Multidisciplinary Approach to Pain ManagementSarah Endrizzi, MDAdvanced Pain ManagementMedical College of Wisconsin
Objectives• Epidemiology of chronic pain• Pain as a disease• What is multidisciplinary pain management
(MDPM)• Discuss goals of MDPM• Treatment modalities
▫Medications▫Interventions▫Pain psychology▫PT/OT▫Complimentary and alternative medicine
So why are you here?• Primary care MD/NPs are the predominant
providers managing pain in the US▫ Little previous teaching
Medical students receive on average <10 hours on pain physiology, neuroanatomy, physiology, diagnosis, management and treatment (Mezei et al, 2011)
Medical students receive on average 1 hr of education on analgesics (Institute of Medicine Report, 2011)
Housestaff education in pain management is not substantially better (Ogle et al, 2008)
2013 Hurley©
Pain Epidemiology and Impact•100 million adults in the US with chronic
pain(Medical expediture panel, 2008)
•#1 cause for disability•Patients with pain cost ~$4,500/year
more than match no pain controls(Iom, 2011)
▫Direct medical costs - $293,000,000,000▫Back Pain was 72% of these costs▫Approximately 150 million work days lost
per year because of back pain
Comparison to Other Diseases•Direct and Indirect Costs in Billions(IOM, 2011)
▫Pain - $635▫Cardiovascular – $309 ▫Cancer - $243▫Trauma/Poisoning - $209▫Endocrine/metabolic - $127▫Digestive System - $112▫Respiratory System - $112
Why is proper evaluation and treatment of chronic pain important?•Chronic pain itself is a disease
▫Anatomical changes▫Physiological changes▫Pharmacological changes▫Psychological changes▫Altered responsiveness to medications
Chronic Pain State•Cortical thinning in CLBP compared to
controls
•Reversal of cortical thinning with treatment of pain
•Reversal of cortical thinning with treatment
Seminowizc, 2011, J Neurosci
Central Pain Disorders•Fibromyalgia•Post-stroke pain•Headache (tension>migraine)•Chronic pelvic Pain•Chronic Low Back Pain•Myofascial Pain/Widespread Chronic Pain•TMJD•Interstitial Cystitis
Phillips & Clauw. 2011
Development of chronic pain
•Pain that remains after the expected healing from an injury
•Pain that is NOT exclusively peripherally driven•Central Nervous System amplifies and distorts
the painful response so that it no longer is directly related to the peripheral input or stimulus
•An uncoupling of the expected stimulus-response relationship
Chicken or the egg?
•Are the differences pre-existing?▫Do they predispose patients to chronic pain
•Do they result from chronic medication exposure?
•Are they the result of anxiety, depression, decreased physical activity, reduced social and intellectual stimulation?
What is Multidisciplinary Pain Management (MDPM)?• Multiple Providers of various specialties who
work together to assess and develop a comprehensive treatment plan for a patient
• Often includes Medicine, psychology, & PT/OT• May also include alternative medicine
▫Massage▫Acupuncture▫Chiropractic
Why MDPM?•Because many Chronic Pain Disorders are
disease states•Many Pain states coexist with depression
& anxiety•We can’t treat all of these changes with
one modality•We are in the midst of an opioid addiction
epidemic
Goals in Multidisciplinary Pain Management•Improve or Maintain physical functioning•Facilitate Re-engagement in typical
activities ▫Maintain or return to employment▫Perform ADLs▫Ability to participate in leisure activities
•Making Removal of Pain as a primary goal can be counter productive
Engaging patients in their treatment plans•Discuss risk/benefits for all interventions•Offer options•Provide realistic, incremental goals•UTILIZE PAIN PSYCHOLOGY!!
Medications•Focus on non-opioid options
Membrane stabilizers NSAIDs Topicals Antidepressants
•Wean current opioid regimen
Results of Opioid Weaning
Harden et al. Pain Medicine 2015
Interventions•Done under fluoroscopy or ultrasound•Epidural steroid injections•Joint injections•Nerve ablations•Sympathetic blocks•Spinal cord stimulators•IT pumps
Pain Psychology•18-85% of patients with chronic pain have
a comorbid psychiatric condition (Doan, Neural Plasticity, 2015)
•35% with Chronic back/neck pain have depression or anxiety disorder (Katz, Spine.
1997,1999)•Correlation between severity of pain and
degree of depression (Fishbain, CJ of Pain, 1997)
•Cognitive approaches include CBT, biofeedback, hypnosis
PT/OT•Physical Therapist/Occupation Therapist
▫Educate on physiological basis of pain▫Teaches body mechanics, pacing▫Role in physical rehabilitation▫Address vocational issues▫Techniques for managing pain on the job
Gatchel, Am Psychologist. 2014
Physical Therapy•Active Treatment (better evidence)
▫Gait Training▫Core Strengthening and stability▫Postural re-education
•Passive Treatment (less evidence)▫TENS▫Heat/ Cold▫Ultrasound
CAM Therapies•Acupuncture
▫Improvement in Pain, but not long lasting (Furlan 2010)
•Massage▫Little Evidence to support use (Furlan. Cochrane
2015)
•Manipulation▫Better than placebo at improving pain,
function (Furlan 2010)
•Yoga and tai chi
• Facet RF: Cohen et al. CJP 2007• Spine surgery: Quigley Surg Neurol 1998, Jacobs Eur
Spine J 2011• Epidural steroids: Kwon et al. Skel Radiol 2007, Benzon
Pain 1984• Pharmacotherapy for CRPS: Perez et al. Pain 2003• IA injections for knee OA: Tanaka et al. Rheum Int 2002• Physical therapy for DJD: Jansen et al. Eur J Phys Rehabil
Med 2010• Vertebroplasty: Ryu & Park J Korean Neurosurg Soc 2009
TAKE HOME MESSAGE….SEND PATIENTS EARLY….
Prolonged duration of Pain Worsens Outcomes
Thank you!
Pain Centers of Wisconsin- Wauwatosa Clinic
Medical College of Wisconsin in partnership with Advanced Pain Management
959 N Mayfair RoadWauwatosa, WI 53226