Treating Chronic Pain Evolving Models of Care MERCY PAIN CENTER - - PowerPoint PPT Presentation

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Treating Chronic Pain Evolving Models of Care MERCY PAIN CENTER - - PowerPoint PPT Presentation

Mar 01, 2023 1.3k likes •2.02k views

Treating Chronic Pain Evolving Models of Care MERCY PAIN CENTER Living Life Well Pain Rehabilitation Program Joel Guarna, Ph.D. Steve Hull, M.D. Todays Objective 1. Summarize the neurologic and immune system underpinnings of chronic pain

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MERCY PAIN CENTER

Living Life Well Pain Rehabilitation Program

Joel Guarna, Ph.D. Steve Hull, M.D.

Treating Chronic Pain Evolving Models of Care

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Today’s Objective

  • 1. Summarize the neurologic and immune system underpinnings of

chronic pain and how this relates to the “hurt vs. harm” paradigm.

  • 2. Summarize the current evidence regarding chronic opioid use for

patients with non-cancer pain and how this relates to new laws (Maine Public Law Chapter 488) that restrict opioid prescribing for this population.

  • 3. Identify behavioral strategies and techniques from your current

repertoire that can be readily adapted to work with chronic pain patient.

  • 4. Summarize a “template for recovery” for chronic pain patients

that emphasizes behavioral and psychological change.

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Overview of Today’s Program

8:45-9:15 Overview and Introduction to Models of Care. 9:15-10:15 The Five Phases of the Matrix 10:15-10:30 Break 10:30-11:00 The Five Phases of the Matrix 11:00-12:00 The Neurophysiology of Pain 12:00-1:30 Lunch, Maine Psychological Association Business Meeting and Psychologically Healthy Workplace Awards 1:30-2:00 The Immunology of Pain 2:00-3:00 Connecting Models and Phases Psych Skills 3:00-3:15 Break 3:15-3:45 Connecting Models and Phases to Psych Skills 3:45-4:30 Opioids (And Other Medications) Changing Models, New Laws 4:30-4:45 Q & A

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What is Pain?

International Association for the Study of Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

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The Problem of Chronic Pain

2012 National Health Interview Survey 25 million reported chronic daily pain 23 million reported severe pain Utilize more healthcare services Suffer greater disability Costs the US $635 billion

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With Persistent Pain

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With Chronic Pain Rehabilitation

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Treatment goals

Symptom reduction Biologic model of pain Restoration of function Bio-psycho-social model of pain Multidisciplinary

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Disillusionment

  • Multiple specialties
  • Over reliance on interventions and opioids

Mercy’s Pain Management Evolution

Living Life Well Pain Rehabilitation Program

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Education CDC/FDA opioid conference Road Trip Cleveland Clinic Dartmouth Hitchcock Mayo Clinic Bath Centre for Pain Services Togus VA

Mercy’s Pain Management Evolution

Living Life Well Pain Rehabilitation Program

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Discouragement “Too small” MaineCare limits (Insurance) Limited behavioral health availability

Mercy’s Pain Management Evolution

Living Life Well Pain Rehabilitation Program

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Mercy’s Pain Management Evolution

Living Life Well Pain Rehabilitation Program

Resources Kevin Vowles, Ph.D.

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Butler & Moseley Resources Kevin Vowles, Ph.D.

Mercy’s Pain Management Evolution

Living Life Well Pain Rehabilitation Program

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A Work in Progress Three years and counting Initially class admission Lock step medical management withdrawal Addition of Joel Move to rolling admissions

Mercy’s Pain Management Evolution

Living Life Well Pain Rehabilitation Program

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Critical components Group Therapy Education CBT Graded Exercise Family/Community Alumni Group

Mercy’s Pain Management Evolution

Living Life Well Pain Rehabilitation Program

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Admission Criteria

Mercy’s Pain Management Evolution

Living Life Well Pain Rehabilitation Program

(Exclusion Criteria) Inability to participate in group Language barrier Inability to exercise because of comorbidity

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Resources Physician Champion Psychologist Physical Therapist Support Staff Space for CBT and Exercise Scalable

Mercy’s Pain Management Evolution

Living Life Well Pain Rehabilitation Program

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Resources Prescribing Clinician Behavioral Health Provider Exercise Director Support Staff Space for CBT and Exercise Cost = $5,000 - $7,000 for 25 sessions

Mercy’s Pain Management Evolution

Living Life Well Pain Rehabilitation Program

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Outcomes Pain in the last week 13% better ........................................................ PHQ-9 6% better ................................................................................... GAD-7 1% worse ..................................................................................... Functional reach 27% better ............................................................... Sit-to-stand 48% better ...................................................................... Six minute walk 21% better ................................................................. Pegboard reach 44% better ................................................................ Activity engagement 46% better ....................................................... Pain willingness 97% better .................................................................

Mercy’s Pain Management Evolution

Living Life Well Pain Rehabilitation Program

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Pain Neuro-physiology

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What’s Pain For?

  • Warn us of an injury
  • Prevent an injury
  • Hasten healing
  • Prevent worsening
  • SURVIVAL
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Tissue damage is neither sufficient nor necessary to experience pain.

