What Every Physician Needs To Know About Pain · •Wide Geographic Variation •Increasing Use, Increasing Costs … •Outcomes Worse Kevin Cuccaro, D.O. StraightShotHealth.com

What Every Physician Needs To Know About

Pain

Kevin Cuccaro, D.O.

StraightShotHealth.com 1

Learning Objectives

• Assess & critique commonly prescribed therapies for chronic

pain.

• Describe the three components of the “Pain Experience.”

• Develop a management plan that addresses risk factors

involved in the development & maintenance of chronic pain.

StraightShotHealth.com 2 Kevin Cuccaro, D.O.

Background

• D.O.

• Anesthesiologist

• Fellowship trained Pain Physician

• Military & Civilian Experience

• Am I Helping People Get Better?

3 Kevin Cuccaro, D.O. StraightShotHealth.com

“Why Should I Care About Pain?”

(“Don’t we have specialists for this?”)

Kevin Cuccaro, D.O. StraightShotHealth.com 4

“Life is Pain, Highness. Anyone who says differently is selling

something.”

The Princess Bride (1987)


A World of Pain

• Common Symptom

• Most Common Disability

• $600+ Billion Annually

• 100 Million Americans (*)

Back Pain

• 2nd Most Common Reason for

ALL physician Visits

• Lifetime Prevalence of 60 – 90%

• Industrialized & Developing

World

• Disability rates very different


How We Treat It…

What We Do …

• Increased MRI’s 307+%

• Increased Injections 130-

700+%

• Increased Surgeries 300+%

• Increased Opioids 690+%*

But What Do We

Get?


Imaging

• Problems noted since 1976

• Wide Geographic Variation

• Increasing Use, Increasing Costs …

• Outcomes Worse


‘Early’ Imaging

• No Increase in Quality of Care

• Longer Disability, Increased Rx Use.

• Mixed Patient Satisfaction

• Patient Anxiety*


Anxiety With Imaging

• ‘Abnormal’ Findings are Common

• Disc Change in Youth

• Bony Change Normal with Age

• Majority of Findings are ‘Normal’

• Label & Reinforce Organic Pain Beliefs


Surgery in the U.S.

• Highest Rates In The World

(& Increasing)

• Complex Sx Increasing

– 15X 5 years

– 3X Costs

– 50+ % ‘Unnecessary’

– (33% ‘Wrong’)

• Geographic Variation

– 8-20X

• ‘Best’ Sx Outcomes…

– Where rates are lowest!


Who Needs Surgery?

Major Neurologic Deficits

Major Spine Trauma

Fusion For Pain?

“No subset of patients with chronic

LBP could be identified for whom

spinal fusion is a predictable and

effective treatment “

(Biomechanical)


Injections For Pain

• Practitioners

• Use

• Costs

• Geographic Variation

– 7.7 X (State)

– 18.4X (City)

Effective? (Guidelines)

Those Who Get Paid To Do Them…

• Nerve Blocks – Yes

• ‘Burning’ Nerves – Yes

• Disc Treatments – Yes/No

• Epidural – Yes

Those Who Don’t…

• Nerve Blocks – No

• ‘Burning’ Nerves – No

• Disc Treatments – No

• Epidural – Limited


Most Common Arguments For Use…

“ Use of Drugs…”

“Prevent Surgery…”

“ Pain…”

Rates of Opioid Use

Rates of Surgery

No Difference

(Effect on Risk Factors?)


Opioids & Chronic Pain

• 1996 APS/AAPM Consensus Statement on Pain

• Pain Undertreated

• Effective in treating Chronic Non-Cancer Pain

• Risks of Addiction & Abuse Low

What Happened Next?

What Followed Sales?

