PAIN RECOVERY- Texters- Weekend

Warriors-Soldiers and Seniors

Louise Stanger Ed.D, LCSW, &

James Flowers Phd, LPC-S

ObjectivesDescribe and Discuss what is Pain Recovery

Demonstrate the difference between Acute and Chronic Pain using case examples

Explain the symbiotic relationship between Chronic Pain-Substance Abuse and Mental Health Disorders

Identify and Recommend Multidisciplinary Treatment Options for the Behavioral HealthCare Field

Opioid UseFor Chronic pain

Used as long back as the Summarians in Mesopotamia 1400 BC

Wars have been fought / Laws have been passed and much money has been made

When we think of today 1990 was turning point

Trick or TreatOct. 31, 2000

Pain PoliciesControlled substances are necessary for public healthPain management is integral part of medical practice. All physicians must assessOpioids are part of professional practicePhysical dependence or analgesic dependence cannot be confused with dependence Pain management encouraged

Did You Know ?There are 133 million people in the US with Chronic PainThat is 1 in 5 adults globally Physical pain increases when there is an emotional factor -Anger-Anxiety-Depression65% of all Americans see care for persistent pain at some point in their lives Opioids are frequently prescribed and over prescribed 75% of all Heroin Users Started With Prescriptions Drugs (JAMA Psychiatry 2014 Theodore Cicero University of Washington)

Cost of Chronic Pain 635 Billion dollars per year The Economic Costs of chronic pain Pain effects work days , number of annual hours worked and hourly wagesCost for year -$4,048.00 for joint pain, $5,838.00 arthritis, $9680.00 functional disabilities This is higher then what is spent yearly on Heart Disease, Cancer and DiabetesAdolescent Chronic pain 189.5 billion

American Pain Society _Journal of American Pain 2012 - John Hopkins University (2008 Medical Expenditure Panel Survey )

Economic Costs 25.6 billion Workplace Cost25 billion Medical costs (By insurers and patients )Criminal Justice 5.1 Billion (mostly jails 2.3 billion , police 1.5 billion )scientific (2011 Howard Birnbaum Analysis Group -)Boston

Scientific America,2016 Candid Conversations

When Folks Complain of Chronic Pain

Physician visits increase

Rx increases

Rehabilitation increases

Diagnostic Procedures Increase’

Invasive Anesthesia Procedures Increase

Surgical Ablative Techniques Increases

Opioid Induced Hyperalgesia

University of Colorado-Peter Grace , May 2016

Chronic Pain Lasts for several weeks, months and years and can cause its own disease

Pain signals are sent to the brain once the pain stops brain signals with acute pain stop

With Chronic pain brain signals are sent to the brain and did not stop

Center for Disease Control- March, 2016Opiates must not be prescribed for long term painPhysicians must look out for co-morbidity mental health, prior history of substance abuse-anxiety -depression etc Physicians should avoid opiates with benzodiazepinesPhysicians should avoid or eliminate 90mne

Screening and Assessment Tools

Structured Clinical Interview

Family Mapping - Genogram

BAI

BDI

MPI

MMPI-II ( If Indicated)

Formal Assessment Tools

• .The Screener and Opioid Assessment for Patients with Pain (SOAPP) 2003.

The Pain Medication Questionnaire (PMQ 2004. The Opioid Risk Tool (ORT) 2005.

The Diagnosis, Intractability, Risk, Efficacy (DIRE) was

2006.

The Screener and Opioid Assessment for Patients with Pain Revised (SOAPP-R) 2007.

Brain Plasticity Pain is often a perceptual issueEvidence suggests that “focused attention”can increase neuronal plastic and can be learned to reprogram brain pathways

Driver Distraction80 Percent of all car accidents -1.6 million

accidents yr

What do Teens and Seniors, Cell Phones have in Common ? Teens while texting or

being distracted have the same reaction time as a 70 year old senior who is driving!

