ACOEMA Systematic Approach to Pain

Posting and Termination DatesOriginal Posting Date: March 14, 2018Termination Date: March 14, 2021

ACCME Accreditation Statement“This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the American College of Occupational and Environmental Medicine (ACOEM) and the Occupational and Environmental Medicine Association of New Jersey (OEMANJ). The ACOEM is accredited by the ACCME to provide continuing medical education to physicians.”

AMA Credit Designation Statement“The American College of Occupational and Environmental Medicine designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credit(s)TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.”

American Board of Preventive Medicine Maintenance of Certification (MOC) CreditThis activity has been approved for 1.0 ABPM MOC credits.

ACOEM continuedDisclosure PolicyAs a sponsor accredited by the ACCME, ACOEM must ensure balance, independence, objectivity, and scientific rigor in all of its educational activities. In accordance with the Accreditation Council for Continuing Medical Education’s Standards for Commercial Support, all CME providers are required to disclose to the activity audience the relevant financial relationships of the planners, teachers, and authors involved in the development of CME content. An individual has a relevant financial relationship if he or she has a financial relationship in any amount occurring in the last 12 months with a commercial interest whose products or services are discussed in the CME activity content over which the individual has control. Relationship information appears below. All faculty are reminded that in addition to their disclosures listed here, that they are to verbally announce their disclosures (or lack thereof) at the beginning of their presentation.

Program Planning Committee Members

Jeffrey A. Jacobs, MD, MPH, MRO, FACOEM Disclosure: No relevant financial relationships

Raul A. Mirza, DO, MPH, MS, CPS/A, FACOEMDisclosure: No relevant financial relationships

Tanisha Taylor, MD, MPH, FACOEM Disclosure: No relevant financial relationships

Faculty/ModeratorsPeter Blumenthal, MD, MPHDisclosure: No relevant financial relationships

Mary Doyle, MPH, RN, COHN-S/CMDisclosure: No relevant financial relationships

AAOHN Disclosure

“A Systemic Approach to Assessment and Treatment of Pain” March 14, 2018

The planners and faculty members for this offering present no conflicts of interest affecting this continuing education activity. There is no commercial support involved in this activity, discussion of off-label drug use, nor any implied endorsement of any commercial product by AAOHN, NJ ACOEM or the Johns Hopkins Education and Research Center.

Participants must attend the entire offering to receive the full continuing education contact hour. A course evaluation must be completed before the participant will receive their continuing education certificate.

Mary L. Doyle, MPH, RN, COHN-S/CMDirector, Johns Hopkins ERC Continuing Education Program

MARCOEM Webinar

A Systemic Approach toAssessment and Treatment of Pain

Peter Blumenthal, MD, MPH

IMX Medical Management Services, Inc.1700 Paoli Pike, Malvern, PA 19335

800-707-0575973-818-3212 (mobile)

I’m not a judge, but I play one on TV …

Investigation Discovery

Seven Deadly Sins‘Anger’ Episode

Stepping into the room, the doctor sees …

Pain

International Association for the Study of PainIASP, 1979

“Pain is an unpleasant sensory and emotionalexperience associated with actual or potential tissue damage or descibed in terms of such damage.”

Acute: 3 days to 3 weeks [PB]ACOEM: up to 4 weeks

Chronic Pain

Bonica, John J.: The Management of Pain2nd ed., Lea & Febiger, Philadelphia 1990

“Pain which persists beyond the usual course of an acute disease … or is associated with a chronic pathologic process that causes continuous pain.”

Chronic: Over 3 months

From Temporary to Permanent Total Disability

Rules of Thumb, Expert Consensus

• 6 months TTD – 50% return to work• 12 months TTD – 20% return to work• 24 months TTD – 10% return to work

DefinitionsProductivity

Absenteeism

Absence from work or absenteeism is non-attendance when expected to work, for anyreason at all, medical or other.

Presenteeism

Decrement in performance associated withremaining at work while impaired by risk factorsor health problems.

Pain Types (1)

• Nociceptive pain is a transient response to a noxious stimulus, performs a protective function to prevent tissue injury.

• Inflammatory pain reflects tissue damage causes both spontaneous pain and hypersensitivity and has a protective function.

Pain Types (2)

• Neuropathic pain stems from a lesion in the nervous system, – due to injury to a peripheral nerve or– due to injury to small peripheral nerve fibers,

e.g. in diabetic neuropathy .

• Functional pain represents hypersensitivity due to abnormal central nervous system processing of normal peripheral sensory input. It is considered maladaptive.