The United States

Population

Rest ofWorld

UnitedStates(4%)

Opioid Consumption

Rest ofWorld

UnitedStates(80%)



What Was Said…

• Work Well for Chronic Pain

• Little Tolerance

• Low Risk of Abuse

• No Ceiling

What Was Found…

• No Studies >16 weeks

• Data from Acute Pain

• Studied w/o Comorbidities

• High Risk of Abuse

• Do Not ‘Eliminate’ Pain


What Was Said…

• Improve Function & Quality

of Life

• Retain or Return to Work

• Retain Cognition, Dexterity,

Reaction times…

What Was Found…

• No Clear Evidence

• No Evidence

• Maybe IF

– Unchanged Dose…and No

Other Impairments Present

Other Problems…

• Endocrinopathy

• Respiratory Depression

• Sleep Disturbance

• Sudden Death & Cardiac Toxicity

• Diversion & Societal Harm

2001-10 The Decade of Pain Control

What We Did…

• MRI’s 300%

• Injections 130-700+%

• Surgeries 300+%

– (15X for Complex)

• Opioids 690+% (sales)

– 1,448% (GPP)

What We Got…

• Disability Rates Increasing

• Complication Rates

Increasing

• No Improvement in Self

Reports

• Costs Continue to Escalate


Overall Results…

2000

US Pop. 282 Million

45 Million Chronic Pain

2010

US Pop. 309 Million

(9.6%)

100 Million Chronic Pain

(122%)


Why? What Are We Treating?

How Should We Treat It?


What Are We Treating?

“Pain is an unpleasant sensory &

emotional experience associated with

actual or potential tissue damage or

described in terms of such damage.” IASP 1994


The Neurobiology of Pain

• Sensory-Discriminative

• Affective-Motivational

• Cognitive-Evaluation

• Sensation (Transmission)

• Emotion (Meaning)

• Cognition (Attention &

Response)


Pain Is A Process…

Fire Pain


Acute Pain Experience

• > Peripheral

– i.e. Nociceptive

– (But Not Always)

• “Broken Leg”

• Cut, Poke, Drug


Cognition

(Brain)

Emotion

(Brain)

Pain

Experience

Sensation

(Body)

Chronic Pain Experience

• > Central

– (Can Cause Peripheral Δ’s)

• “Fibromyalgia” (& Chronic

Back Pain)

• Peripheral Tx Poor


Cognition

(Brain)

Emotion

(Brain)

Pain

Experience

Sensation

(Body)

All Pain Has 3 Components Broken Leg

Cognition

(Brain)

Emotion

(Brain)

Pain

Experience

Sensation

(Body)

FMS or Chronic Back Pain

Cognition

(Brain)

Emotion

(Brain)

Pain

Experience

Sensation

(Body)


What Is This?


?

Sensation

(Transmission)

Nociception ≠Pain!

Nociception

• Nerve stimulation that

conveys information about

potential tissue damage to

the brain.

• Anesthesia INDEPENDENT

• OBJECTIVE

Pain

• Perception & Response of

Sensory Information

• Genetics, prior learning,

current psychological status

& sociocultural influences

• Anesthesia DEPENDENT

• SUBJECTIVE

Why Is This Important?

Chronic Acute


Examples

• Context

– Threat

– Accidental vs.

Intentional

• Meaning

– Abdominal Pain

• Learning

– Snake Bite

• Emotion

– Anxiety

– Anger

• Sensation Δ

– Epidural


Great…Now What?

(How Should We Treat It?)


What Are The Risk Factors?

• Genetic

• Epigenetic

• Developmental

– Childhood Illness, Abuse, Neglect

• Adult Victimization/PTSD

• Psychosocial

– Chronic Social Stress

– Low Social Support

– Acute Stressors

• Psychiatric Comorbidities

• Pain Intensity

• Pain Beliefs

• Maladaptive Coping

• Nonorganic Signs

• High Baseline Impairment

• (What’s Missing?)


Positive Outcomes?

• Pain Beliefs

(Fear Avoidance)

• Coping Strategies

– Passive Active

• Pain Self-Efficacy

• Psychological Distress

Not With…

Imaging

‘Satisfactory Fusion’

Passive Coping


Three Primary ‘Pain Targets’

Beliefs

Coping

Self-Efficacy


Beliefs That Pain

• Fear Avoidance

– ‘Hurt’ = ‘Harm’

– Avoidance of Activity

– Kinesiophobia

• Catastrophizing

– Rumination

– Helplessness

– Magnification

• ‘Organic’ Pain Beliefs • Persistent pain is the result of damage to tissues of the body

• Physical exercise makes the persistent pain worse

• It is impossible to do much for oneself to relieve persistent

pain

• Persistent pain is a sign of illness

• Experiencing persistent pain is a sign that something is

wrong with the body

• It is Impossible to control your own persistent pain

• Being in persistent pain prevents you from enjoying hobbies

and social activities

• The amount of persistent pain is related to the amount of

damage.


