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Alchemy: Allopathy to Repatriation

Palmer MacKie

Integrative Pain Program

Eskenazi Health

Dept. of Medicine, IUSOM

Objectives

1. View Pain as complex social entity, not nociception

2. Identify and address the 3 pain domains

3. Polymodal Therapy is optimal:

– Education(mind), participation(body),creative(spirit)

4. Yoga, CBT, Hypnosis, Acupuncture and oral CAM all

have evidence and their place but nothing trumps….

5. Therapeutic Relationship allows:

– Education, expectation and engagement

What is Pain?

• A complex experience embracing physical,

mental, social, and behavioral processes,

compromising the life of many individuals.

SSI Commission For Evaluation of Pain

Willing, motivated Partner

Clin J Pain Vol. 24, No.4, May 2008

Accept reports

of pain with

belief and

compassion.

Then find the

meaning(s).

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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.

NeuroImage 23 (2004) 392–401

Sensory

Evaluative Affective

Components of Persistent Pain Break this Cycle

“I feel like my son spent his first year of

life in his crib in a darkened room”

• TM a 41 “married mother” of two with debilitating

headaches. Onset at 26 and worse after children…

• Quit work as photographer, quit hobbies, etc…

• Headache calendar = 25 days per month

• Had seen a number of doctors with marginal successes

• Opioids, TADs, beta-blockers, Bio-feedback

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Be occupied, then, with what you really value and

let the thief take something else

Rumi

That’s out of my price range. Do you have

anything that’s free?”

Sensory

Evaluative Affective

Components Pain Treatment

Control not Cure

Treatment Options

• EDUCATION

• Progressive Exercise

– Aerobic

– Strength

– Range of motion

• Rehabilitation Medicine

• Massage

• Acupuncture

• Psychological

• Heat, TENS, ice

• Co-analgesics

• Relaxation Response

• C B T & Mindfulness

• Non-opioid medicine

• Chiropractic

• Cranio-sacral

• Nutrition

• Yoga /Tai Chi/Qi qong

• Hypnosis / biofeedback

• EDUCATION

Only need to exercise on days you eat

Breaking the Cycle Lumbar instrumented fusion compared with cognitive

intervention and exercises in patients with chronic back pain

A 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

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Spinal fusion vs. Comprehensive Program

• Randomized and controlled, N=349

• 24 mo f/u: Oswestry and SF-36 (short)

• Both groups improved

• surgery not superior to CPP

• Cost analysis

• Surgery $14,400

• CPP $8,323

Is Acupuncture a Punitive Placebo?

Brinkhaus, B. et al. Arch Intern Med 2006;166:450-457.

Low back pain in the 3 treatment groups

NeuroImage 47 (2009) 1077–1085

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Acupuncture, Fibromyalgia and Brain

• Those receiving true acupuncture had

– Short-term increase in mor binding potential (BP)

• Cingulate, insula, thalamus, caudate, amygdala

– Long-term increase in mor binding

• Cingulate cortex, and amygdala

– Long-term increase in mor BP was associated with

greater pain reductions

• Those receiving sham acupuncture had

– No long term increase in mor BP and little analgesia

Improvement in function and pain compared with

credible sham Ann. Intern Med. 2004;141:901-910

Compared with a sham control, acupuncture provided

clinically irrelevant short-term improvements in pain

Ann Intern Med. 2007;146:868-877.(Meta-analysis)

0

2

4

6

8

10

12

14

Wk

4 P

Wk

4 F

Wk

8 P

Wk

8 F

Wk

14 P

Wk

14 F

Wk

26 P

Wk

26 F

Verum Acu

Sham Acu

PAIN 147 (2009) 60–66

Sham Lacked Efficacy?

GERAC

Chronic LBP

Haake, M. et al. Arch Intern Med 2007;167:1892-1898

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Musculoskeletal Pain:

Sham vs. Verum Acupuncture

Linde et al Arch Intern Med 2012

Acupuncture: What’s the Point?

• Study data & practices too heterogeneous

• Analgesia consistent in short-term

– Electroacupuncture > manual

– 25 – 30 min.

