Chronic Pain and Alternative Therapies

1. Chronic Pain and
Alternative Therapies
Presenters:
• Robert Hall, MD, Corporate Medical Director, Helios
• Traci Green, PhD, MSC, Deputy Director, Boston Medical
Center Injury Prevention Center, and Associate Professor of
Emergency Medicine, Boston University
Clinical Track
Moderator: Robert L. DuPont, MD, Founding President, Institute
for Behavior and Health, Inc., and Member, Rx and Heroin Summit
National Advisory Board

2. Disclosures
• Traci Green, PhD, MSC, and Robert Hall, MD, have
disclosed no relevant, real, or apparent personal or
professional financial relationships with proprietary
entities that produce healthcare goods and services.
• Robert DuPont – Employment: Bensinger, DuPont &
Associates-Prescription Drug Research Center

3. Disclosures
• All planners/managers hereby state that they or their
spouse/life partner do not have any financial
relationships or relationships to products or devices
with any commercial interest related to the content of
this activity of any amount during the past 12 months.
• The following planners/managers have the following to
disclose:
– John J. Dreyzehner, MD, MPH, FACOEM – Ownership
interest: Starfish Health (spouse)
– Robert DuPont – Employment: Bensinger, DuPont &
Associates-Prescription Drug Research Center

4. Learning Objectives
1. Explain the impacts of chronic pain and opioid
analgesics on body systems.
2. Identify strategies to mitigate the adverse effects of
chronic pain and opioid analgesics.
3. Describe findings of a chronic pain management pilot
program for high emergency-department utilizers.
4. Outlines barriers and facilitators to participation in
complementary and alternative therapies for chronic
pain.
5. Provide accurate and appropriate counsel as part of
the treatment team.

5. The Impact of Opioid Analgesics on
the Body Systems
Robert Hall, MD
Corporate Medical Director
National Rx Drug Abuse & Heroin Summit
Wednesday, March 30, 2016 │2:00 – 3:15 PM

6. Learning Objectives
• Review the impact of opioid analgesics and chronic pain on the
different body systems.
• Identify strategies to mitigate the adverse effects of opioid analgesics
and chronic pain.

7. MEET TOM

8. Tom’s Story
49-year-old man injured his
back when he tripped while
unloading his truck. He lost his
balance, fell, and twisted his
lower back, causing immediate
right-sided, low-back pain.
Initially, the pain only affected the
lower spine and his symptoms were
effectively treated with non-steroidal
anti-inflammatories (NSAIDs).

9. Tom’s Story
A few weeks later, his low-back pain started
traveling down the back of his right upper thigh,
through his calf muscles, and onto the bottom of
his right foot. He developed right leg weakness
that, in combination with the pain, decreased his
balance and made walking difficult.
Treatment Course
• Physical therapy and epidural steroid injections
• Short and long-acting opioid analgesics,
muscle relaxant, benzodiazepine and a non-
steroidal anti-inflammatory drug (NSAID)
• Two lumbar spine fusions
• Spinal cord stimulator (later removed)

10. Tom’s Story
Tom experienced side effects from the opioids
that would eventually impact nearly every major
body system.

11. The Impact of Opioid Analgesics on
the Body Systems

12. Skeletal System
• Hormones
• Osteoblasts
• Osteopenia and osteoporosis

13. Muscular System
• Hormones
• Fatigue, inactivity and deconditioning
• Muscle mass and strength

14. Cardiovascular System
• Myocardial infarction (heart attack)
• Single opioid analgesics
• Multiple opioid analgesics

15. Respiratory System
• Carbon dioxide
• Breathing
• Overdose

16. Nervous System
• Depression and social isolation
• Sleep disturbance
• Dependence and addiction
• Opioid-induced hyperalgesia

17. Endocrine System
• Hormones
• Bones and muscles
• Reproductive health

18. Reproductive System
• Hormones
• Libido and erectile dysfunction
• Infertility

19. Digestive System
• Nausea
• Vomiting
• Constipation

20. Urinary System
• Urinary retention
• Bladder sensation and resistance to urine flow
• Urinary tract infections and kidney injury

