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Integrative Pain Care: focus on non-opioid modalities

Integrative Pain Care: focus on non-opioid modalities. Palmer MacKie Integrative Pain Program Eskenazi Health Dept. of Medicine, IUSOM. I wish I could show you, when you are lonely or in darkness, the astonishing light of your own being Hafiz. Objectives.

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Integrative Pain Care: focus on non-opioid modalities

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  1. Integrative Pain Care:focus on non-opioid modalities Palmer MacKie Integrative Pain Program Eskenazi Health Dept. of Medicine, IUSOM

  2. I wish I could show you, when you are lonely or in darkness, the astonishing light of your own beingHafiz

  3. Objectives • View Pain care as social not simply a clinical entity • Identify and address all three domains of Pain • Polymodal Therapy is optimal: • Education(mind), participation(body),creative(spirit) • Yoga, CBT, Hypnosis, Acupuncture and oral CAM all have evidence and their place but nothing trumps…. • Therapeutic Relationship allows: • Education, expectation and engagement

  4. Philosophy and Goals Pain is unavoidable, suffering is modifiable • Primary Goals are Two: • Reduce pain and suffering • Increase functioning • Employ poly-modal approach • Feelings, beliefs, thoughts and actions • We possess ability to use these to create negative feedback loops that entrench pain and suffering. Thankfully, the reverse is true.

  5. Willing, motivated Partner Clin J Pain Vol. 24, No.4, May 2008

  6. Sensory Affective Evaluative Components of Persistent Pain Control not Cure

  7. EDUCATION Progressive Exercise Aerobic Strength Range of motion Rehabilitation Medicine Massage Acupuncture Psychological Heat, TENS, ice Co-analgesics Relaxation Response C B T Non-opioid medicine Chiropractic Cranio-sacral Nutrition Yoga /Tai Chi/Qi qong Hypnosis / biofeedback Mindfulness Meditation EDUCATION Treatment Options Only need to exercise on days you eat

  8. NeuroImage 23 (2004) 392–401

  9. Lumbar instrumented fusion compared with cognitiveintervention and exercises in patients with chronic back painA prospective randomized controlled study • For patients with chronic low back pain after previous surgery for disc herniation • The success rate was 50% in the fusion group and 48% in the cognitive intervention/exercise group • lumbar fusion failed to show any benefit over cognitive intervention and exercises. J.I. Brox et al. Pain 122 (2006) 145–155

  10. Stepped Care for Affective disorders and Musculoskeletal Pain (SCAMP) JAMA 2009;301(20):2099-2110 • Randomized Controlled Trial • Intervention : 12 wk plus 12 wk • Optimize depression then 6 Pain self-management • Outcomes: determined at 12 months • Hopkins Symptom Check list-20 • Pain Severity • Global Improvement in Pain • Pain Interference

  11. SCAMP results • > 50 % reduction in depression • 37% vs. 16% RR 2.3 • > 30% reduction in pain • 41% vs. 17% RR 2.4 • Global Improvement in Pain • 47% vs. 12% RR 3.7 • Double success: Depression and Pain • 26% vs. 8% RR 3.3

  12. Life-style and pre-diabetic Neuropathy • 12 month intervention with N=32 • Intraepidermal nerve fiber density (IENFD) • Proximal and Distal • Michigan Diabetic Neuropathy score • Results: • IENFD both increased • Change in proximal correlated with lower neuropathic pain and sural sensory amplitude Diabetic Care 2012

  13. Knee OA and Acupuncture Ann. Intern Med. 2004;141:901-910

  14. GERAC Chronic LBP Arch Intern Med 2007;167

  15. Hypnosis Pain 146(2009)235-237

  16. Fibromyalgia: Behavioral Therapy Cognitive BT Alter negative feelings, beliefs from dysfunctional thinking Identify harmful/incorrect thoughts disrupting progress Connect these with negative consequences Provide alternative coping and action strategies Internal nidus of control for helplessness Cognitive BT 6-24 months 50 % reduction in 40-55 % in study Responders: affective distress, low adaptive coping, less catastrophizing, low pain behaviors Cut MD visits, Hospital days, lowers cost Dose response 4 trials showed no response Current Rheumatology Reports 2009, 11:443–450

  17. Yoga Interventions: Pain and Disability • Meta-analysis • 12 randomized and 4 nonrandomized trials • 6 trials for back pain • 2 trials for headache/migraine • Studies reported positive effect sizes • SMD for Pain -.74 • SMD Overall Treatment -.79 Journal of Pain, 2012 Vol 13, No 1 : pp 1-9

  18. Migraine Prevention • Magnesium • B2/ riboflavin • Butterbur • Feverfew • CoE Q10 • Acupuncture • Bio-feedback • Trigger Avoidances • Clin J Pain Volume 25, Number 5, June 2009 • Cochrane Database of Systematic Reviews. (1):CD007587, 2009. • Acupuncture for migraine prophylaxis: update of Cochrane Database Syst Rev

  19. “I’m investing less than 7 hours a month on headache prevention and getting next to no headaches”

  20. “The world is full of suffering…Its also full of overcoming it”Helen Keller

  21. Pain Care Paradox Standard Approach, Individual Treatment • Tincture of Time • Informed and Involved • Polymodal diagnosis & treatment • Community: More than Par-a-docs • Improved outcomes • Fewer adverse events

  22. Integrative Pain ProgramPain School % change in measure10/12 1/133/13 • Fatigue - 28 -17 -24 • Pain -13 -14 -14 • Aerobic exercise >100 >100 >100 • Pain interfering -22 -46 -27 • Emotions interfering -22 -36 -28 • Non-Rx to control Sxs 31 13 24

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