Is Persistent (Chronic) Pain a Preventable Disease

Ruben Halperin, MD MPHMay 31, 2014

Conflict of Interest DisclosureRuben Halperin, MD MPH

Has no real or apparent conflicts of interest to report.

Objectives

• Understand the:– Current paradigm for treatment of persistent pain– New biopsychosocial paradigm for evaluation and

treatment and maybe predicting and preventing persistent pain

– Risks and benefits of opioid treatment• Public health & individual health

Chronic Pain Treatment? How Did We Get Here?

The Old Cartesian Model

Risks vs. Benefits

Public Health Individual Health

What do we know about the risks and benefits of chronic opioids?

Risk vs. Benefit

What is the benefit we are seeking?– Better function?– Decreased suffering?– Improved Quality of

Life?

What risks are we willing to take?

?

100,000,000 people in the US have Chronic pain. An effective treatment might be worth some risk. . . . . .if that treatment worked

Risks of Opioids to Individuals are Well Known

• Dependence• Addiction• Overdose death• Ventilatory Impairment/ Central sleep apnea• Narcotic Bowel Syndrome• Opioid endocrinopathy• Opioid induced hyperalgesia

A 30 Year Public Health Experiment

Death is Not the Only Issue

2010 Cost of Non-Medical Use of Opioids

Do Opioids Improve Function, Decrease Suffering and Improve Quality of Life?

“Ask your doctor if taking a pill to solve all your problems is right for you.”

Danish Epidemiologic StudyN=1906 : opioid users vs. matched controls

• Opioid use significantly associated with physical activities levels of employment self-rated health self-rated QOL by SF-36

self-reported severe pain

Eriksen et al. Pain 2003

Kaiser NW Study

Longer duration of opioid use associated with:DepressionAnxietyPTSDSubstance AbuseSedative-hypnotic useEscalating doses of opioids

Deyo et al. JABFM 2011

CONsortium to Study Opioid Risks and TrendsGroup Health + KP Northern CA

For > 100 mg HR 8.87 (3.99 – 19.72) for all overdose events

VA/Univ. of MichiganOpioid Prescribing and Overdose

Cochrane review 2013

• 31 studies, 1237 subjects, – 10 different opioids

• Short term studies:– lasting up to 1 day

• Intermediate studies – – Up to 12 weeks– Median 28 days ( 8 – 70)

• 1˚ Outcome ≥ 30 or ≥ 50%↓ pain from baseline

• Short term – no difference• Intermediate term– Opioids better than

placebo for pain reduction ≥ 30% and 50%

– No difference in physical functioning

Efficacy of Opioid Withdrawal + Pain Rehabilitation

Mayo Clinic N = 373• 213 taking opioids, 160 not taking– Mean pain duration 9.4 years

• 3 week intensive outpatient interdisciplinary program + opioid withdrawal

• Follow-up post treatment and at 6 months

Townsend et al. Pain 2008

Outcome variable Pretreatment Posttreatment 6 months

Opioids No opioids

Opioids No opioids

Opioids No opioids

Mean (SD)

Depression* 29.3 (12.4)

24.8 (12.5)

16.3 (11.7)

14.7 (10.7)

17.8 (13.4)

16.9 (11.6)

Catastrophizing* 28.3(11.5)

25.3 (13.1)

12.9 (11.0)

12.1 (12.3)

13.9 (11.4)

13.1 (11.2)

Pain severity* 49.3 (8.6)

46.2 (10.3)

40.0 (12.9)

37.2 (13.8)

39.1 (14.5)

38.2 (14.7)

Activity level* 52.0 (8.9)

52.7 (9.5)

58.4 (10.3)

57.9 (9.9)

58.2 (10.6)

57.7 (10.5)

Health perception* 34.8

(12.7)36.5 (12.7)

42.4 (12.7)

43.0 (11.6)

41.3 (12.3)

39.7 (12.9)

Physicalfunctioning*

28.2 (13.9)

30.4 (14.9)

39.7 (12.2)

41.2 (12.3)

37.8 (13.6)

38.9 (14.7)

*p<00.1 pre to post treatment

It’s Time to Move Beyond Opioids

Infinity

Opioids

A New Paradigm

If opioids aren’t the answer, then what?

PAIN IS AN OUTPUT FROM THE BRAIN

ALL PAIN IS REAL PAIN

PAIN ≠ HARM

TISSUE DAMAGE (nociception) IS NEITHER NECESSARY NOR SUFFICIENT FOR PAIN

Fear Avoidance Model

Vlaeyen (2000)

Sympathetic Tone, Cortisol

Catastrophizing

The Keele STarT Back Screening Tool Agree Disagree

1My back pain has spread down my leg(s) at some time in the last 2 weeks □ □

2 I have had pain in the shoulder or neck at some time in the last 2 weeks □ □

3 I have only walked short distances because of my back pain □ □

4In the last 2 weeks, I have dressed more slowly than usual because of back pain

□ □

5It’s not really safe for a person with a condition like mine to be physically active

□ □

6 Worrying thoughts have been going through my mind a lot of the time □ □

7I feel that my back pain is terrible and it’s never going to get any better □ □

8 In general I have not enjoyed all the things I used to enjoy □ □

9 Overall, how bothersome has your back pain been in the last 2 weeks?

not at all slightly moderately very much extremely

© Keele University 01/08/07

Total score (all 9): __________________ Sub Score (Q5-9):______________

Pain Catastrophizing Scale PCS

Total _______

PCS Implications

• 30 is 75th percentile - normal distribution sample of injured workers in Nova Scotia who filed work-comp claim

• At a score > 30– 70% remain unemployed one year post injury– 70% describe themselves as totally disabled– 66% scored > 16 on Beck Depression Index

(moderate depression)

Fear and Catastrophizing in the Development of Persistent Pain

• Self-Perceived disability, but not pain intensity at 2 months predicts disability at 6 and 12 months1

• Psychological factors and opioid use predict disability 2 mos. after skeletal trauma2

• Catastrophizing was the sole independent predictor of disability at 5-8 mos.2

• Severity of injury and extent of surgery did not predict disability at 2 mos. Or 5-8 mos. 2

1 Epping-jordan et al. Health Psych 19982 Vranceau AM et al. J Bone Joint Surg Am. 2014 Feb

Catastrophizing

Pain Catastrophizing associated withPain intensityPain related activity interferenceDisabilityDepressionAlterations in social support networks

Severeijns et al Clinical J Pain, 2001

Catastrophizing Predicts Poor Surgical Outcomes

Pre- TKA, ↑ catastrophizing associated with: post- op pain rating1,2,3 increased disability1,2,3

increased opioid usage2

increased length of hospital stay3

1Riddle D et al. Clin Orthop Relat Res. Mar 20102Forsythe ME et al. Pain Res Manag. Jul-Aug 20083 Vitvwrow E et al. Knee Surg Sports Traumatol Arthrosc 2009

Changing Beliefs Changes Function

• 141 patients, 3 week multidisciplinary pain treatment (UW)↓ catastrophizing, ↓ belief that pain = harm, ↓belief that one is disabled

self-report disability, pain intensity depression

Jensen MP et al. Pain 2001Jensen MP et al. Pain 2007

Catastrophizing and fear avoidance can be treated

• Engaged, activated patient• Multidisciplinary team • Behavioral health intervention• Pain education / cognitive change of faulty

beliefs• Return to activity/pacing• Self-management/self-soothing techniques

More Importantly

• Identifying Catastrophizing and Fear early can help us predict who is at risk for developing persistent pain

Questions?