– 3 – 5 treatments over 14 – 21 days

– Often better than conventional care

• Specific and nonspecific effects

– Amygdala, insula and hypothalamus

– Dorsolateral Prefrontal and ACC

– Expectation influences effect

– Genetic component: “responders”

Acupuncture Safety

• Relative Contraindications

– Pacemaker

– Emphysema

– Coagulopathy/Coumadin

• Side-effects

– PnTx, infection, needle shock,

– cardiac tamponade, pain, hematoma

– symptom aggravation , forgotten needle

Mind-Body Therapies for

Common Conditions

Condition % who used

in the last

year

% who found

MBT “very

helpful”

Est. of folk

using MBT

Anxiety 34 47 6.3

Depression 26.5 29.3 3.8

Ch. Pain 19.5 55 3.2

Headache 18.5 40.7 2.8

Back/neck 18 40.3 11.2

Trends in Cognitive Sciences. 8(5):193-4, 2004

“The human reward system has been shown to be

activated by a wide range of reinforcers, including food,

money, sex, drugs, and beauty. Now, a recent fMRI

study has found mesolimbic reward activation

associated with humorous cartoons, providing a

neurobiological link between theories of humour and

hedonic processes in the brain.”

Anatomy of an Illness

A cheerful heart doeth good like a medicine l

Proverbs 17:22

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Effect of Depression on Pain:

1. Magnifies medical/somatic symptoms

• Increases pain intensity and disability

• 40 % Symptom related visits are for Pain

• Depression co-morbid with Pain 30-50 %

2. Elevation of Cost

• Increases treatment non-adherence

• Increases medical utilization

3. Diminishes treatment success for both

• less symptom reduction / worse outcomes

• Less satisfaction & meaningful recovery

Diagnose & treat depression early & aggressively

Stepped Care for Affective disorders and

Musculoskeletal Pain (SCAMP)

• 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

JAMA 2009;301(20):2099-2110

SCAMP results

1. > 50 % reduction in depression

– 37% vs. 16% RR 2.3

2. > 30% reduction in pain

– 41% vs. 17% RR 2.4

3. Global Improvement in Pain

– 47% vs. 12% RR 3.7

4. Double success: Depression and Pain

– 26% vs. 8% RR 3.3

Hypnosis

• Neurophysiologic imaging and pain tested

• Thalamus, Anterior Cingulate Cortex, SI,

Prefrontal Cortex

• Not for everyone, requires practice, effect size

often not huge.

• Pain ( interference, unpleasantness & intensity)

sleep, psychological metrics improvements

• Empowering, portable & possible targeting

PAIN 146 (2009) 235–237

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We are what we think. All that we are arises with our

thoughts. With our thoughts, we make the world 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

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

Oral CAM & Headaches:

What one’s have evidence?

1. Magnesium

2. Butterbur (P. hybridus)

3. Feverfew (T. pathenium)

4. Co-Enz Q10

5. Chondroitin

6. Riboflavin

Headache Prevention: Where’s the Beef?

• 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

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:

– Both IENFDs increased, proximal more

– Change in proximal correlated with lower

neuropathic pain and sural sensory amplitude

Diabetic Care 2012

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Glucosamine

RCT Glucosamine, Chondroitin and Celebrex,

N 1229 mild & 354 severe knee OA

• Primary outcome 20% decrease in pain

• Glucosamine 3.9 % > placebo

• Chondroitin 5.3

• Glucos.+ Chond. 6.5

• Celebrex 10

• Subgroup analysis: Combination may have worked in Mod.-Severe OA 25% (P=0.002)

NEJM Feb. 2006

Glucosamine and Chondroitn

JOURNAL OF ORTHOPAEDIC RESEARCH MAY 2012

Glucosamine Supplements as a Possible

Ocular Hypertensive Agent What is he treating? Preventing?

What is he treating? Preventing?

• Treating alopecia

• Preventing …promotion

• Making Wishard’s food palatable

• All of the above

• Why might medicine be going to Pot?

High Hopes

Medical Marijuana

• Neuropathic pain

• Glaucoma

• Nausea and low appetite

• Diabetes prevention

– Lower waist circumference

– Lower fasting insulin levels

– Lower insulin resistance

– Lower BMI

American J. of Medicine 2013Vol.126

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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

Integrative Pain Program

7-Week Pain School

• Pain Education

• Establish community

• Expectations

• Exercise

• Relaxation response

• Sleep Education

• Mindfulness

• Goal setting

• CBT

• Nutrition/Life Style

• Making a change

• Peer Advocates

Integrative Pain Program

Pain School

% change in measure 10/12 1/13 3/13

• 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

Pain Care Paradox

Standard Approach, Individual Treatment

1) Tincture of Time

2) Informed and Involved

3) Polymodal diagnosis & treatment

4) Community: More than Par-a-docs

5) Improved outcomes

6) Fewer adverse events

“The world is full of

suffering…

It’s also full of

overcoming it”

Helen Keller

The End

Thank you

pmackie@iu.edu

Pager 312-1667

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Neuroscience Letters 520 (2012) 156– 164