforcement of pain • Maladaptive beliefs • Job dissatisfaction • Poor social support • Compensation

6. PHYSICAL “Yellow Flags” INTERDISCIPLINARY FUNCTIONAL RESTORATION, FEINBERG, GATCHEL, STANOS ET AL; CH. 82 IN COMPREHENSIVE TREATMENT OF CHRONIC PAIN BY MEDICAL, INTERVENTIONAL AND INTEGRATIVE APPROACHES, DEER ET AL, 2013, AMERICAN ACADEMY OF PAIN MEDICINE Pain moves from local to regional Guarding of the injured area Fear of movement Fear of re-injury Decrease in proper movement patterns

7. MEDICATION “Yellow Flags” • Continued use of meds w/o pain reduction or improved function • Despite continuation of side effects • Beyond the natural history of recovery • Escalating doses w/o benefit • Multiple opioids • Early use of long acting opioids • Use of opioids w/ benzodiazepines • Intolerance of PT w/ medications

8. SELECTION CRITERIA • WHAT DOES A FUNCTIONAL RESTORATION PROGRAM CHANGE?

9. RIC Full Program Completers 2013 Very Much Worse No Change No Change No Change Very Much Improved

10. REVIEW OF CASE ISSUES OK THIS WORKS! HE HAS • ILL DEFINED PAIN • POOR SLEEP • DEPRESSION AND ANXIETY • FAILED PROCEDURES • INEFFECTIVE MEDICATIONS

11. COMMON RESPONSES • WHAT DO PATIENTS THINK?

12. PAIN REGIONS/AREAS ARE EXPANDING DOCTOR SAYS! GOOD NEWS, LIKELY MYOFASCIAL

13. PAIN REGIONS/AREAS ARE EXPANDING PT SAYS! “IT HURTS TOO MUCH TO BE THE MUSCLES” “SHOULDN’T WE DO ANOTHER MRI?” “WON’T SURGERY OR MORE INJECTIONS TAKE AWAY THE PAIN?”

14. FUNCTIONAL RESTORATION OR INTERDISCIPLINARY PAIN PROGRAM NEEDED NEEDED DOCTOR SAYS! GOOD NEWS, PAIN PROGRAM INCLUDEs PT, OT, BIOFEEDBACK, & PSYCHOLOGY!

15. FUNCTIONAL RESTORATION OR INTERDISCIPLINARY PAIN PROGRAM NEEDED PT SAYS! “SO YOU THINK IT IS ALL IN MY HEAD?” “I’M NOT DEPRESSED!” JUST FRUSTRATED AND/OR IRRITABLE

16. Processing of Pain in the Brain Occurs in Several Regions Somatosensory cortex Pain + emotion Pain only Insular cortex Prefrontal cortex Thalamus Hippocampus Anterior cingulate cortex Amygdala Adapted from Apkarian AV, et al. Eur J Pain. 2005;9:463-484. Image courtesy of Apollo Marcom.

17. The Triad: Pain, Sleep, and Mood Pain Functional impairment Depression /anxiety Sleep disturbances

18. FUNCTIONAL RESTORATION OR INTERDISCIPLINARY PAIN PROGRAM NEEDED MR. CARR SAYS! I HAVE TO DO THE WORK? “I’VE ALREADY DONE PT!” “MY PAIN IS NEVER GOING AWAY?

19. MEDICATIONS NEED TO BE CHANGED DOCTOR SAYS! TREAT SLEEP TCA OR TRAZODONE TREAT MOOD – SNRI DULOXETINE OR VENLEFEXINE REDUCE THE USE OF OPIOIDS

20. MEDICATIONS NEED TO BE CHANGED PT SAYS! “I NEED MORE PAIN MEDICATION” “I CAN’T DO IT WITHOUT PAIN MEDS” “IT WORKS BETTER WHEN I TAKE IT WITH THE ALPRAZOLAM”

21. DOCTOR SAYS: “YOU Can do it without opioids!” • OPIOID CESSATION AND MULTIDIMENSIONAL OUTCOMES AFTER INTERDISCIPLINARY CHRONIC PAIN TREATMENT • MURPHY ET AL, CLIN J PAIN 2013;29:109-117. • LACK OF CORRELATION BETWEEN OPIOID DOSE ADJUSTMENT AND PAIN SCORE CHANGE IN A GROUP OF CHRONIC PAIN PATIENTS • CHEN ET AL, J PAIN 2013 APR; 14(4): 384-92. • LOW PAIN INTENSITY AFTER OPIOID WITHDRAWAL AS A FIRST STEP OF A COMPREHENSIVE PAIN REHABILITATION PROGRAM PREDICTS LONG-TERM NONUSE OF OPIOD IN CHRONIC NONCANCER PAIN • KRUMOVA ET AL, CLIN J PAIN 2013; 29: 760-769.