21. Integumentary System
• Rash
• Itching

22. Immune and Lymphatic Systems
• Risk of infection
• Pneumonia (elderly patients)

23. MANAGING CHRONIC PAIN

24. Managing Chronic Pain
1. Comorbid conditions
2. Plan of care
3. Medication patterns
4. Multiple prescribers and pharmacies
5. Medication monitoring
6. Nonpharmacologic treatment
7. Return to work

25. Thank you
Follow us @ HeliosComp │ 877.275.7674 │HeliosComp.com

26. Traci C. Green, PhD, MSc
Deputy Director, Boston Medical Center Injury Prevention Center
Boston Medical School, Department of Emergency Medicine, Boston, MA
Associate Professor of Emergency Medicine & Epidemiology
The Warren Alpert School of Medicine at Brown University, Rhode Island Hospital
Complementary and Alternative
Therapies for a Medicaid Population
with Chronic Pain

27. Disclosures-Traci C. Green
• Traci C. Green PhD, MSc, wishes to disclose prior (past 5 year)
employment at Inflexxion, Inc., a small business that creates
behavioral health interventions using technology. She will
present this content in a fair and balanced manner.
• Funding: Research reported in this presentation was funded
through a Patient-Centered Outcomes Research Institute
(PCORI) Award #IHS-1306-02960
• The views in this work are solely the responsibility of the
authors and do not necessarily represent the views of the
Patient-Centered Outcomes Research Institute (PCORI), its
Board of Governors or Methodology Committee

28. Learning Objectives
• Describe findings of a chronic pain management
pilot program for high emergency-department
utilizers
• Outline barriers and facilitators to participation in
complementary and alternative therapies for
chronic pain

29. • Pain that lasts longer than 3 months
• Often linked to initial episode of acute pain that
becomes chronic
• Pain severity varies over time, may or may not have a
known relationship to a discernible, active
pathophysiologic or pathoanatomic process
• Profound impacts to quality of life
• Imposes greater economic impact than any other
disease: $635 billion per year
• RI spent $1.7 billion on Medicaid services serving
174,718 Rhode Islanders in FY2009, 24.2% of the total
state budget
Burden of Chronic Pain

30. • Opioid analgesics primary treatment modality, but associated
with addiction, diversion, overdose, death
• High rates of substance use among chronic pain patient samples
(20-50% in literature), non-adherence
• People with histories of mental health, substance use disorders
may be at higher risk of developing chronic pain conditions
• Strong need to extend behavioral health care, consider
alternative pain care strategies to better address chronic pain
• New draft CDC guidelines for chronic pain emphasize non-opioid
based therapies and non-pharmacological therapies
• Non-opioid and non-pharmacological therapies are often outside
of patients’ reach, are not incentivized, not well integrated into
care
Chronic Pain Treatment

31. • Many seek care for chronic pain at the ED, especially
those out of care, uninsured
– up to 42% of ED visits related to painful conditions (Pletcher,
Kertesz, Kohn, & Gonzales, 2008)
• EDs are significant source of dispensing and diversion
of prescription opioids
– Up to 20% of ED visits may involve patients seeking
medications for nontherapeutic purposes (Grover, Elder, Close, & Curry,
2012)
• Rhode Island multi-agency work group on ED
overutilization identified chronic pain as a key
condition driving overuse & RI Medicaid costs
ED use, overuse, & chronic pain

32. Communities of
Care (CoC)
Peer
Navigator
Health Plan
Case Management
Behavioral Health
Case Management
Integrated Pain Management Program/
Chronic Pain Initiative (CPI)
AMI Holistic Case
Management
Complementary & Alternative Medicine
(CAM) services:
Chiropractor, Acupuncture, Massage Therapy
Rhode Island Medicaid, 2010 to date
2012 to date
Incentives for attendance, surveys; pharmacy
lock-in program for heaviest ED users

33. • Non-opioid alternative
• Profound influences on patient quality of life (Hsu et al., 2010)
• Safe, widespread use
• Potentially effective across different pain conditions
– Systematic reviews indicate evidence base for CAM for
cancer pain, fibromyalgia, neck/back pain, chronic knee pain,
pediatric pain
• Evidence supports use of CAM for addiction
– Acupuncture indicated to treat addiction and pain by the
1998 NIH Consensus Development Panel on Acupuncture
Why CAM for chronic pain?

