1
Dr. Kashyap Patel Chief Medical Officer, Agape Healthcare
President, SCOS 2014-15Board member, community oncology alliance
Chief of Staff, Springs Memorial HospitalCAC Member, Palmetto-GBA, Medicaid,SC
I have no conflict of interest to declare I will not be discussing any off label use of any
products I will not be mentioning any brand name or
commercial drug
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Recognize the prevalence, magnitude, challenges and opportunities for multidimensional approach to chronic pain in the US
Describe the science and evidence behind different components of integrative medicine based approach to pain management
Utilize innovative ideas to incorporate integrative approach to pain management
POPULATION HEALTH INDIVIDUAL PATIENT AND CARE GIVER The annual cost of chronic
pain in the United States is estimated to be $100 billion (healthcare expenses, lost income, and lost productivity)
Chronic pain is common, exists as the number one cause of disability in the United States, and creates a large burden on the healthcare system.
Back pain is the leading cause of disability in Americans under 45 years old.
More than 26 million Americans between the ages of 20-64 experience frequent back pain.
50 million Americans live with chronic pain An additional 25 million live with acute pain Mismanagement of pain has far reaching societal
consequences In fighting illicit misuse, must not hinder patients’
access to beneficial medical treatments Non-medical use of prescription drugs = 2nd most
commonly abused drug category Prescription drug abuse is 3x more prevalent than
illicit use of cocaine, crack, and hallucinogens This pattern presents both challenges and
opportunities in creating integrative approach to pain management
76 78 8086 91
96 100109
120131
139 144151
158169
180192
201 202210
219
0
50
100
150
200
250
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Num
ber o
f Pre
scrip
tions
(in
mill
ions
)
Year
IMS Vector One. From “Prescription Drug Abuse: It’s Not what the doctor ordered.” Nora Volkow National Prescription Drug Abuse Summit, April 2012. Available at http://www.slideshare.net/OPUNITE/nora-volkow-final-edits.
http://www.slideshare.net/OPUNITE/nora-volkow-final-edits
0
2
4
6
8
10
12
14
16
18
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Adm
issi
ons
per 1
0,00
0 Po
pula
tion
Year
Alcohol only Alcohol w/secondary drugHeroin Other opiatesCocaine Marijuana/hashishStimulants Other drugs
SAMHSA Treatment Episode Data Set, 2000-2010.
NCHS Data Brief, December, 2011. Updated with 2009 and 2010 mortality data.
0
5
10
15
20
25
1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010
Dea
ths
per 1
00,0
00 p
opul
atio
n
Year
Motor Vehicle Traffic Poisoning Drug Poisoning (Overdose)
Specified drug(s) other than opioid analgesic
Any opioid analgesic
Only non-specified drug(s)
CDC, National Center for Health Statistics, National Vital Statistics System.
Chart1
199919991999
200020002000
200120012001
200220022002
200320032003
200420042004
200520052005
200620062006
200720072007
200820082008
200920092009
201020102010
Opioid analgesic involved drug poisoning
Only non-specified drug(s) involved drug poisoning
Specified drug(s) other than opioid analgesic involved in drug poisoning
Number of deaths
4030
3566
9253
4400
3942
9073
5528
4420
9446
7456
5288
10774
8517
5910
11358
9857
6253
11314
10928
6822
12063
13723
7964
12738
14408
8856
12746
14800
9242
12408
15597
9196
12211
16651
9429
12249
Sheet1
YearOpioid analgesic involved drug poisoningOnly non-specified drug(s) involved drug poisoningSpecified drug(s) other than opioid analgesic involved in drug poisoning
19994,0303,5669,253
20004,4003,9429,073
20015,5284,4209,446
20027,4565,28810,774
20038,5175,91011,358
20049,8576,25311,314
200510,9286,82212,063
200613,7237,96412,738
200714,4088,85612,746
200814,8009,24212,408
200915,5979,19612,211
201016,6519,42912,249
CDC, National Center for Health Statistics, National Vital Statistics System, CDC Wonder. Updated with 2010 mortality data.
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Num
ber o
f Dea
ths
Year
Opioids Heroin Cocaine Benzodiazepines
$72.5 billion in health care costs1
Opioid abusers generate, on average, annual direct health care costs 8.7 times higher than nonabusers2
1. Coalition Against Insurance Fraud. Prescription for peril: how insurance fraud finances theft and abuse of addictive prescription drugs. Washington, DC: Coalition Against Insurance Fraud; 2007.2. White AG, Birnbaum, HG, Mareva MN, et al. Direct costs of opioid abuse in an insured population in the United States. J Manag Care Pharm2005;11(6):469-479.
