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Pain recovery


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Pain management is a critical component to patient care. However, it is leading to opioid addiction at an alarming rate in the United States. For many patients, a paradigm shift is needed to go from pain management to pain recovery.

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Pain recovery

  1. 1. PAIN RECOVERY- Texters- Weekend Warriors-Soldiers and Seniors Louise Stanger Ed.D, LCSW, & James Flowers Phd, LPC-S
  2. 2. Objectives Describe and Discuss what is Pain Recovery Demonstrate the difference between Acute and Chronic Pain using case examples Explain the symbiotic relationship between Chronic Pain-Substance Abuse and Mental Health Disorders Identify and Recommend Multidisciplinary Treatment Options for the Behavioral HealthCare Field
  3. 3. Opioid Use For Chronic pain Used as long back as the Summarians in Mesopotamia 1400 BC Wars have been fought / Laws have been passed and much money has been made When we think of today 1990 was turning point
  4. 4. Trick or Treat Oct. 31, 2000
  5. 5. Pain Policies Controlled substances are necessary for public health Pain management is integral part of medical practice. All physicians must assess Opioids are part of professional practice Physical dependence or analgesic dependence cannot be confused with dependence Pain management encouraged
  6. 6. Did You Know ? There are 133 million people in the US with Chronic Pain That is 1 in 5 adults globally Physical pain increases when there is an emotional factor -Anger-Anxiety- Depression 65% of all Americans see care for persistent pain at some point in their lives Opioids are frequently prescribed and over prescribed 75% of all Heroin Users Started With Prescriptions Drugs (JAMA Psychiatry 2014 Theodore Cicero University of Washington)
  7. 7. Cost of Chronic Pain 635 Billion dollars per year The Economic Costs of chronic pain Pain effects work days , number of annual hours worked and hourly wages Cost for year -$4,048.00 for joint pain, $5,838.00 arthritis, $9680.00 functional disabilities This is higher then what is spent yearly on Heart Disease, Cancer and Diabetes Adolescent Chronic pain 189.5 billion American Pain Society _Journal of American Pain 2012 - John Hopkins University (2008 Medical Expenditure Panel Survey )
  8. 8. Economic Costs 25.6 billion Workplace Cost 25 billion Medical costs (By insurers and patients ) Criminal Justice 5.1 Billion (mostly jails 2.3 billion , police 1.5 billion )scientific (2011 Howard Birnbaum Analysis Group -)Boston Scientific America,2016 Candid Conversations
  9. 9. When Folks Complain of Chronic Pain Physician visits increase Rx increases Rehabilitation increases Diagnostic Procedures Increase’ Invasive Anesthesia Procedures Increase Surgical Ablative Techniques Increases
  10. 10. Opioid Induced Hyperalgesia University of Colorado-Peter Grace , May 2016
  11. 11. Chronic Pain Lasts for several weeks, months and years and can cause its own disease Pain signals are sent to the brain once the pain stops brain signals with acute pain stop With Chronic pain brain signals are sent to the brain and did not stop
  12. 12. Center for Disease Control- March, 2016 Opiates must not be prescribed for long term pain Physicians must look out for co-morbidity mental health, prior history of substance abuse-anxiety -depression etc Physicians should avoid opiates with benzodiazepines Physicians should avoid or eliminate 90mne
  13. 13. Screening and Assessment Tools Structured Clinical Interview Family Mapping - Genogram BAI BDI MPI MMPI-II ( If Indicated)
  14. 14. Formal Assessment Tools •.The Screener and Opioid Assessment for Patients with Pain (SOAPP) 2003. The Pain Medication Questionnaire (PMQ 2004. The Opioid Risk Tool (ORT) 2005. The Diagnosis, Intractability, Risk, Efficacy (DIRE) was 2006. The Screener and Opioid Assessment for Patients with Pain Revised (SOAPP-R) 2007.
  15. 15. Brain Plasticity Pain is often a perceptual issue Evidence suggests that “focused attention”can increase neuronal plastic and can be learned to reprogram brain pathways
  16. 16. Driver Distraction 80 Percent of all car accidents -1.6 million accidents yr
  17. 17. What do Teens and Seniors, Cell Phones have in Common ?Teens while texting or being distracted have the same reaction time as a 70 year old senior who is driving! Cell phones are involved in 1.6 million accidents anytime of day at least 11% of drivers are talking on the phone Cost of Motor Crashes was $836 billion dollars in 2010