34. • Unprecedented CAM exposure for low SES, Medicaid
population
• 1500+ patients enrolled
• Unprecedented exposure to Medicaid population for
CAM providers
• How?
– Medicaid waiver granted for CAM
– Alternative Medicine Integration (AMI) performs billing,
certifies providers, carries out holistic case management
– Providers competitively compensated by Medicaid,
compensated for no-shows visits
Why CAM in CoC?

35. • Patient engagement in CPI lower than anticipated
(55% vs. 70% per month in prior FL pilot)
– Populations very different?
– Prevalence of behavioral health problems-~50% in RI?
– Resources inadequate in the community?
– Implementation differences?
– Preference for opioid therapies?
– Something else?
But…..

36.  What are the current barriers and initiators to
involvement in the Chronic Pain Initiative (CPI)?
 How could interventions -- such as a text-message
patient support tool or patient navigators -- help increase
patient participation in the CPI, support healthy coping
techniques during chronic pain care, and encourage self-
confidence and chronic pain self-management skill
development?
 Do these interventions work, and for whom? Do they
improve patient care experience, healthcare systems?
Do they change how people experience chronic pain care
in RI?
S study:
Research Questions

37. Year 1:
March 2014 – Feb 2015
Interviews and Summary of Findings
Development of Text Message
Intervention
Year 2:
March 2015 – Aug 2016
Finalize Intervention
Open pilot testing
Participant Recruitment, Data
Collection
Year 3:
Sept 2016 – Feb 2017
Complete Data Collection &
Analyze
Final Study Results
Study Timeline
Partnered Development
& Planning Phase
Randomized
Control Trial
Community
Dissemination

38. Community
Advisory
Group
Researc
h
Team
Health
Care
Providers
Community
Members/
Patients
Health
Plans
Community
Based
Organization
s

39. • Barriers & facilitators to CPI participation, patient navigation,
text message prospects
• In-depth Qualitative interviews
– 24 patients (engaged, not engaged, new)
• Recruitment by AMI case management, ED
– 24 providers & administrators
• 45-60 min interviews, structured interview guide
– Audio-recorded, transcribed
– Analysis in NVivo
• Coding schema informed by theory, derived from interview
content
• Emergent themes & subthemes identified to inform the
intervention
Formative Interviews

40. In-depth
Interviews
(n=24)
%
Age (n=22)
21-34 5 23%
35-44 6 27%
45-54 8 36%
55-64 3 14%
Gender (n=24)
Female 14 58%
Male 10 42%
Race (n=23)
Black 2 9%
White 17 74%
Other* 4 17%
Hispanic (n=24)
Yes 4 17%
No 20 83%
Patients Interviewed

41. Provider Organization(s) No.
Nurse Case Management AMI,
Neighborhood
Health Plan RI
3
Behavioral Health Case
Management
Beacon Health
Strategies
1
Peer Navigator RIPIN 2
Alternative Medical
Provider: Acupuncture,
Massage, Chiropractic
Various
Alternative
Medical Providers
Contracted by
AMI
3
Mental Health Provider The Providence
Center
1
Emergency Dept Physician Hospitals 2
Other: Living Well
(Chronic pain self
management course)
Instructor
RI Department of
Health
1
TOTAL 13
Administrator/Provider Interviews
Administrator Organization(s) No.
Medicaid Executive Office
of Health and
Human services
(EOHHS)
4
Health Plans United
Healthcare,
Neighborhood
Health Plan
4
Mental Health Clinic The Providence
Center
1
Federally Qualified Health
Center
Thundermist 1
Alternative Medical
Treatment Management
AMI 1
TOTAL 11