Cell phones are involved in 1.6 million accidents anytime of day at least 11% of drivers are talking on the phone Cost of Motor Crashes was $836 billion dollars in 2010

Concussions Heads UpBrain injury that changes the

way brain normally functions children and teens are at greatest riskCorrelated with SA Pain MHJournal of Neurotrauma explains that a trauma to the head may have the same impact to the brain that drugs and alcohol have to the brainCDC reports there are 4-5 million concussions annually 38 million reported 2012

Concussion RecoveryRest

Light Aerobic Activity

Short Specific Activity

No-Contact Drills

Full Contact Drills

Return To Activity

Recreational

Warriors HeadNeck FaceSpine

ThoraxAbdomen

Meet Sally -40 yo Herniated Disc

Out of work herniated disc C3-C4 with nerve impingement, chronic pain syndrome;

out of work 1 year

Previous Treatments

-ESI -No benefit

Physical Therapy with traction and massage-minimal relief

Medications-Vicodin/Flexeril

Behavioral Assessment

SallyClinical Interview- Substance Abuse Assessment MMPI MPI II

Results :9/10 on pain scale sleep at 6 2 pack a day smoker MPI Sally is experiencing above pain levels and is the case with chronic pain sufferers reduced activity

Not able to do household chores: work etc

Med seeking

Sally- Treatment and Outcome

Chronic Back pain recovery managementBiofeedback-relaxation-mindfulness- yoga -stretching Psychophysiological educationGroup- Lifeskill -CBTTriggerOutcome sleeps 8 hrs a night works cut down to less then 1 pack a day decrease in medication -vicadent prn

Meet Jack 50 yo male

Previous TreatmentPrevious TreatmentsLaminectomy L3/L4, L4/L5

Outcome – increased pain, radiculopathy

Lumbar fusion and Lysis of adhesionsOutcome – failed fusion, pain continued

Physical therapyOutcome – moderate but temporary

Jack Presupposed Treatment: Drug Delivery with morphine

Behavioral Assessment ; Clinical Interview , MMPI-2, MPI,BAI/BDI , Chemical use questionnaire

RESULTS:: Activity < 3, Reported 10/10 constant pain, Sleep < 3, Used Alcohol to increase drug effect, Severe Anxiety/Depression, Results of the MPI indicate that the patient is experiencing average pain severity, above average interference (+2 SD), below average life control (-2 SD) and an above average level of affective distress (+1 SD). These findings are compared with other chronic pain sufferers. A significantly reduced general activity level (-2 SD) was endorsed. These findings are consistent with many chronic pain sufferers

Goals

May not be the Abolition of pain but adaptation to Pain

ACCEPTANCE CAN BE KEY

Paradigm Shift

Moving From Passive :Cure me Doctor to

Being an ACTIVE

Treatment Plan Biofeedback and relaxation therapy

Psychophysiological education

CBT , MI, Group Therapy

Postpone implantable drug delivery

Outcome Significant Increase in Activity (8)Reported Intermittent Pain (4-10)Sleep 7 hours per nightNo alcohol consumptionDecrease in Drug utilization -Vicodin prn Zero invasive proceduresTwo Doctor visits in 12 monthsReturn to Full time work

Hips -Knees or

Shoulders Temptation to use

Very PainfulTough Rehabilitation

Pain Recovery Management

Seniors Don’t Want to Get HiGH!!!!

Want to get well!!!

4% of the population with 30%of opioid prescriptions

Pain Recovery Muti-pronged

Approach Public Health -Prevention Government Intervention Intervention-Hub and Spoke Model -additional resources for states (given built speciality centers , special numbers Training of Professionals Pharmaceutical Development Treatment

Vermont Dept. of Health Barbara Cimaglio (Deputy Commissioner AOD

Pain Recovery Treatment

Physical Plant-Environment

Staff Training and Credentials

Philosophical Beliefs

Ethical Standards

Spiritual Underpinnings

Medical Interventions

Pain Recovery Muti-pronged

Approach Public Health -Prevention Government Intervention Intervention-Hub and Spoke Model -additional resources for states (given built speciality centers , special numbers Training of Professionals Pharmaceutical Development Treatment

Vermont Dept. of Health Barbara Cimaglio (Deputy Commissioner AOD

ResourcesCenter for Disease Control, March 2016

Scientific America -Crucial Conservations , May, 2016

ASAM National Practice Guideline for the Use of Medications in the Treatment of Addiction and Opioid Use,2016

Chou R, Turner JA, Devine EB, et al. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Int Med. 2015;162(4):276-286.

Centers for Disease Control and Prevention. NCHS Data Brief. Prescription opioid analgesic use among adults:United States 1999-2012 , Number 189, February,2015

2013 National Drug Student Data Bank