Sunday, August 21, 2011
Friday, August 19, 2011
Pain care management needs to be improved, with health care professionals committing to improve care as well as a retooling of the health care system to help people who are suffering, states an editorial in CMAJ (Canadian Medical Association Journal) (pre-embargo link only) http://www.cmaj.ca/site/embargo/cmaj111065.pdf.
According to a recent analysis, chronic pain affects people of all ages, with an estimated 500,000 Canadians aged 12 to 44 years, 38% of seniors in long-term care institutions and 27% of seniors living at home experiencing regular pain.
"Experts agree that much can be done now with newer analgesics, nonpharmacologic techniques such as nerve blocks and physical therapies, as well as spiritual and supportive care," write Drs. Noni MacDonald, Ken Flegel, Paul Hébert and Matthew Stanbrook. "Availability of quality care for pain is the major problem. Health professionals have not mounted a response commensurate with the magnitude of the problem."
The authors argue for a broad strategy to help increase pain management expertise, including education, technology, and supported self-care and lay coaching.
- Myths & Facts About Sleep & Chronic Pain
- Utilizing Science and the Arts to Transform Pain
- Work Accommodation & Return to Work for Persons with Chronic Pain & Disability
- The Pain Puzzle: Diagnosis and Treatment of Pain in the Elderly
- Mindfulness Based Stress Reduction as a Strategy in Reducing Pain
Once we have finalized our schedule, I will announce it here, so stay tuned!!
IASP e-Newsletter - Chronic Pain: An Integrated Biobehavioral Approach By Herta Flor and Dennis C. Turk
This month, IASP Press releases its latest book, Chronic Pain: An Integrated Biobehavioral Approach, written by Herta Flor, PhD, of the Central Institute of Mental Health, University of Heidelberg, Germany, and Dennis C. Turk, PhD, Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, USA. We asked the authors to give us a glimpse inside the book:
Q: The book describes how cognitive and behavioral factors play a major role in chronic pain. Can you give an example (from your own clinical experience, perhaps) that shows how powerful memories or expectations of pain can be?
One of our patients, a 48-year-old woman, came to an assessment interview with her husband. As she slowly walked into the room, her husband was carrying her purse. He helped her to sit down, which was accomplished with some difficulty and posturing. The husband was extremely solicitous, encouraging her to move carefully and not "overdo it." He explained that he was carrying her purse because the weight added to her pain. The husband's behavior demonstrated the role of reinforcement contingencies on the patient's behaviors and became an important target of treatment because we did not want him to undermine his wife's plan to increase her activity, which would most likely be accompanied by some behaviors that conveyed distress.
Q: Is this book intended to be a handbook for clinical psychologists? Will other clinicians—physicians or nurses, for example—be able to use the assessment and treatment protocols you provide?
The biobehavioral perspective and many of the assessment methods and treatment principles that we describe can be used by the entire range of health care providers, not just clinical psychologists. Some of the treatment techniques can be used by most clinicians. Specific treatments such as biofeedback or cognitive restructuring, however, do require specialized knowledge and training and would best be provided by clinicians with appropriate behavioral health care training.
Q: Why is it that patients with low back pain, for example, are coming to psychological treatment only after a series of medical treatments have failed?
Several factors contribute to such excessive delays. Health care providers as well as patients tend to believe in what we call an acute illness model, in which the presence of symptoms is an indication of underlying physical pathology. The assumption is that once the cause of the symptoms is identified, it should be removed, or if that is not possible, then treatments should be provided—whether pharmacological or surgical—that cut or block the "pain signals." If pain persists, then a quest begins to find THE treatment that will resolve the problem. Unfortunately, there may not be any treatment that can eliminate all of the pain, yet the futile search drags on and may contribute to even greater disability.
Q: According to the evidence base, would it be better to apply treatments such as relaxation training or operant group therapy earlier on, rather than as a last resort?
Absolutely! The longer the patient continues to seek treatment, going from provider to provider and from treatment to treatment, the greater the chance for excessive disability and depressed mood. In an early study, the pioneer of behavioral pain treatment, Bill Fordyce, and his colleagues once showed that a simple limitation of bedrest, along with taking medication not "as needed" but on a fixed schedule, greatly reduces the chronicity of acute back pain.
Q: What's your philosophy on tailoring a treatment to the individual patient? How can you tell whether behavioral (operant) therapy, cognitive-behavioral therapy, biofeedback, or relaxation training will be most effective?
