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Chronic Pain andAlternative 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
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
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
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.
The Impact of Opioid Analgesics on the Body Systems
Robert Hall, MDCorporate Medical Director
National Rx Drug Abuse & Heroin SummitWednesday, March 30, 2016 │2:00 – 3:15 PM
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.
MEET TOM
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).
Tom’s StoryA 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)
Tom’s StoryTom experienced side effects from the opioids that would eventually impact nearly every major body system.
The Impact of Opioid Analgesics on
the Body Systems
Skeletal System• Hormones • Osteoblasts• Osteopenia and osteoporosis
Muscular System• Hormones• Fatigue, inactivity and deconditioning• Muscle mass and strength
Cardiovascular System• Myocardial infarction (heart attack) • Single opioid analgesics• Multiple opioid analgesics
Respiratory System• Carbon dioxide• Breathing• Overdose
Nervous System• Depression and social isolation• Sleep disturbance • Dependence and addiction• Opioid-induced hyperalgesia
Endocrine System• Hormones• Bones and muscles• Reproductive health
Reproductive System• Hormones• Libido and erectile dysfunction• Infertility
Digestive System• Nausea• Vomiting • Constipation
Urinary System• Urinary retention• Bladder sensation and resistance to urine
flow• Urinary tract infections and kidney injury
Integumentary System• Rash• Itching
Immune and Lymphatic Systems• Risk of infection• Pneumonia (elderly patients)
MANAGING CHRONIC PAIN
Managing Chronic Pain1. Comorbid conditions2. Plan of care3. Medication patterns4. Multiple prescribers and pharmacies5. Medication monitoring6. Nonpharmacologic treatment7. Return to work
Thank you
Follow us @ HeliosComp │ 877.275.7674 │HeliosComp.com
Traci C. Green, PhD, MScDeputy Director, Boston Medical Center Injury Prevention Center
Boston Medical School, Department of Emergency Medicine, Boston, MA
Associate Professor of Emergency Medicine & EpidemiologyThe Warren Alpert School of Medicine at Brown University, Rhode Island Hospital
Complementary and Alternative Therapies for a Medicaid Population with Chronic Pain
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
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
• 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
• 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
• 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
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
• 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?
• 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?
• 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…..
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
Year 1: March 2014 – Feb 2015
Interviews and Summary of Findings
Development of Text Message Intervention
Year 2: March 2015 – Aug 2016
Finalize InterventionOpen 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
Community Advisory
GroupResearch
Team
Health Care
Providers
Communi
ty Members/ Patients
Health Plans
Community Based
Organizations
• 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
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
Provider Organization(s) No.
Nurse Case Management AMI, Neighborhood Health Plan RI
3
Behavioral Health Case Management
Beacon Health Strategies
1
Peer Navigator RIPIN 2Alternative Medical Provider: Acupuncture, Massage, Chiropractic
Various Alternative Medical Providers Contracted by AMI
3
Mental Health Provider The Providence Center
1
Emergency Dept Physician Hospitals 2Other: Living Well (Chronic pain self management course) Instructor
RI Department of Health
1
TOTAL 13
Administrator/Provider InterviewsAdministrator 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
Experience in the program: PatientsThe 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.
Experience in the program: PatientsThe 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.
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.
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
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 servicesThus 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
Experience in the program: ProvidersThe 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.
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
Experience in the program: PatientsAcupuncture 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.
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
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!
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 CAMSkepticism, 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
• 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?
Living Well Topics OPENtext Self Management TopicsBeing an active self manager Orientation (in person + via SMS)Problem solving & action plans CAM 101Understanding the pain and symptom cycle
Goal setting
Physical activity and exercise Exercise/physical activityBalancing activity and rest Mood*Medications Safe Medication Use (storage, disposal,
addiction)*Nutrition Food as medicineCommunications – with family and care providers
Sleep
Relaxation and meditation MindfulnessDealing with difficult emotions Social Support
Health Literacy*Stress & Stress Management*
*Explicit relapse, recovery supports
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
contentBesides 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
contentRemember, 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
contentNo 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.
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 supportOPENnav
Esteem, social support, tailored
motivationOPENtext
CAM engage-ment increased
• # visits, retention
• Self efficacy to self manage chronic pain
• Readiness to self manage chronic pain
OPENnavPeer Navigator,
n=150
Eligible for or enrolled inChronic 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% retention80% female, 47% Non-White, 15% Hispanic/Latino
Chronic Pain andAlternative 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
