Treating Chronic Pain Evolving Models of Care MERCY PAIN CENTER Living Life Well Pain Rehabilitation Program Joel Guarna, Ph.D. Steve Hull, M.D.
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.
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 Lunch, Maine Psychological Association Business Meeting and 12:00-1:30 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
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.
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
With Persistent Pain
With Chronic Pain Rehabilitation
Treatment goals Symptom reduction Biologic model of pain Restoration of function Bio-psycho-social model of pain Multidisciplinary
Mercy’s Pain Management Evolution Living Life Well Pain Rehabilitation Program Disillusionment • Multiple specialties • Over reliance on interventions and opioids
Mercy’s Pain Management Evolution Living Life Well Pain Rehabilitation Program 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 Discouragement “Too small” MaineCare limits (Insurance) Limited behavioral health availability
Mercy’s Pain Management Evolution Living Life Well Pain Rehabilitation Program Resources Kevin Vowles, Ph.D.
Mercy’s Pain Management Evolution Living Life Well Pain Rehabilitation Program Resources Kevin Vowles, Ph.D. Butler & Moseley
Mercy’s Pain Management Evolution Living Life Well Pain Rehabilitation Program 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 Critical components Group Therapy Education CBT Graded Exercise Family/Community Alumni Group
Mercy’s Pain Management Evolution Living Life Well Pain Rehabilitation Program Admission Criteria (Exclusion Criteria) Inability to participate in group Language barrier Inability to exercise because of comorbidity
Mercy’s Pain Management Evolution Living Life Well Pain Rehabilitation Program 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 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 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
Pain Neuro-physiology
What’s Pain For? • Warn us of an injury • Prevent an injury • Hasten healing • Prevent worsening • SURVIVAL
Tissue damage is neither sufficient nor necessary to experience pain.
Couvade’ s Syndrome
No pain nerves No pain system
Neuron Primer Resting Potential Graded Stimulation Threshold Stimulation Action Potential Refractory Period
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
Synaptic Transmission Action Potential Arrives Packets of Neurotransmitters Released Neurotransmitters Diffuse Across Cleft Post-synaptic Membrane is Stimulated Neurotransmitter Reuptake of Disposal
WARNING!
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.
What is Pain? International Association for the Study of Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage
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 output of the brain designed to protect you.
When Pain Less Associated With the Tissues Hurt ≠ Harm
If Hurt ≠ Harm, Avoiding Hurt = Harm
Is it hurt or is it harm?
Nociception ≠ Pain When tissue injury has healed nociception can be unreliable
Modes of Pain Control Mode Suppression Mode Sensitization Mode
Sensitization
Sensitization Central Sensitization
The brain is amazing Brain cells use 26 di ff erent 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, or 100 times the data in the 19 million volumes of the US Library of Congress.
Sensitization Central Sensitization Facilitation Disinhibition (imprecision)
Sensitization Central Sensitization Facilitation Disinhibition (imprecision) Immune system mediation
Chronic Pain as Gliopathy
Sensitization Peripheral Sensitization Spinal synaptic facilitation Peripheral nociceptor proliferaton Immune system mediation Endocrine system mediated
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 output of the brain designed to protect you.
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
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.
Neurotags Each of the “member cells” of a particular neurotag are also “member cells” of other neurotags.
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.
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.
Imprecision within cortical body matrix – multiple system dysfunction Blood flow Perceived size Pain Motor Inflammation Tactile Meaning Ownership From Explain Pain by Butler and Moseley
Recommend
More recommend