We strongly advocate customizing treatments to individual patient needs and characteristics. Having said that, we are only just beginning to learn about how to match treatments to individual patients. This is an important area of future research. It is also important to monitor progress and modify treatments depending on how well the patient is accomplishing the goals of pain reduction, functional improvement, and improvement in overall health-related quality of life.
Q: What are the most promising new treatment methods based on new insights about learning-related maladaptive plastic reorganization of the brain?
Recent treatment methods that focus on the reversal of brain changes related to chronic pain attempt to eliminate pain memory traces from the brain. This can be accomplished by a number of methods, including pain extinction training, which focuses on reducing pain-related behaviors and increasing positive pain-incompatible behaviors. Other promising methods include cognitive interventions that divert attention from the pain and treatments such as mirror therapy or virtual reality training that provide feedback of an intact body to the brain. Various types of biofeedback may achieve similar results. They all have the goal of altering maladaptive brain changes by providing "normal feedback" to the brain, which helps to target maladaptive changes and replace them with non-pain-related positive associations.
Q: Are psychological therapies appropriate or feasible in the low-resource setting? What about in war-torn parts of the world?
Not only are they feasible, psychological methods may be the best alternatives for use when sophisticated and expensive interventions are not available. We do need to develop more efficient ways to deliver these treatments, or at least components of these treatments, more efficiently and effectively. Developing technologies from the Internet and smart phones with lower costs are making these approaches more reasonable. A number of studies are beginning to demonstrate potential creative and innovative uses of these technological advances. We expect to see them used much more in the next few years.
Q: This book promises to be very accessible and useful for psychologists as well as pain clinicians. Any final comments?
We have provided a detailed and comprehensive rationale for the biobehavioral approach to the management of patients with chronic pain. We show how assessment should follow this model and guide treatment. We believe this integrated approach will lead to the best outcomes for the majority of patients. We provide detailed clinical protocols for assessment and treatment, and we also include our clinical insights from over 60 (combined) years of experience working in the field of pain management. We present the empirical and evidence-based background for this approach. Of course, we also acknowledge the limitations in our current knowledge. We realize that additional research will surely lead to refinements in assessment methods and treatment methods; however, we believe the perspective on patients that we have presented will continue to guide the evolution of successful outcomes in the future.
Tuesday, August 16, 2011
Despite decades of research, doctors have few tools to measure pain objectively. Generally, they ask patients to rate it themselves from one to 10, or point to the cartoon face on the wall chart whose expression best matches how they feel.
"We don't have a pain-o-meter," says Joel Saper, director of the Michigan Head Pain and Neurological Institute in Ann Arbor, which draws about 10,000 patients a year, including some of the nation's toughest migraine cases.
Dr. Saper estimates that 15% to 20% of them are faking—or at least, aren't as incapacitated as they say. Some are dependent on painkillers or seeking to resell them, he says. Some want a doctor to certify that they'll never be able to work again and deserve disability payments. Some, he thinks, don't really want to get well because they subconsciously find power in their pain.
Even when pain is real, it's highly subjective. "Two people can have the same nerve compression, but one guy will be bedridden and the other guy will be saying, 'Nah, I'm fine,' " says David Kloth, an anesthesiologist and past president of the American Society of Interventional Pain Physicians.
Evaluating patients' pain is posing a greater dilemma than ever for doctors, given two colliding health-care trends.
On the one hand, opioid painkillers—the most commonly prescribed medications in America—have become a major drug of abuse. With prescriptions up 48% since 1999, opioids are now the nation's second-leading cause of accidental death, after car crashes, according to the Office of National Drug Control Policy.
On the other hand, the Institute of Medicine, which advises the government on health issues, reported last week that pain is all too often undertreated in the U.S. For many of the 116 million Americans afflicted with chronic pain, help is delayed, inaccessible or inadequate, the IOM found.
Many patients feel stigmatized even asking for help. "I hear from people all the time who say they are at a loss to communicate how bad they feel to their doctors—without being eyed as potential criminals," says Karen Lee Richards, a co-founder of the National Fibromyalgia Association. Like many people with fibromyalgia, a complex disorder in which even mild sensations are interpreted as pain, Ms. Richards was told for years that she was probably just getting older.
Some doctors say they have to look at every patient as a potential drug abuser, since there are no typical ones—although there are suspicious patterns. "Sometimes it's the patients with elegant clothes and three kids who call a week after a filling and say they need pain medication. That's when my radar goes up," says George Kivowitz, a dentist in New York City and Newtown, Pa. Insisting that the patient come in to be re-examined usually ends the conversation, he says.
Some physicians make patients take periodic urine tests and sign treatment contracts, promising to take medications only as prescribed and not seek drugs from other sources, or face expulsion from the practice.