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Couvade’ s Syndrome

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No pain nerves No pain system

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Neuron Primer

Resting Potential Graded Stimulation Threshold Stimulation Action Potential Refractory Period

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Toilets ≈ Neurons

Resting Potential = Tank full of water Graded Stimulation = giggle the handle Threshold Stimulation = Full handle push Action Potential = Waste sent down pipe Refractory Period = Tank filling

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Synaptic Transmission

Action Potential Arrives Packets of Neurotransmitters Released Neurotransmitters Diffuse Across Cleft Post-synaptic Membrane is Stimulated Neurotransmitter Reuptake of Disposal

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WARNING!

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NEUROTAG

If the brain thinks you are under threat, the output is pain. If it doesn’ t think you are under threat, there will be no pain. 100% of the time.

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What is Pain?

International Association for the Study of Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage

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What is Pain?

Pain is the end result of the brain interpreting information from inside the body AND from the outside world as threat, a very motivating

  • utput of the brain designed to protect you.
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When Pain Less Associated With the Tissues

Hurt ≠ Harm

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If Hurt ≠ Harm, Avoiding Hurt = Harm

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Is it hurt

  • r

is it harm?

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Nociception ≠ Pain

When tissue injury has healed nociception can be unreliable

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Modes of Pain

Control Mode Suppression Mode Sensitization Mode

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Sensitization

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Sensitization

Central Sensitization

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The brain is amazing

Brain cells use 26 different ways to code its “bits”, not the 0’s and 1’s of computers. Its 100 billion neurons, are each able to make thousands of connections in the brain. It is estimated that the brain can hold in its memory as much as the entire internet,

  • r 100 times the data in the 19 million volumes of the US Library of Congress.
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Sensitization

Central Sensitization Facilitation Disinhibition (imprecision)

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Sensitization

Central Sensitization Facilitation Disinhibition (imprecision) Immune system mediation

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Chronic Pain as Gliopathy

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Sensitization

Peripheral Sensitization Spinal synaptic facilitation Peripheral nociceptor proliferaton Immune system mediation Endocrine system mediated

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Modulators of Pain

100% of the time, no exceptions, pain is an an output of the brain that occurs when it interprets information from inside the body AND from the outside world as threat, a very, perhaps the strongest, motivating

  • utput of the brain designed to protect you.
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Modulators of Pain

Nociceptive activity Change in activity Change in mood Change in weather Change in health (endocrine and immune) Beliefs, knowledge, social context, culture, meaning and expectations Triggering of the Pain Neurotag

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Neurotags

A pattern of neuron activation which creates a certain output of the brain, such as a perception, thought, movement, endocrine or immune system response.

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Neurotags

Each of the “member cells”

  • f a particular neurotag are

also “member cells” of other neurotags.

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Cortical Body Matrix

A dynamic neural representation that extends beyond the body surface to integrate both body- centered spatial and somatosensory data and peripersonal sensory data and then integrates this efferent input with knowledge, beliefs and meaning to produce afferent cognitive, emotional, motor and homeostatic outputs.

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Cortical Body Matrix

This construct could help to explain experimental and clinical observations of multiple system disruptions experienced by chronic pain patients and in patients struggling with other conditions, including mental illnesses, for instance schizophrenia.

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Imprecision within cortical body matrix – multiple system dysfunction

Motor Tactile Ownership Perceived size Blood flow Inflammation Meaning Pain

From Explain Pain by Butler and Moseley

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Cortical Body Matrix

Intriguing observations: Body distortions Magnification illusions Mirage box Hemineglect Dysfunction in the space occupied by a body part

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Therapeutic Targets

100% of the time, no exceptions, pain is an an

  • utput of the brain that occurs when it

interprets information from inside the body AND from the outside world as threat, a very, perhaps the strongest, motivating output of the brain designed to protect you.

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Therapeutic Targets

Understanding Pain

  • 1. Metaphors provide non-threatening evidence against

the stories patients carry.

  • 2. Knowledge decreases catastrophizing, pain and

disability.

  • 3. Knowledge increases participation in the next

treatment.

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Therapeutic Targets

Understanding Pain Identify and Defuse All Threats Nociceptive activity Change in activity Change in mood Change in weather Change in health (inflammation) Beliefs, knowledge, social context, culture, meaning and expectations Triggering of the Pain Neurotag

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Therapeutic Targets

Understanding Pain Identify and Defuse All Threats Normalize the Cortical Matrix (A future development)

  • 1. Graded motor imagery
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Nociception Reduction

Surgery Injections Manipulative Interventions Physical Therapy Complementary Medicine Treatments Life Style Changes Medication

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Nociception Reduction

From Explain Pain by Butler and Moseley

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Medications

Opioids (Public Law Chapter 488) Antiepileptics Antidepressants Prostaglandin Inhibitors Muscle Relaxants Topical Analgesics Counter Irritant Therapy

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Opioids (Chapter 488)

Background (Messaging) Provisions Prescription Monitoring Program Mandatory Continuing Education Mandatory Electronic Prescribing Strict Limits on Dose and Duration of Prescriptions Unintended Consequences