0
1
2
3
4
5
6
7
8
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Rat
e
Year
Opioid Sales KG/10,000 Opioid Deaths/100,000 Opioid Treatment Admissions/10,000
CDC. MMWR 2011. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm60e1101a1.htm?s_cid=mm60e1101a1_w. Updated with 2009 mortality and 2010 treatment admission data.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm60e1101a1.htm?s_cid=mm60e1101a1_w
Pain often co-exists with mood, sleep, and functional disorders that require additional attention for optimal management: Sleep Disturbance. 20% of American adults (42 million people)
report that pain disrupts their sleep a few nights a week or more
Depression and Anxiety. Example in facial pain and its relation to anxiety and depression: A cross-sectional study on 649 patients. The analysis showed that, regardless of the diagnostic group, anxiety and depression independently increase the likelihood of having … higher muscle tenderness...
Chronic back pain is accompanied by brain atrophy (1.3 cm3 loss of gray matter/year of pain;
*Apkarian J et al. Neurosci. 2004 24 (46): 10410.
Chronic back pain is accompanied by brain atrophy (1.3 cm3 loss of gray matter/year of pain; see figure above)Cortical Plasticity: Adult brain (is) capable of substantial plastic change in primarysomatosensory cortex ... formerly thought to be modifiable only during early experience...Cortical plasticity related to chronic pain can be modified by behavioral interventionsthat provide feedback to the brain areas that were altered by somatosensory painmemories.fMRI biofeedback for control of brain activity in pain patients: “…individuals can gain voluntary control over specific brain region given appropriate training, these effects were powerful enough to impact severe, chronic clinical pain.
1. NIH Consensus Statement: a. Strong evidence for the use of relaxation techniques in
reducing chronic pain in a variety of medical conditions, b. Strong evidence for the use of hypnosis in alleviating
pain associated with cancer2. Mind-body medicine: state of the science, implications for practice. “There is considerable evidence of efficacy for several
mind–body therapies in the treatment of headaches, insomnia, chronic low back pain, symptoms of cancer, and improving post surgical outcomes.”
3. Examples: Behavioral van Tulder et al. Therapy in Low `Back Pain: Behavioral treatment for
chronic low back pain: a systematic review Cochrane Back Review Group. Spine. 2000;25:2688-2699
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Relieve acute and chronic pain Employ appropriate pharmacological and
nonpharmacological techniques Minimize side effects
PATIENTS FIND MORE SATISFACTION FROM CAM
INTERVENTION PERCEIVED TO BE MOST EFFECTIVE FOR LBP
Massage 65% Chiropractic 61% Relaxation techniques 43% Conventional providers 27%Patients rated CAM as "very helpful" for back / neck pain
Alternative medicine 62.8%Therapeutic exercise 56.9%Bed rest 51.9%Physical therapy 46.8% the least effective were
physicians' office visits. A gap was found between clinical guidelines and physicians referrals for other therapeutic interventions.
Non-opioid Analgesics Used for mild to moderate nociceptive pain Anti-inflammatory drugs (NSAIDs) Carry risk of gastrointestinal bleeding and impaired
renal function Avoid persistent use in older adult population
Acetaminophen (Tylenol) Use safe with older adults having normal kidney and liver
function and no history of alcohol abuse Dosages not to exceed 4,000 mg/day
Non-opioid Analgesics Anti-inflammatory drugs (NSAIDs) Cyclooxygenase-2 (COX-2) Tramadol Used for moderate pain May cause dizziness, nausea, and headache
Opioid analgesics Used for moderate to severe pain management May be used for long periods of time without risk of
organ damage Available in a variety of routes Titrate slowly Mild sedation and cognitive impairment are
anticipated in initial therapy
Opioid analgesics Potential medications Morphine Meperidine Methadone Oxycodine Fentenyl Transdermal
Opioid analgesics Potential adverse effects Constipation Sedation Respiratory depression Nausea and vomiting Myoclonus Pruritis
Adjuvant drugs for chronic pain Examples Antidepressants and anticonvulsants Topical analgesics Muscle relaxants Antianxiety medications
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PATIENTS FIND MORE SATISFACTION FROM CAM
INTERVENTION PERCEIVED TO BE MOST EFFECTIVE FOR LBP
Massage 65% Chiropractic 61% Relaxation techniques 43% Conventional providers 27%Patients rated CAM as "very helpful" for back / neck pain
Alternative medicine 62.8%Therapeutic exercise 56.9%Bed rest 51.9%Physical therapy 46.8% the least effective were
physicians' office visits. A gap was found between clinical guidelines and physicians referrals for other therapeutic interventions.