‘Organic’ Pain Beliefs

– Structural Focus

– Imaging Reinforcement

– Negative Future

Outlook

– Worse Outcomes

– Iatrogenic*

O’Sullivan P, Lin I. Acute low back pain: Beyond drug therapies. Available at:

http://www.pain-ed.com/. Accessed March 25, 2015.

Waddell G - Spine (1987) 1987 Volvo award in clinical sciences. A new clinical model for the

treatment of low-back pain.pdf

Allan DB, Waddell G. An historical perspective on low back pain and disability. Acta Orthop

Scand Suppl. 1989;234:1-23.

Lin IB, O'sullivan PB, Coffin JA, Mak DB, Toussaint S, Straker LM. Disabling chronic low back

pain as an iatrogenic disorder: a qualitative study in Aboriginal Australians. BMJ Open.

2013;3(4)

Darlow B, Dowell A, Baxter GD, Mathieson F, Perry M, Dean S. The enduring impact of what

clinicians say to people with low back pain. Ann Fam Med. 2013;11(6):527-34.

Zusman M. Belief reinforcement: one reason why costs for low back pain have not

decreased. J Multidiscip Healthc. 2013;6:197-204.

Darlow B, Fullen BM, Dean S, Hurley DA, Baxter GD, Dowell A. The association between

health care professional attitudes and beliefs and the attitudes and beliefs, clinical

management, and outcomes of patients with low back pain: a systematic review. Eur J Pain.

2012;16(1):3-17.


Words That Harm Or Heal

Harmful

• Structural Scapegoat

– “You have disc degeneration, etc.”

• Prolong Fear

– You should avoid…”

• False Prophecy

– “Your back will wear out..”

• Hurt = Harm

– “Let pain guide you…”

Helpful

• Discuss Pain*

– “Back pain is not ‘damage’”

• Promote Resilience

– “The back is strong…””

• Promote movement

– “Motion is lotion…”

• ‘Frame’ Imaging

– “Your MRI shows wrinkles…”

• Self-Management*

– “Let’s create a plan to help you help

yourself…”


Coping & Pain

Passive Coping

• Avoidant behaviors

• “It’s awful & I can’t do anything!”

• ‘External’ reliance for solution or

relief.

• Reactive

Active Coping

• Engaged behaviors

• Reliance on self

• Social Support (w/o drowning)

• Humor

• Proactive


What Coping Style Is Reinforced?

• Cut, Poke, Drug

• Physical Therapy

• Behavioral Health

• Groups

• Acupuncture, etc.

• Passive

• Mixed

• Active

• Active*

• Passive


Self-Efficacy

Individual’s perception…

they can carry out a specific action…

…when challenged.


Sources Self-Efficacy

‘Mastery Experiences’

– Overcoming obstacles

through persistent effort.

Role Models

– Seeing people similar to

oneself succeed by sustained

effort.

• Social Persuasion

– Peer group that persuades &

encourages*

• Eustress Not Distress

– Improved stress &

interoceptive management


Goals of Treatment

Ideal

• Develop & Reinforce

Positive Beliefs

• Encourage & Reinforce

Active Coping

• Teach & Reinforce Self-

Management

No Harm

• Do Not Contribute To Bad

Beliefs

• Do Not Promote Passive

Coping

• Do Not Decrease Self-

Efficacy


How To ‘Manage’ Pain.

• Rule out “Badness”

• What Else On Problem

List?

• Over- vs. Under-treatment

– Downstream Effects

• Focus on Function

• Encourage & Engage

• Find the “Bright Spots”

• Scheduled follow up *

• Behavioral Health

• More Coach…Less Genie

Summary

Crisis of Pain…

…Management

– Imaging

– Surgery

– Injections

– Drugs

Pain Is A Process…Like Fire

– Nociception ≠Pain

– Risk Factors Are

Psychosocial

– Focus On Biomechanical


The Decade of Pain Control & Research

US Pop. 9.6%

Chronic Pain 122%


Last Words…


Questions or Comments?


True or False

• There are two types of pain—Emotional &

Physical.

• Injections for back pain reduce chronic opioid

consumption.


Selected Bibliography Roth RS, Geisser ME, Williams DA. Interventional pain medicine: retreat from the biopsychosocial model of pain. Transl Behav Med. 2012;2(1):106-16.

