Team Based Approach to Managing Chronic...

IMPLEMENTING A TEAM BASED

APPROACH TO MANAGING

CHRONIC PAIN

Talal Khan, MD and Jennifer Surprise, APRN

Objectives

• Review the pathophysiology of pain and the development of chronic pain.

• Understand that chronic pain is a complex biopsychosocial disease.

• Describe the interdisciplinary management philosophy for this complex patient population.

Definition of Pain

International Association for the

Study of Pain (IASP)

“An unpleasant sensory and

emotional experience associated

with actual and potential tissue

damage or described in terms of

such damage ...”

Scope of The Problem

IOM 116 million Americans suffer from chronic pain

Unrecognized and under-recognized disease

One of the leading causes of lost work time

May affect 65% - 85% of the US population at some point

in their lives

More patients afflicted with

pain than with heart disease,

diabetes and cancer combined

Cost up to $635 billion dollars in the US alone

Pain Pathways

Pain Pathways

Pain Pathways

Brain

Spinal cord

Peripheral nerve fibers

Altered “gating”Dorsal horn denervation hypersensitivity

Molecular changes

Gene expression changes

Receptive field changes

Ectopic discharges

Mechanosensitivity

Ephaptic crosstalk

Altered “gating”Molecular changes

Gene expression changes

Receptive field changes

Sympathetic fibers

Ephaptic crosstalk

Postulated Mechanisms Involved in Sustaining

Neuropathic Pain

Scope of The Problem

The Bio-Psycho-Social Axis

Changes Associated with the

Chronification of Pain

Brain Move from nociceptive to

emotional circuits

Spinal Cord Plasticity, abnormal connections

Sensitization

Nerves Neural plasticity

Brain. 2013

Do we try enough to prevent the

development of chronic pain?

• Unrecognized/underrecognized

• Mechanisms not completely understood

• Production pressure

• After thought

• Lack of clear preventive guidelines

• Treatments have side effects

• Combination treatments

• Care coordination

Mechanistic Management of Neuropathic Pain

Existing Evidence• Multimodal Analgesia for Perioperative Pain

Preoperative

• Antineuralgics

• Antiinflammatories

• Opioids

• Nerve blocks

Intraoperative

• Nerve sparing

• Muscle sparing

• Intraoperative opioids

• Nerve block

Postoperative

• Aggressive approach

• Nerve block

• Opioids

• Early mobility

• Continue NSAIDs and Antineuralgics

Team Approach

Evaluation History and Examination

Testing if Necessary

Discussion of root causes and treatment options suitable for YOU!

EDUCATION

Team discussion if necessary

Appropriate Treatments

BETTER!

Not Better

Re-evaluation

Interdisciplinary Treatment Approach

Stanton-Hicks M et al. The Clinical Journal of Pain;1998; 14:155-166.

Psychological Treatment

Pain ControlRehabilitation

Functional

Restoration

Surgical Correction

Patients with chronic pain are at increased risk for:

• emotional disorders (such as anxiety, depression,

and anger)

• maladaptive cognitions (such as catastrophizing and

poor coping skills)

• functional deficits

• physical deconditioning (due to decreased physical

activity and fear of re-injury)

• basic nociceptive dysregulation

All of these aforementioned variables, in turn, are often

interdependent so that one cannot simply treat one

to the exclusion of the others.

So what does this mean?

Evolution

• John Bonica

• University of Washington

Structure

Pain Physician

Behavioral Therapy

Physical & Occupational

Therapy

Surgery

Neurology

Rheumat

Social Worker

Interdisciplinary pain management

Embraces the fact that the comprehensive

assessment and treatment of all dimensions

(biologic, psychological, social) is needed in

order to be effective.

Such an approach has been demonstrated to

be the most therapeutic and cost-effective means of

managing the often recalcitrant chronic pain

syndromes.

Interdisciplinary vs. Multidisciplinary

Interdisciplinary

Individuals from various

disciplines

Individuals meet as a group

to provide

recommendations

Group collaborates to

achieve common goal

Improved outcomes through

communication

Multidisciplinary

Individuals from various

disciplines

Individuals provide

recommendations to the

physician, who ultimately

decides on patient

treatment

Benefits

Numerous experts working together to develop a plan to manage pain

Combined treatments are superior to single treatments

Increased return-to-work rate (Chapman, et al., 2000; Sanders, 2000)

Decrease in health care utilization

Improvement in psychological functioning (Mills, et al., 2004)

Outcomes

Outcomes

Outcomes

Goals of Interdisciplinary Pain

Management Decreased pain intensity

Increased physical function

Appropriate medication utilization

Increased sleep

Improved mood

Self-care strategies

Medications

Physical & Occupa-tional Therapy

Patient roles Provider

roles

Family/Care-giver roles

Interventional Techniques Radiofrequency ablation, anesthesia, surgery

Counseling/Support Group

Complementary and Alternative Medicine