42. Experience in the program: Patients
The Chronic Pain program helps illuminate the relationship
between stress and pain
Then massage, if it’s a muscle pain, I mean, massage is definitely
gonna help. Worst comes to worst, it will relieve stress, which—
stress causes muscle tenseness and pain…
Another patient reflects their knowledge of the stress-pain cycle:
Now [since receiving CAM services], when I get upset, or overly
anxious, or something like that, I learned to try to focus on what
my body—remember what my body feels like, and that my body's
okay, and not live so much in my mind.

43. Experience in the program: Patients
The Program provides an opportunity to build a trusting
relationship with a provider
She just inspires me to just—not even just with the massage, but just to do
what I wanna do in life. I was really abused, so that’s where a lot of my pain
comes from. She encourages me to write my books. I wanna write a book,
and she encourages me to do that and encourages me to lose weight and
just—she’s more than just giving me a massage.
Another patient describes learned techniques and coping skills :
…she taught me how to do different moves as if I was in pain...That was a
good part with the massage therapy. When I’m in pain, I put my mind
somewhere else so I don’t take the anger out on my kids.

44. Reducing patient medication exposure
Patients expressed interest in trying new modalities to
treat their pain without medication:
She just massages areas that just—ya know get right in there—that
you can’t just—you can take a pill and it’s good. It’s not gonna last.
It’s just gonna come back. She’s actually working on the problem.
Medication I know was basically for the brain. It’s not gonna help
the area. Once that wears off you’re back in pain again, but at least
a massage, she gets to the area unless—sometimes it lasts for
longer and I can take less of what I need to do.

45. Addresses lack of trust in medical system, limited therapeutic alliance,
few long-term relationships
People are getting more time, specifically with AMI Providers, that they may not
receive with traditional health care providers:
When they get to go to these modalities, these alternative modalities, they’re given
minimal half hour, more than likely an hour, with their provider. It is a hands-on and a
listening process. They get the touch. They get the person-to-person connection. A
lot of ‘em haven’t gotten that before.
For people who are homebound or have difficulty leaving the home they are able to
have providers come to them:
What I've particularly heard good things about, too, is when they're able to be flexible
and come to the patient and provide services in the member's home, as opposed to
them having to get out. For these people, transportation is almost always a barrier. If
you have somebody who has real, horrible chronic pain issues, sometimes that comes
with depression, either before or as a consequence. Just getting mobilized to get out
of the house may not happen. Even though they want the treatment, they may not be
able to access it unless the services come to them.
Positive Impact of CAM: Provider/ Admins

46. People are using CAM services for pain management because they have tried
but failed with other options:
Because they have utilized every other resource possible to make themselves
feel better, and it’s not working. We’ve got a lot of fibromyalgias, a lot of
diabetes, and a lot of lower back pain patients. Just from whatever has
happened to them. I’ve got some people that have—I think it’s Crohn’s, where
they have to have the remicade infusion. It’s painful, and they hurt. That’s why
they do it, is because nothing else is working.
Many CAM providers were able to meet these special patients “where they
are at” to provide their services
Thus we’ve got an array of people that—some of ‘em can’t leave their home, so
that’s great that AMI will find a provider to come into their home and help
them.
Why it’s working: Provider/ Administrator

47. Experience in the program: Providers
The Program provides a way to reach the disenfranchised
By contrast, an emergency department employee described her own experience
of having little to offer patients, now that there is a 3-day supply of opioid
medications, confirming that the Pain Management program is unique in its focus
on providing services to this particular population:
…Right now, because I don’t have much to offer them, I’m not sure what
they could say to me that could really be helpful. ‘Cause if they come in, say
“I have chronic pain, I’m out of my medications.” Or, “I have chronic pain,
and my doctor just cut me off.” They’re setting me up for just to say , “I
can’t give you narcotics”, and I don’t have any other resources to give
you…it’s horrendous.