Garland EL. Pain processing in the human nervous system: a selective review of nociceptive and biobehavioral pathways. Prim Care. 2012;39(3):561-71.

Mularski RA, White-chu F, Overbay D, Miller L, Asch SM, Ganzini L. Measuring pain as the 5th vital sign does not improve quality of pain management. J Gen Intern Med.

2006;21(6):607-12.

The state of US health, 1990-2010: burden of diseases, injuries, and risk factors. JAMA. 2013;310(6):591-608.

Mehta N. Mind-body Dualism: A critique from a Health Perspective. Mens Sana Monogr. 2011;9(1):202-9.

Turk DC, Wilson HD, Cahana A. Treatment of chronic non-cancer pain. The Lancet. 2011;377(9784):2226-2235.

Villemure C, Schweinhardt P. Supraspinal pain processing: distinct roles of emotion and attention. Neuroscientist. 2010;16(3):276-84.

Wiech K, Tracey I. The influence of negative emotions on pain: behavioral effects and neural mechanisms. Neuroimage. 2009;47(3):987-94.

Willems PC, Staal JB, Walenkamp GH, De bie RA. Spinal fusion for chronic low back pain: systematic review on the accuracy of tests for patient selection. Spine J.

2013;13(2):99-109.

Zale EL, Lange KL, Fields SA, Ditre JW. The relation between pain-related fear and disability: a meta-analysis. J Pain. 2013;14(10):1019-30.


Selected Bibliography Chou R, Loeser JD, Owens DK, et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline

from the American Pain Society. Spine. 2009;34(10):1066-77.

Chou R, Shekelle P. Will this patient develop persistent disabling low back pain?. JAMA. 2010;303(13):1295-302.

Garland EL. Pain processing in the human nervous system: a selective review of nociceptive and biobehavioral pathways. Prim Care. 2012;39(3):561-71.

Roth RS, Geisser ME, Williams DA. Interventional pain medicine: retreat from the biopsychosocial model of pain. Transl Behav Med. 2012;2(1):106-16.

Burns JW, Quartana P, Bruehl S. Anger suppression and subsequent pain behaviors among chronic low back pain patients: moderating effects of anger regulation style. Ann

Behav Med. 2011;42(1):42-54.

Burns JW, Holly A, Quartana P, Wolff B, Gray E, Bruehl S. Trait anger management style moderates effects of actual ("state") anger regulation on symptom-specific

reactivity and recovery among chronic low back pain patients. Psychosom Med. 2008;70(8):898-905.

Burns JW, Quartana PJ, Bruehl S. Anger management style moderates effects of attention strategy during acute pain induction on physiological responses to subsequent

mental stress and recovery: a comparison of chronic pain patients and healthy nonpatients. Psychosom Med. 2009;71(4):454-62.

Burns JW, Quartana P, Gilliam W, et al. Effects of anger suppression on pain severity and pain behaviors among chronic pain patients: evaluation of an ironic process model.

Health Psychol. 2008;27(5):645-52.


Selected Bibliography Manchikanti L, Hansen H, Pampati V, Falco FJ. Utilization and growth patterns of sacroiliac joint injections from 2000 to 2011 in the medicare population. Pain Physician.

2013;16(4):E379-90.

Manchikanti L, Pampati V, Singh V, Falco FJ. Assessment of the escalating growth of facet joint interventions in the medicare population in the United States from 2000 to

2011. Pain Physician. 2013;16(4):E365-78.

Manchikanti L, Pampati V, Falco FJ, Hirsch JA. Assessment of the growth of epidural injections in the medicare population from 2000 to 2011. Pain Physician.

2013;16(4):E349-64.

Manchikanti L, Helm S, Fellows B, et al. Opioid epidemic in the United States. Pain Physician. 2012;15(3 Suppl):ES9-38.

Noble M, Treadwell JR, Tregear SJ, et al. Long-term opioid management for chronic noncancer pain. Cochrane Database Syst Rev. 2010;(1):CD006605.

Nyström B. Spinal fusion in the treatment of chronic low back pain: rationale for improvement. Open Orthop J. 2012;6(1):478-81.

Paulus MP, Stein MB. An insular view of anxiety. Biol Psychiatry. 2006;60(4):383-7.