Pain DimensionsFive Axis Assessment, IASP

Axis I Body Region or Site AffectedAxis II Body System Producing the PainAxis III Temporal CharacteristicsAxis IV Intensity and Time of OnsetAxis V Presumed Etiology

Psychiatric Dimensions DimensionsFive Axis Assessment, DSM IV

Axis I Clinical DisordersAxis II Personality Disorders; Mental RetardationAxis III General Medical ConditionsAxis IV Psychosocial and Environmental ProblemsAxis V Global Assessment of Functioning

DefinitionsWith language borrowed from Webster’s New Twentieth Century Dictionary

Simon & Schuster, NY, NY 1979

• Symptoms [subjective]– disturbing structural or functional deviations from

well-being, recognized by the affected

• Signs [objective]– structural or functional deviations from the norm,

recognized by a trained observer, either• nonspecific, or• specific, typical, or• diagnostic, i.e. establishing a specific disease

Common Symptoms in Ambulatory Care (I)Kroenke, K. & Mangelsdorff, D., Am J Med 1989, 86: 262-266

Symptoms in 1,000 patients

Number Organic Psychol. Unknown– Chest PAIN 96 11% 6% 83%– Fatigue 82 13% 21% 66%– Dizziness 55 18% 2% 80%– HEADACHE 45 36% 0% 64%– Back PAIN 41 10% 0% 90%– Dyspnea 37 24% 3% 73%– Insomnia 34 3% 50% 47%

Common Symptoms in Ambulatory Care (II)Kroenke, K. & Mangelsdorff, D., Am J Med 1989, 86: 262-266

Symptoms in 1,000 patients

Number Organic Psychol. Unknown– Abdominal PAIN 30 10% 0% 90%– Numbness 26 19% 4% 77%– Impotence 24 21% 4% 75%– Weight loss 18 5% 28% 67%– Cough 15 40% 0% 60%– Constipation 12 0% 0% 100%

– Total 567 16% 10% 74%

DefinitionsGrading Focal Strength

DefinitionsGrading Global Strength - DOL

Personality Assessment

• MMPI – Minnesota Multiphasic Personal Inventoryhttp://download.cnet.com/s/mmpi/

• PAI – Personality Assessment Inventoryhttps://www.wpspublish.com/store/p/2893/pai-personality-assessment-inventory

• ACE Scale – Adverse Childhood Events‘when it’s not one thing, it’s your mother’

• Life Events Scale

Global Pain Measures

• Pain Analog Scale• Ransford Pain Drawing & Scoring• BPI – Brief Pain Inventory – cancer pain• Oswestry Low Back Disability Questionnaire• McGill Pain Questionnaire

Functional Disorder Assessment

• Fatigue Severity Scale• Fibromyalgia tender points 1990• PHQ-15 – Somatization Symptom Severity Scale

Fibromyalgia

Regional Pain Assessment

• www.orthopaedicscore.com – QuickDash, etc.• Boston Carpal Tunnel Questionnaire• Male Sexual Function Questionnaire• Female Sexual Function Questionnaire

Clinical Crossroads, Jennifer E. Potter, MD, Discussant, JAMA 2007: 297(6), 623

• Pelvic Pain Questionnaire NHI-CPSI• CRPS Criteria - Budapest

Seven years after three fingers of the right hand went into a table saw …

Neuropsychiatric Assessment

• Folstein Mini-Mental State Evaluation• SLUMS Examination

– for soldiers• MOCA Test

– for presidents

Psychiatric Assessment

• BRPS Brief Psychiatric Rating Scale• General Anxiety Tool• PHQ-9 Depression Scale• Zung Depression Scale• Columbia Suicide Severity Rating Scale

Zung Depression

Scale Sample

Psychiatric Disorders and Conditions Comorbid with Chronic Pain Syndrome

Daniel Greenfield, MD, 1999

Comorbid Psychiatric Condition

Depressive disorderAnxiety / Panic disorderPost-traumatic stress disorderPhysical or sexual abuse

Epidemiologic Prevalence

22 – 78%50% or higher‘high prevalence’‘high prevalence’

Impact Assessment

• PDQ Pain Disability Questionnaire• ACPA Quality of Life Scale• ADL Index• Activities of Daily Living• Katz Index of Independence• Global Functioning Scale• Karnofky Performance Scale

Functional Assessment Tools

• Folstein Mini Mental State Evaluation• Global Functioning Scale

– featured in DSM IV

• PDQ Pain Disability Questionnaire– featured in NY Workers Compensation Guidelines

• Activities of Daily Living– featured in AMA Guides 5th Edition

• Katz Index of Independence

Treatment Modalities

• Reduction of fractures• Splinting of sprains• R-I-C-E

Objective: Treat where it hurts

• NSAIDS – non-steroidal anti-inflammatories• Opioids• Oral steroids• Local Steroids – ‘blocks’• Nerve ablation

Surgical Treatment Modalities

• Reduction and internal fixation of fractures• Surgical stabilization of spinal joints• Surgical release of

– bony tendon impingement– peripheral nerve impingement– nerve root impingement by spurs and discs– cord impingement [spasticity and gait changes]

Electrical Treatment Modalities

• Electrical stimulation- Percutaneous – TENS- Root – Dorsal root ganglion stimulation “DRG”- Spinal – spinal cord stimulator “SCS”- Cerebral – deep brain stimulation in terminal

cancer pain

Physical Treatment Modalities

• Rehabilitation – physical therapy– Restoring range of motion– Restoring strength– Restoring normal sensation– Restoring confidence– Overcoming fear avoidance