In 38 states, doctors can also check prescription registries to see whether patients are getting similar drugs from other physicians in the state. A nationwide version, passed by Congress and signed by President George W. Bush in 2005, has been stalled by lack of funding.
Several bills before Congress would require doctors to undergo additional training in opioid use and abuse as a condition of renewing their license to prescribe them.
"I always ask a patient, 'How are we going to show that this intervention has helped?' " says Scott Fishman, president of the American Pain Foundation who wrote a widely used guide to responsible opioid prescribing. "The person who is just trying to get opioids will say, 'Ah, later, dude' and go somewhere else."
Experts also say it's critical for primary-care physicians, who treat 80% of pain issues, to take time to know a patient's history and circumstances. The lower-back pain he's experiencing may be magnified by an unhappy work situation or pressures at home.
"The answer may not be a neuropathic pain drug but reassurance and counseling," says Perry Fine, a professor of anesthesiology at the University of Utah and president of the American Academy of Pain Medicine (AAPM). But connecting all those dots is very difficult, he concedes, when the typical office visit lasts less than 12 minutes.
There's growing recognition that acute pain and chronic pain require very different approaches. Acute pain is a warning signal to stop something that's harmful, experts say. In chronic pain, that alarm keeps sounding and producing pain long after the original cause is gone, probably due to a malfunction in the central nervous system.
Chronic pain, in turn, can cause changes in the emotional and attention centers of the brain, and lower pain tolerance even further. Antidepressants are helpful in some cases. There is little evidence that opioids are effective at alleviating chronic pain, yet some doctors keep prescribing them, in ever higher doses.
Many pain-management centers now have a multidisciplinary team including anesthesiologists, neurologists, physical therapists and psychologists evaluate patients. At University of California, Davis, where he is chief of pain medicine, Dr. Fishman says, "We start from the beginning and assess where the pain is, what it's robbed the patient of, and how treatment might help," says Dr. Fishman. "It's not a quick visit."
Some centers typically stop all of a patients' pain medicine and start over. If they protest, "I say, 'If the drugs were working, you wouldn't be here,' " Dr. Saper says.
At his migraine center in Michigan, some patients with intractable pain are admitted and observed around the clock. "We can learn a lot that you don't see in an office visit such as how they party in the cafeteria and how they argue with their spouse," he says. One patient who said her chronic migraines made her unable to work was overheard planning an ambitious honeymoon in Europe. Dr. Saper refused to sign her disability form. "We make some patients angry," he says, "but about 75% of the people who come to us improve and are grateful."
Pain psychologists also play a key role, especially when physicians can't minimize patients' pain and have to help them live with it instead. Therapists often wish they were brought in sooner. "Many patients feel like the doctors are saying to them, 'There's nothing we can do from a medical standpoint, so it must be mental,' " says Robert Twillman, a veteran pain psychologist who is now director of advocacy for the AAPM. He often tells patients that whatever the initial cause, the pain must be taking an emotional toll as well, which is in their own power to change.
Many centers focus on improving function rather than eliminating pain. Sean Mackey, chief of Stanford University's division of pain management, doesn't even ask patients how much pain they are in. Instead, he asks, " 'If I could wave a magic wand and take away all your pain, what would you be doing in a month?' We may not be able to measure a patient's pain, but we can define some goals and work toward them," he says.
Chronic pain affects 116 million Americans (one-third of the population) and costs $550 billion to $635 billion a year in medical bills and lost productivity. The most common types people reported in a survey:
• Low back pain – 28%
• Knee pain – 20%
• Severe headache or migraine - 16%
• Neck pain – 15%
• Shoulder pain – 9%
• Finger pain – 8%
• Hip pain – 7%
Source: Institute of Medicine; 2011 survey of U.S. adults reporting that they had pain in the past three months
Use and Abuse
Opioids are the most commonly prescribed drugs in the U.S. Hydrocodone (Vicodin) is the No. 1 drug.
• Prescriptions rose nearly 50% from 2000 to 2009; milligrams prescribed per person rose 400% from 1997 to 2007.
• 15% to 20% of doctor visits in the U.S. involve an opioid prescription.
• Four million Americans a year are prescribed a long acting opioid.
• Abuse of opioid pain relievers is the second-leading cause of accidental death in the U.S., after car crashes.
• Fatalities rose from 3,000 in 1997 to 12,000 in 2007.
• Emergency-room visits due to prescription-drug overdose more than doubled from 2004 to 2008, according to the Drug Abuse Warning Network.
Source: Archives of Internal Medicine, 2011; Office of National Drug Control Policy