Phillips K, Clauw DJ. Central pain mechanisms in chronic pain states--maybe it is all in their head. Best Pract Res Clin Rheumatol. 2011;25(2):141-54.

Picavet HSJ. Pain Catastrophizing and Kinesiophobia: Predictors of Chronic Low Back Pain. American Journal of Epidemiology. 156(11):1028-1034.

Roy M, Lebuis A, Peretz I, Rainville P. The modulation of pain by attention and emotion: a dissociation of perceptual and spinal nociceptive processes. Eur J Pain.

2011;15(6):641.e1-10.

StraightShotHealth.com 56 Kevin Cuccaro, D.O.

Selected Bibliography Shibasaki, H. (2004). Central pain mechanisms. In: M. Hallet, L. H. Phillips, & D. L. Schommer (Eds.), Advances in Clinical Neurophysiology (pp. 39–48). Elsevier B.V.

Clauw DJ, Arnold LM, Mccarberg BH. The science of fibromyalgia. Mayo Clin Proc. 2011;86(9):907-11.

Lin CW, Mcauley JH, Macedo L, Barnett DC, Smeets RJ, Verbunt JA. Relationship between physical activity and disability in low back pain: a systematic review and meta-

analysis. Pain. 2011;152(3):607-13.

Daubresse M, Chang HY, Yu Y, et al. Ambulatory diagnosis and treatment of nonmalignant pain in the United States, 2000-2010. Med Care. 2013;51(10):870-8.

Dunn KM, Jordan KP, Croft PR. Contributions of prognostic factors for poor outcome in primary care low back pain patients. Eur J Pain. 2011;15(3):313-9.

Edwards TM, Stern A, Clarke DD, Ivbijaro G, Kasney LM. The treatment of patients with medically unexplained symptoms in primary care: a review of the literature. Ment

Health Fam Med. 2010;7(4):209-21.

Friedly J, Standaert C, Chan L. Epidemiology of spine care: the back pain dilemma. Phys Med Rehabil Clin N Am. 2010;21(4):659-77.

Gatchel RJ, Peng YB, Peters ML, Fuchs PN, Turk DC. The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychol Bull. 2007;133(4):581-

624.

Izard CE. The Many Meanings/Aspects of Emotion: Definitions, Functions, Activation, and Regulation. Emotion Review. 2(4):363-370.

Jacobs WC, Van der gaag NA, Kruyt MC, et al. Total disc replacement for chronic discogenic low back pain: a Cochrane review. Spine. 2013;38(1):24-36.


Selected Bibliography Kroenke, K. (2003). The interface between physical and psychological symptoms. Primary Care Companion J Clin Psychiatry, 5(suppl 7), 11-18.

Lumley MA. The two views of emotion in psychosomatic research. J Psychosom Res. 2010;68(3):219-21.

Lumley MA, Cohen JL, Borszcz GS, et al. Pain and emotion: a biopsychosocial review of recent research. J Clin Psychol. 2011;67(9):942-68.

Berna C, Leknes S, Holmes EA, Edwards RR, Goodwin GM, Tracey I. Induction of depressed mood disrupts emotion regulation neurocircuitry and enhances pain

unpleasantness. Biol Psychiatry. 2010;67(11):1083-90.

Carreon LY, Glassman SD, Howard J. Fusion and nonsurgical treatment for symptomatic lumbar degenerative disease: a systematic review of Oswestry Disability Index and

MOS Short Form-36 outcomes. Spine J. 2008;8(5):747-55.

Chou R, Atlas SJ, Loeser JD, Rosenquist RW, Stanos SP. Guideline warfare over interventional therapies for low back pain: can we raise the level of discourse?. J Pain.

2011;12(8):833-9.

Chou R, Baisden J, Carragee EJ, Resnick DK, Shaffer WO, Loeser JD. Surgery for low back pain: a review of the evidence for an American Pain Society Clinical Practice

Guideline. Spine. 2009;34(10):1094-109.

Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2):113-30.

Olsen Y, Daumit GL. Chronic pain and narcotics: a dilemma for primary care. J Gen Intern Med. 2002;17(3):238-40.


Documents

What Every Physician Needs To Know About Pain · •Wide Geographic Variation •Increasing Use, Increasing Costs … •Outcomes Worse Kevin Cuccaro, D.O. StraightShotHealth.com