‘Nothing works unless you do’(attributed to Wooden v. Angelou)

Chronic Pain Treatment Modalities

• Gabapentinoids• Tricyclic antidepressants• Serotonin - norepinephrine re-uptake inhibitors• Home exercise training

Goal: Increase of function

Medical Treatment Modalities Differentiated

• Nociceptive pain– NSAIDS, Opioids, Steroids

• Neuropathic pain ‘burning’– Tricyclic antidepressants, Gabapentinoids

• Neuralgic pain ‘sharp, shooting’– Gabapentinoids, Baclofen

Objective: Treat how it hurts

Adopted from McCaffrey & Pasero, Pain: Clinical Manual, Mosby 1999

Other Chronic Pain Treatment Modalities

• Cognitive behavioral therapy• Self-help groups• Progressive relaxation• Home exercises• Tai-chi• Acupuncture

– I have always been uncertain about Heisenberg

Goal: Increase of function

Injury and Dis/Ability

Definitions

• Flare of symptoms previously encountered, with return to baseline = Exacerbation

• Permanent worsening of symptoms previously encountered = Aggravation(Additional impairment of previously injured body part requires new clinical signs or structural findings)

References - Causation

• Mark Melhorn, MD , James Talmage, MD, William Ackerman, MD and Mark Hyman, MD Guides to the Evaluation of Disease and Injury Causation2nd Edition, AMA, Chicago, IL 2011

• Bruce B. Bernard, MD, MPH, editorMusculoskeletal Disorders and Workplace FactorsNIOSH Report 97-141

Arbiters of Causationand Apportionment

• Old primary care records• Old specialty care records• ISO Search

Pain Behavior

• ‘those behaviors that communicate to others the fact that pain is being experienced.’

Fordyce, W.E., Behavioral methods for chronic pain and illness .St. Louis, Mosby 1976

• ‘Pain behavior is a form of abnormal illness behavior and includes audible and body language, displays of grimacing, bracing or guarding, persistent complaints, repeated visits to physicians and emergency rooms , and excessive use of analgesic and/or sedative drugs.’

Aronoff, Feldman & CampionOcc Med State of the Art Review 15: 755-770 (2000)

Worries: Emory Pain Estimate ModelBrena & Koch, Anesthesia Review 2, 8-13, 1975

High pathology‘Faking good’ | Sick

Class IV | Class III|

Lower behavioral ________ | ________Higher behavioraldisturbances | disturbances

|Class II | Class I

Well | ‘Faking bad’Low pathology

Illness Behavior as Coping Technique‘Medicalization’

Brodsky, Psychosomatics 24: 673-680 (1984)

• Validation through– Invocation of a medical diagnosis– Application of medical treatment

• ‘Somatization is facilitated in cultures that acceptphysical disease for entry into the sick role, but reject psychological symptoms as an excuse for disability.’

Definitions of Illness BehaviorsSymptom Generation

• Symptoms consistent with pathology

• Symptoms inconsistent with pathology– Invention of symptoms de novo– Simulation

• mimicking known symptoms & signs• exaggeration of existing symptoms• preservation of earlier symptoms

• Malingering – (a) conscious generation (b) for gain

DSM-IV Criteria of MalingeringRogers, Bull Am Acad Psychiatry Law

18: 323-333 (1990)

• Classified as ‘condition that may be a focus of clinical attention’ - not a disorder

• Criteria:– Context of forensic exam– Discrepancy between complaints and findings– Uncooperative with exam and treatment– Antisocial personality disorder diagnosed

DSM-IV Criteria of MalingeringRogers, Bull Am Acad Psychiatry Law

18: 323-333 (1990)

• Two or more criteria qualified for the diagnosis of malingering.

• Two-thirds of the malingerers were correctly identified.

• For every malingerer correctly identified,there were four times as many bona fide patients mischaracterized as malingerers.

Base Rates of Malingering and Symptom Exaggeration

Mittenberg et al., J Clin and Exp Neuropsychol 24: 1094-1102, 2002

Where?Legal Context

• 29% personal injury• 30% disability cases• 19% criminal cases• 8% medical problems

What?Medical Issues

• 39% mild head trauma• 35% fibromyalgia &

chronic fatigue• 31% chronic pain• 27% neurotoxicity• 22% electrical injury

Challenges

• The challenge to the treating physician is to improvepatient experience and satisfaction without resortingto useless tests or the needless use of opiates.

• The challenge is to tell pain from withdrawal.

• "People may not remember what you did or said, butthey will always remember how you made themfeel." [Maya Angelou]

Pain Treatment and Drug AbuseWe have a problem – ‘who dunnit?’

National Drug Overdose Deaths, 2016

• Total Drug Deaths 64,070• Fentanyl & Derivatives 20,145• Heroin 15,446• Prescription Opioids 14,427

• Total US Casualties 58,200of the Vietnam War

National Drug Overdose Deaths

Regional Opioid Prescribing RulesCompiled by Jeffrey Jacobs, MD