CAM-complementary and alternative medicine Specific therapies/modalities Not typically taught, used or reimbursed in USA
hospitals A group of diverse practices not presently
considered part of conventional medicine 5 domains defined by NIH-NCCAM Mind/Body Biological Manipulative/Body- based Alternative Systems Energetic
Integrative Medicine-A system of care that emphasizes wellness and healing Principles Mind/body/spirit Patient –provider as collaborative partners Natural, less invasive approaches when possible Facilitating the body’s natural healing capacities Need for provider self-care Conventional and CAM in balance Customized to patient need and preference Balance of evidence and safety considerations
Psychological approaches Counseling Biofeedback Imagery Hypnosis Relaxation
Mind-body medicine focuses on the interaction among the mind, thoughts, brain and body. It explores the ways in which
emotional, mental and spiritual attitudes can directly alter the
status of health.
Mind-Body Interventions and healthy outcomes The treatment of disease Decrease pain Helps physicians deal with compassion fatigue Improve mood, QOL, and coping Improve disease or treatment related symptoms
Mind-Body connection Immunity Positive effects of emotions on immunity
Meditation and Imaging Use of fMRI to investigate the effects of meditation on the
activation of regions of the brain Stress and Wound Healing
Positive and negative effects of mood or stress on the rate of wound healing
Surgical Preparation Reduce discomfort and adverse effects
Genomic changes introduced by relaxation response
Dusek JA, Otu HH, Wohlhueter AL, Bhasin M, et al. (2008) Genomic Counter-Stress Changes Induced by the Relaxation Response. PLoS ONE 3(7): e2576. doi:10.1371/journal.pone.0002576http://www.plosone.org/article/info:doi/10.1371/journal.pone.0002576
http://www.plosone.org/article/info:doi/10.1371/journal.pone.0002576
PARIETAL LOBE FRONTAL LOBE
Physical therapy Ultrasound Exercise Hot and cold packs
Neurostimulation
Behavioral Therapy Herbal therapy Biofeedback Physical Therapy Osteopathic
Manipulation Craniosacral Therapy
Acupuncture Massage Yoga Reiki
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Pharmacologic therapy
Mind Body and integrative approach
Wholisticapproach
Combined integrative approach
Non narcotic
Naorctoic for a small selected
sub group
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Integrative Approach to pain managementConflict of interest declarationObjectives: �At the end of the presentation participants will be able to:Burden of Chronic pain: Population and IndividualWhy Current approach with aggressive narcotic use is sub-optimal pain managementOpioid Prescriptions Dispensed by Retail Pharmacies—United States, 1991–2011Primary Substance of Abuse at Treatment Admission—United States, 2000–2010Motor Vehicle Traffic, Poisoning, and Drug Poisoning (Overdose) Death Rates�United States, 1980–2010Number of Drug Overdose Deaths Involving �Opioid Pain Relievers and Other Drugs�United States, 1999–2010Drug Overdose Deaths by Major Drug Type,�United States, 1999–2010�Economic CostsRates of Opioid Overdose Deaths, Sales, and Treatment Admissions, United States, 1999–2010Why Integrative approach to pain management is beneficialNeurocognitive alteration and potential therapeutic approachesCognitive behavioral therapy and Mind Body interventions in chronic painSlide Number 16Pain Management GoalsChronic pain requires an integrative / holistic approachPharmacological ManagementPharmacological ManagementPharmacological ManagementPharmacological ManagementPharmacological ManagementPharmacological ManagementSlide Number 25Chronic pain requires an integrative / holistic approachIntegrative Medicine Vs. CAM 1Integrative Medicine Vs. CAM 2Nonpharmacological Methods to Manage Pain – Based on Mind body interventions IntroductionResearch in Mind Body MedicineMind body intervention and changes in Neuro-endocrine-immune axisGenomic changes during meditation: Genes can be modifiedSlide Number 34Spect Images at baseline and meditationLatest evidence of Mind Body Approach in Pain ManagementOther Nonpharmacological Methods to Manage Chronic PainIntegrative Toolkits for Chronic Pain ManagementSlide Number 39APPROACH TO CHRONIC PAINEvidence based approach to chronic painTHOUGHTS?�QUESTIONS?