48. Experience in the program: Patients
The Program contributes to increased quality of life
Slowly, over time, I noticed—well, not slowly. It was almost immediately.
Probably within the third or fourth visit I began noticing when I would
drive my car that I wasn't having to hold my head up….I was having less
headaches, and that's obviously—now I know where the tension
headaches were coming from. I'm not a huge fan of medication, so it's
helped me in that I'm—it can keep me off of medication, Tylenol. Even
things like that that "are considered safe." I don’t like to take those
either…It's kept me able to refrain from having to take those things. It
keeps the pain down, although like right now when it starts to come back
it's like I can't wait to go and get that relief... “Because I was always like
this. Very, very, very uncomfortable. Because I get massage on Friday,
they're [family] home on the weekends, so now it's a lot easier to do
things like go to the movies, or go to dinner, and stuff like that, and not
be in pain all the time

49. Experience in the program: Patients
Acupuncture is a cause of anxiety and discomfort
I’m hard of hearing, and my sight is not all that great. My
sense of touch is very sensitive. Acupuncture gave me a lot of
anxiety just getting the needles in. There were a couple of
things that the acupuncture helped with, but you had to keep
going back and keep having it done, and I just couldn’t do that
with the needles.

50. Even with the additional services, addressing complex health
care needs are a challenge:
We had some intense patients in Florida, but up in Rhode Island, the percentage of
patients with intense behavioral health needs was far greater. We’ve actually had
extra training on behavioral health needs because we were being hit with stuff that
we had not been exposed to, to such a degree.
Staff, Providers insufficiently prepared to deal with complex
needs ; training indicated:
I think if anything, that if the COC had to be overlooked again, and someone were
gonna begin it somewhere else, provide adequate, proper training to the employees
that are going to be going into this- home visit training. Safety training. Mental
health training. Behavior training. Even clinical training helps too.
System Adjustments for CAM:
Provider/ Administrator

51. Appropriate CAM candidates: Admins
Unanswered questions remain over whether the program
adequately serves patients with the greatest needs
It works especially well for people who have been socially
disenfranchised, patients who haven’t been treated well by
the system. They are used to less than respectful care. They
respond well to the caring and concern extended…at the
holistic care provider level….You cannot discount the spiritual
enlightenment that comes from a different approach, one
that’s not cut-and-dry, and quick (as they’ve become
accustomed to receiving)….We have to do something with
THESE patients! We can’t keep doing the same thing because
it is not working!

52. Barriers Facilitators
Pain Improved communication on
cancelations/rescheduling (including
texting)
Transportation Mobile CAM options, clear instructions for
transportation assistance
Childcare/dependent care CAM provider flexibility
Motivation Daily interaction*
Uncertainty of CAM
Skepticism, extended distrust of medical
system, lack of information on CAM, Fear
CAM-knowledgeable case managers
Memory challenges, recall, lack of reminder
system
Simple reminders for appointments,
transportation assistance
Low self-efficacy, health/literacy Holistic, patient-centered case
management; patient education to nurture
health literacy; CAM providers
“reintroduces” patient to their body
Low priority of self-care, health MI-based case management
Insufficient number of visits/”dose” Billing/visit # flexibility

53. • Already using it
– Most people [27 out of 32 total patients interviewed] had ‘smart phones’ but some
share phones with family members because of eligibility restrictions for government
phones
– All text. 13 currently receive texts from health providers or pharmacies; mostly
appointment/refill reminders. All expressed contentment with interacting with the
healthcare system in this way.
– Some skepticism about texting technology in general from a minority of patients
• Messages should be relevant to health needs & supportive
– Participants interested in appointment reminders, motivational support messages, self-
care, prep for appointments, hearing peer “voice”
• No major concerns about privacy or safety
– One concern: receiving texts while driving
Is Text Messaging the Right Mode of
Communication?