22. OK, LET’S GET STARTED! • PROGRAM STRATEGIES • ACTIVE APPROACH • MEDICATION TAPERING OR DETOX PROGRAM

23. RIC’S CPM Program Components • Nurse Education • Physical therapy • Occupational therapy • Recreation Therapy • Psychology (CBT) • Relaxation Training • Mind Body Treatment/ Feldenkrais/ Mindfulness • Vocational Therapy

24. Phases of Treatment • Educational • Skills training • Application and relapse prevention • Individual Goal Setting • Monitor • Reassess & Readjust

25. Physical Therapy Occupational Therapy • Comprehensive assessment • “Active” instead of “Passive” • Movement based • Strengthening • Aerobic conditioning • Home exercise plan • Positioning/Posture • Pacing Techniques • Body mechanics • Stress Loading • Desensitization • Graded Motor Imagery (Left/Right discrimination; Mirror Therapy) • Graded Activity Exposure • Functional Capacity Evaluation (FCE)

26. Pain Psychology • Mind-Body Connection • Coping Skills Training • Emotion Regulation • Cognitive Restructuring • Stress Management • Mindfulness • Family Education

27. Relaxation Training/ Biofeedback • Deep Breathing • Imagery and Visualization • Progressive Muscle Relaxation (PMR) • Biofeedback

28. Full DAY Program Schedule

29. Medical Management • Team lead by a physiatrist, pain medicine specialist • Nursing monitoring and education • Inpatient or outpatient detoxification incorporated into program as needed • Medication adjustments • Sleep Assistance • Nerve Pain • Myofascial Pain

30. INITIAL MEDICATION ADJUSTMENTS • TRANSITION FROM ESCITALOPRAM TO DULOXETINE • INITIATE GABAPENTIN • ADDING NORTRIPTYLINE AT HS • ADDING CLONIDINE AT HS

31. Detox at 2 weeks • OPIOID USE AT 260 MEQ PER DAY • TOO LARGE TO TAPER IN PROGRAM • 25-33% REDUCTION WEEKLY • TRANSITION TO BUPRENORPHINE/ NALTREXONE FILMS • BEGINNING SLOW TAPER OF ALPRAZOLAM

32. Pt report at f-u visit after detox • RTC ON BUPRENORPHINE FILM AT 1 MG SL BID • REDUCTION EVERY 2-5 DAYS • 3/8 FILM BID • ¼ FILM BID • 1/8 FILM BID • DC • MOOD GOOD • SLEEP IMPROVED • PROGRAM COMPLETED

33. OUTCOMES

34. FULL DAY INTERDISCIPLINARY PROGRAM OUTCOME DATA 2013

35. All Full Program Completers 2013 Very Much Worse No Change Very Much Improved

36. Patients with WC Very Much Worse No Change Very Much Improved

37. Patients with WC versus Patients without WC Very Much Worse No Change Very Much Improved

38. AT DC TEAM CONFERENCE • PAIN 4/10; MOVEMENT MUCH BETTER • “I’M SO HAPPY TO BE OFF THE MEDS.” • “I WOKE UP” • “PAIN IS NOT GOING TO KILL ME,” • “DON’T HAVE TO HAVE DRUGS TO FIX IT!” • TEARFUL AND THANKFUL

39. INTERDISCIPLINARY PROGRAM OUTCOME DATA 2013

40. INTERDISCIPLINARY PROGRAM OUTCOME DATA 2013

41. INDIVIDUAL Results • FUNCTIONAL CAPACITY EVALUATION (FCE) • VALID • LIGHT-MEDIUM • MAXIMAL MEDICAL IMPROVEMENT

42. 4 WEEK FOLLOW-UP • AFTERCARE • HEP • CORE & PRONE EXERCISE MANEUVERS • COGNITIVE TREATMENTS • IMAGERY • DEEP BREATHING • MEDICATIONS STABLE • OFF BUPRENORPHINE AND CYMBALTA • CONTINUES GABAPENTIN AND NORTRIPTYLINE • TIZANIDINE PRN w/ FLARES • WORKING FULLTIME @ STAPLES • INCORPORATES PACING & BODY MECHANICS

43. THANK YOU!

44. Questions jatchison@ric.org