  18. 18. Concussions Heads Up Brain injury that changes the way brain normally functions children and teens are at greatest risk Correlated with SA Pain MH Journal of Neurotrauma explains that a trauma to the head may have the same impact to the brain that drugs and alcohol have to the brain CDC reports there are 4-5 million concussions annually 38 million reported 2012
  19. 19. Concussion Recovery Rest Light Aerobic Activity Short Specific Activity No-Contact Drills Full Contact Drills Return To Activity
  20. 20. Recreationa l Warriors Head Neck Face Spine Thorax Abdomen
  21. 21. Meet Sally -40 yo Herniated Disc Out of work herniated disc C3- C4 with nerve impingement, chronic pain syndrome; out of work 1 year Previous Treatments -ESI -No benefit Physical Therapy with traction and massage-minimal relief Medications-Vicodin/Flexeril
  22. 22. Behavioral Assessment Sally Clinical Interview- Substance Abuse Assessment MMPI MPI II Results :9/10 on pain scale sleep at 6 2 pack a day smoker MPI Sally is experiencing above pain levels and is the case with chronic pain sufferers reduced activity Not able to do household chores: work etc Med seeking
  23. 23. Sally- Treatment and Outcome Chronic Back pain recovery management Biofeedback-relaxation- mindfulness- yoga -stretching Psychophysiological education Group- Lifeskill -CBT Trigger Outcome sleeps 8 hrs a night works cut down to less then 1 pack a day decrease in medication - vicadent prn
  24. 24. Meet Jack 50 yo male Previous TreatmentPrevious Treatments Laminectomy L3/L4, L4/L5 Outcome – increased pain, radiculopathy Lumbar fusion and Lysis of adhesions Outcome – failed fusion, pain continued Physical therapy Outcome – moderate but temporary
  25. 25. Jack Presupposed Treatment: Drug Delivery with morphine Behavioral Assessment ; Clinical Interview , MMPI-2, MPI,BAI/BDI , Chemical use questionnaire RESULTS:: Activity < 3, Reported 10/10 constant pain, Sleep < 3, Used Alcohol to increase drug effect, Severe Anxiety/Depression, Results of the MPI indicate that the patient is experiencing average pain severity, above average interference (+2 SD), below average life control (-2 SD) and an above average level of affective distress (+1 SD). These findings are compared with other chronic pain sufferers. A significantly reduced general activity level (-2 SD) was endorsed. These findings are consistent with many chronic pain sufferers
  26. 26. Goals May not be the Abolition of pain but adaptation to Pain ACCEPTANCE CAN BE KEY
  27. 27. Paradigm Shift Moving From Passive :Cure me Doctor to Being an ACTIVE
  28. 28. Treatment Plan Biofeedback and relaxation therapy Psychophysiological education CBT , MI, Group Therapy Postpone implantable drug delivery
  29. 29. Outcome Significant Increase in Activity (8) Reported Intermittent Pain (4-10) Sleep 7 hours per night No alcohol consumption Decrease in Drug utilization - Vicodin prn Zero invasive procedures Two Doctor visits in 12 months Return to Full time work
  30. 30. Hips -Knees or Shoulders Temptation to use Very Painful Tough Rehabilitation Pain Recovery Management
  31. 31. Seniors Don’t Want to Get HiGH!!!! Want to get well!!! 4% of the population with 30%of opioid prescriptions
  32. 32. Pain Recovery Muti-pronged Approach Public Health -Prevention Government Intervention Intervention-Hub and Spoke Model - additional resources for states (given built speciality centers , special numbers Training of Professionals Pharmaceutical Development Treatment Vermont Dept. of Health Barbara Cimaglio (Deputy Commissioner AOD
  33. 33. Pain Recovery Treatment Physical Plant-Environment Staff Training and Credentials Philosophical Beliefs Ethical Standards Spiritual Underpinnings Medical Interventions
  34. 34. Pain Recovery Muti-pronged Approach Public Health -Prevention Government Intervention Intervention-Hub and Spoke Model - additional resources for states (given built speciality centers , special numbers Training of Professionals Pharmaceutical Development Treatment Vermont Dept. of Health Barbara Cimaglio (Deputy Commissioner AOD
  35. 35. Resources Center for Disease Control, March 2016 Scientific America -Crucial Conservations , May, 2016 ASAM National Practice Guideline for the Use of Medications in the Treatment of Addiction and Opioid Use,2016 Chou R, Turner JA, Devine EB, et al. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Int Med. 2015;162(4):276-286. Centers for Disease Control and Prevention. NCHS Data Brief. Prescription opioid analgesic use among adults:United States 1999-2012 , Number 189, February,2015 2013 National Drug Student Data Bank