54. Living Well Topics OPENtext Self Management Topics
Being an active self manager Orientation (in person + via SMS)
Problem solving & action plans CAM 101
Understanding the pain and
symptom cycle
Goal setting
Physical activity and exercise Exercise/physical activity
Balancing activity and rest Mood*
Medications Safe Medication Use (storage, disposal,
addiction)*
Nutrition Food as medicine
Communications – with family and
care providers
Sleep
Relaxation and meditation Mindfulness
Dealing with difficult emotions Social Support
Health Literacy*
Stress & Stress Management*
*Explicit relapse, recovery supports

55. CAM P1 P2 Topic
Message
Type
content
There are traditional and alternative
treatments for chronic pain. Common
alternative treatments are Chiropractic,
Acupuncture and Massage (or CAM for
short).
I will be texting you a lot about CAM -
Chiropractic, Acupuncture and Massage.
These are common alternative treatments
for chronic pain.
Alternative
Treatments
Knowledge
content
Besides CAM, there are lots of alternative
treatments. Some are 1000s of years old.
We STILL don't understand how they work,
but they do!
Besides CAM, there are lots of alternative
treatments. Some are 1000s of years old.
Scientists aren’t sure what makes them
work, but they do!
Alternative
Treatments
Knowledge
content
Remember, in figuring out how to be most
useful to you, CAM providers consider the
whole person, not just the symptoms.
Remember, in figuring out how to be most
useful to you, CAM providers consider the
whole person, not just the symptoms.
Alternative
Treatments
Knowledge
content
No treatment works right away. Whatever
CAM you try will need time before your
body feels any different. Give it a few visits
to see if it works.
I have to remind myself that every
treatment takes time—even CAM. The body
needs at least a few visits before it feels the
difference. Keep that in mind.
Alternative
Treatments
Motivation
keyword/
Quick
page
For tips on things you should do to prepare
for your CAM visit, text PREPARE or go to
XXXXXXXXXXXXXXXXXXXXX
For tips on things you should do to prepare
for your CAM visit, text PREPARE or go to
XXXXXXXXXXXXXXXXXXXXX
Massage
Therapy
ACTION
PEER
story
KV’s story: One surprise from getting acupuncture has been learning to relax my mind. My first visit, she put the
needles in & said she’d be back in 15 minutes.
I panicked a little, wondering how I could lie there not moving with a bunch of needles in me. But then I decided
to try meditating.
I closed my eyes and breathed deeply. It really relaxed me, even after the needles were out and I’d gotten up
and left.
Fortune
cookie
Fortune says: Life does not get better by chance. It gets better by change.
Fortune says: He who laughs at himself never runs out of things to laugh at.

56. OPEN Comparative Effectiveness Trial
Patients with
chronic pain, ED
overutilization
lower ED
utilization,
costs
•Pain
•Quality of
life
•Medication
use/misuse
•Primary
care visits
Basic needs support
OPENnav
Esteem, social
support, tailored
motivation
OPENtext
CAM engage-
ment increased
•# visits,
retention
•Self efficacy to
self manage
chronic pain
•Readiness to
self manage
chronic pain

57. OPENnav
Peer Navigator,
n=150
Eligible for or enrolled in
Chronic Pain Initiative (CPI), referral to OPEN
•AMI case manager
•Health plan case manager
OPENtext,
n=150
Complementary & Alternative Medicine (CAM) services:
Acupuncture, Chiropractor, Massage Therapy
N=79 enrolled (as of 2/29/16)
1 drop out
98% retention
80% female, 47% Non-White, 15% Hispanic/Latino

58. • Traci.c.green@brown.edu
• tcgreen@bu.edu
Thank you!

59. Chronic Pain and
Alternative Therapies
Presenters:
• Robert Hall, MD, Corporate Medical Director, Helios
• Traci Green, PhD, MSC, Deputy Director, Boston Medical
Center Injury Prevention Center, and Associate Professor of
Emergency Medicine, Boston University
Clinical Track
Moderator: Robert L. DuPont, MD, Founding President, Institute
for Behavior and Health, Inc., and Member, Rx and Heroin Summit
National Advisory Board