Rollin Gallagher

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Responsible Prescribing PracticesNational Rx Drug Abuse Summit 4-11-12

Text of Rollin Gallagher

Rollin Gallagher Responsible Prescribing Practices.ppt

Responsible Prescribing Practices

April 10-12, 2012 Walt Disney World Swan Resort

Rollin M. Gallagher, MD, MPH Deputy National Program Director for Pain

Management. Veterans Health Administration

Co-Chair, Workgroup on Pain Management DoD-VA Health Executive Council

Clinical Professor of Psychiatry and Anesthesiology Director of Pain Policy and Primary Care Research, Penn

Pain Medicine University of Pennsylvania

The Best Risk Management is Effective Pain Management:

The Stepped Pain Care Model in the Veterans Health System

Disclosures

Board of Directors of the American Academy of Pain Medicine

Editor-in-Chief, Pain Medicine

Board of Directors of the American Pain Foundation

Board of Directors, Audubon Pennsylvania

Learning Objectives:

1.Identify the factors contributing to the public health problem of chronic pain and prescription opioid abuse

2.Identify a population-based, patient-centered approach to managing pain in a health system and describe best practice strategies that can be used by clinicians for pain management treatment as risk management for prescription drug abuse.

To hear about pain is to have doubt;

to experience pain is to have certainty.

Elaine Scarry, The Body in Pain

What is Pain?

radiculopathy (sciatica)

There Are Many Painful Diseases and Pain Diseases

*Complex regional pain syndrome.

Nociceptive pain Caused by activity in neural pathways in

response to potentially tissue-damaging stimuli

Neuropathic pain Initiated or caused by a

primary lesion or dysfunction in the nervous system

Postoperative pain

Mechanical low back pain

Sickle cell crisis

Arthritis

Peripheral neuropathy

Postherpetic neuralgia

Diabetic neuropathy

Sports/Exercise injuries

Central post- stroke pain

Trigeminal neuralgia

Inflammatory / Immunological Mediation

MIXED PAIN STATES: cancer, low back, pelvic,

facial, crush injury, amputation CRPS*

Phantom pain

SENSITIZATION

Diagnosis (Broad ICD-9 Categories) Frequency Percent

Infectious and Parasitic Diseases (001-139) 78,869 14.0

Malignant Neoplasms (140-209) 6,816 1.2

Benign Neoplasms (210-239) 30,053 5.3 Diseases of Endocrine/Nutritional/ Metabolic Systems (240-279) 157,823 27.9

Diseases of Blood and Blood Forming Organs (280-289) 16,917 3.0

Mental Disorders (290-319) 277,112 49.0 Diseases of Nervous System/ Sense Organs (320-389)

231,524 41.0

Diseases of Circulatory System (390-459) 108,940 19.3

Disease of Respiratory System (460-519) 135,699 24.0

Disease of Digestive System (520-579) 195,631 34.6

Diseases of Genitourinary System (580-629) 73,772 13.1

Diseases of Skin (680-709) 107,616 19.1 Diseases of Musculoskeletal/Connective System(710-739) = PAIN

300,752 53.2

Symptoms, Signs and Ill Defined Conditions (780-799) 267,745 47.4

Injury/Poisonings (800-999) 149,000 26.4 Cumulative from 1st Quarter FY 2002 through 2nd Quarter FY 2010

Transition to the VHA: Frequency of Dx, OEF/OIF Veterans

Why chronic pain in OEF-OIF troops?

Wear and tear of military duty during war a) Prolonged, repeated deployments b) Osteoarthritis and spinal / limb injuries c) Post-traumatic stress

90% survival, battlefield injuries: a) Physical wounds b) Blast injuries and TBI c) Psychological wounds

Organizational issues in health care

Sarah, a 28 y/o woman reservist discharged after training camp spine and foot injury:

failed back surgery syndrome with radiculopathy (sciatica) Back and shooting leg pain on sitting or

standing > 30 minutes

CRPS foot after multiple surgeries Foot pain on weight bearing or walking Difficulty wearing shoes

finishing legal degree marital stress

Michael, 25 y/o decorated combat veteran, married, one son:

MVA multiple R leg fractures 2001 MVA 2002, concussion blast injury 2003 with shoulder dislocation,

cervical injury, brachial plexus injury Residual:

TBI with HA, cognitive impairments, seizure disorder

CRPS II R leg back, neck, shoulder pain PTSD, depression

Family stress

Courtesy of C. Buckenmaier, MD

A New Injury with an Uncertain Course

BLAST TBI

NERVE INJURY / SENSITIZATION

FEAR

COGNITIVE / BEHAVIORAL IMPAIRMENTS

PTSD

PTSD N=232 68.2% 2.9% 16.5%

42.1% 6.8%

5.3%

10.3%

12.6%

TBI N=227 66.8%

Chronic Pain

N=277 81.5%

Prevalence of Chronic Pain, PTSD and TBI in a sample of 340 OEF/OIF veterans

Lew et al., (2009). Prevalence of Chronic Pain, Posttraumatic Stress Disorder and Post-concussive Symptoms in OEF/OIF Veterans: The Polytrauma Clinical Triad. Journal of Rehabilitation Research and Development, 46, 697-702)

If you cannot control their pain, you will never be able to help them with their PTSD and depression

Congressman John Murtha, at the opening of the Acute Pain Research Unit at Walter Reed, discussing the NEJM article describing 350,000 returning troops with mental health problems:

THE CONSEQUENCE PAIN HURTS! Causalgia (CRPS 2) in artist: Injury Vietnam

Courtesy of N. Wiedemer, CRNP

Pain affects the whole person

Mismanaged chronic pain is often a personal,

biopsychosocial catastrophe! .and is a huge public health

problem.

Quality of life Physical functioning Ability to perform

activities of daily living Ability to work Pleasurable activity

Social consequences Marital/family relations Intimacy/sexual activity Social roles and

friendships

Psychological / CNS morbidity Fear, anger, suffering Sleep disorders Cognitive impairments

Medical consequences Accidents Medication side effects Immune function Clinical depression / suicide Neuroplasticity

Societal consequences Health care costs Disability, lost workdays Business failures Higher taxes

Established (by research) effects of chronic pain

Pain has an element of blank.

It knows not where it began, or

If there was a day when it was not.

It has no future but itself.

Its infinite realms contain its past,

Enlightened to perceive

new periods of pain.

Emily Dickinson

Chronification to Maldynia: The Chronic Pain Cycle (Gallagher , Pain Med 2011)

Pathology: -Muscle atrophy, weakness; -Bone loss; -Immunocompromise -Depression

Less active Kinesophobia Decreased motivation Increased isolation Role loss Sleep disorder

Disability

Pathophysiology of Maintenance: -Radiculopathy -Neuroma / traction -Myofascial sensitization -Brain, SC pathology (atrophy, reorganization)

Neuro-psychopathology of maintenance: -Encoded anxiety dysregulation - PTSD -Emotional allodynia -Mood disorder -Cognitive disorder -Substance abuse

Neurogenic Inflammation: - Glial activation - Pro-inflammatory cytokines - blood-nerve barrier dysruption

Acute injury and pain

Peripheral Sensitization: New Na+ channels cause lower threshold

Central Sensitization -Neuroplastic changes

Gallagher RM in Ebert & Kerns 2010

Key elements, continuum of pain care

Primary prevention: Avoid injury, nociception, nerve damage

Secondary prevention: Once pain starts, minimize access to the CNS concurrent augmenting factors (e.g. high stress) neuroplastic pathophysiology of the CNS

Tertiary prevention: Once chronification starts reverse its impact on quality of life by functional, emotional,

physical, and spiritual rehabilitation restore social networks (love, support, fun) provide motivation (goals) reverse neuroplastic damage

1) Growing societal expectation of pain relief: 2) Cancer pain specialists document that patients with cancer-

related pain: 3) Emphasis on short-term cost-containment in managed systems

to maximize profitability: Brief visits; Cost-shifting; Elimination of rehabilitation

4) Recognition that: CP is common, damages the nervous system, has major morbidity, and if uncontrolled pain, is a major public health problem

5) COT demonstrates efficacy / effectiveness, safety and tolerability in cross-sectional and short-term studies of patients in structured clinical and experimental settings

6) Documented dangers of alternatives: NSAIDs, Cox 2, surgery 7) Opioid efficacy in neuropathic pain conditions 8) After severe trauma, early use of opioids associated

with reduced chronicity

Over 30 years a major shift occurred in the use of opioids for chronic pain

1) Growing societal expectation of pain relief: Terminal cancer pain (Hospice movement) Pain as 5th Vital Sign in the VA health system JCAHO standards

2) Cancer pain specialists document that patients with cancer-related pain: Are under-treated When in remission from cancer, tolerate opioids

long-term without difficulty

Over 30 years a major shift occurred in the use of opioids for chronic pain

Over 30 years a major shift occurred in the use of opioids for chronic pain