INTEGRATIVE APPROACHES TO MEDICAL MANAGEMENT

You hear the voice of the nurse saying:
“Doctor, you have a new chronic pain patient in room 1”

1. What are the Initial thoughts that would come into your mind?
2. Very negative connotations
3. “Drug-seeker”
4. What would be your concerns?
5. Medical
6. Legal

How would you approach this patient?

1. Subjective (History)
2. Patient’s perspective
3. Rapport a key
4. Communication skills critical
5. Positive bedside manner helpful
6. Medical info as you’ve learned
7. CC, HPI, Past Med/Surg History, etc

1. Objective (Examination)
2. Vital Signs
3. General appearance/affect
4. Musculoskeletal system
5. Neurologic

1. Assessment and Plan
2. Diagnostic tests
3. Treatment thoughts
4. Behavioral/lifestyle issues
5. Physical therapy
6. Medications

Goals and Objectives

1. Recognize the critical value of a patient-centered interview in patients with chronic pain
2. Review how to minimize conflict in dealing with pain issues
3. Review signs to distinguish behavioral from physiologic pain
4. Explore integrative approaches to pain management
5. Review pharmacologic approaches to augment other strategies
6. Address the role and use of narcotics

Pain Management creates many challenges in treatment

1. Subjective vs. objective issues
2. Perception is a baseline component
3. Recognizing the power of one's own buttons and emotions

HOW TO APPROACH A PATIENT WITH PAIN

1. Patient-Centered Approaches

Communication Skills

1. Non-judgmental
2. Avoid immediate “distrust” if possible
3. Watch nonverbal cues very closely
4. Open-ended questions
5. Facilitation
6. Recognizing and responding to emotions
7. Fear
8. Anger/Frustration
9. Time management
10. Negotiating common ground

2. Medical information must be obtained

1. Nature of injury/problem
2. Symptoms
3. Previous treatments
4. History of poor relationship with controlled drugs

3. Biopsychosocial spiritual information must be obtained

1. Support system
2. Work to minimize/address stress factors of isolation and control
3. Coping skills
4. Identify activities limited by pain
5. Ask patient to give his/her expectations of treatment, and to set functional goals

4. Identify activities limited by pain

1. Ask patient to give their expectations of treatment
2. Ask patient to set functional goals
3. Identify and address any sleep disorders

5. Be open about your own boundaries

1. With respect to medical management
2. With respect to availability to patient
3. Set expectation about patient’s responsibility for their health and healing
4. Patient must be actively involved in own care plan

Several studies have demonstrated health benefits of patient-centered interview alone

6. Make diagnosis

Distinguishing between physical and behavioral components of pain

1. In 1980, Dr. Waddell studied 26 clinical signs in 350 patients
2. Eight behavioral signs were consistently reliable and reproducible for suggesting non-structural pain
3. Patients with physical back problems can demonstrate Waddell signs because of fear, desire to please

Physical and behavioral components of pain

1. “Non-organic” pain does not mean “No” pain
2. The predictive value is improved if >/= 3 signs present
3. Base decisions on tests and treatment
4. on the patient
5. not the presence or absence of any one sign or finding         

EXAMINING SUCH A PATIENT
Waddell Signs

1. Superficial tenderness of skin
2. Physical pain does not make the skin hurt
3. Very rare in patients with demonstrated pathology
4. Non-anatomic tenderness
5. Crosses dermatomes or somatic boundaries
6. Magnuson’s Test: nonreproducible localization of pain (it moves during the exam)
7. Axial loading
8. Pressing on the top of the head in a standing patient
9. Should not cause LBP
10. Neck pain can occur
11. Simulated rotation
12. Standing patient, with shoulders and hips rotated in unison
13. No pain should occur as the back is not stressed
14. Distracted straight-leg raise
15. Performed when hip is flexed with knee straight
16. Organic pain will have same results with both standard and distracted SLR
17. The “flip” test adds stretch to sciatic nerve: dorsiflex foot with knee straight
18. Reverse flip (plantar flexion) relieves sciatic pain
19. Regional sensory change
20. Sensory changes should follow expected neurologic/dermatomal patterns
21. Global (stocking) changes rarely has traumatic cause
22. Few spinal conditions involve more than 1 or 2 roots
23. Carefully check and recheck sensory changes on each side and in affected areas to look for inconsistencies
24. Regional weakness
25. Muscle weakness follows expected patterns
26. Any test of 5/5 suggests normal muscle group function
27. True weakness in a muscle
28. Results in smooth overpowering with resistance;
29. “Breakaway” or sudden giving way suggests behavioral origins
30. Overreaction
31. An exaggerated, nonreproducible reaction to light touch
32. Also inappropriate sighing, grimacing, collapse

Other Signs to Check

1. If limping, look at shoe wear pattern
2. Check canes, braces and supports for          wear
3. Look at callous patterns in laborers
4. If unable to work
5. They disappear in 3 weeks
6. Mankopf’s test:
7. Palpation of painful area should raise pulse by 5%
8. O’Donoghue’s maneuver:
9. Passive ROM greater than active with physiologic pain
10. Suspect behaviorial if reversed
11. Hoover’s test:
12. Hold heels of supine patient up off table
13. When one leg is raised easily, the test is negative
14. If this is difficult, someone with physiologic pain will compensate by pushing contralateral leg down against your hand
15. Lack of this downward pressure is a positive behavioral sign

Remember:

1. Know about behavioral aspects of pain
2. Try to avoid playing “detective”
3. To “Prove” the patient is “drug-seeking”
4. To be punitive
5. Creates “You” against “Them”

Basic Integrative Approaches
These include

1. Behavioral choices/issues

1. Diet
2. Anti-inflammatory for RA, asthma: less animal fat, omega 3 vs omega 6
3. Exercise/weight loss
4. Personal habits
5. Role of nicotine in chronic pain
6. Choice of “relaxants” like alcohol
7. Coping skills & support system
8. Stress reduction efforts and options

2. Multi-disciplinary involvement

1. Psychologic support/counseling
2. Behavioral and cognitive approaches
3. Patient education an important factor at decreasing fear and anxiety
4. Group process -Pain group
5. Works to improve coping and reframing of pain issues

Other Frequently Utilized and Accepted Approaches
These include

1. Placebo Effects

1. Influence on patient outcome in all cases
2. Often greater than 30% effect frequently cited
3. Similar effects to meds
4. No way to predict
5. Emerging research on nocebos

2. Mind-Body

1. Simple Relaxation Techniques
2. Mindfulness Meditation
3. 225 patients studied for 4 years
4. Significant impact on McGill Melzack Pain Rating Index

3. Psychoneuroimmunology

1. Relationship of stress to immune/endocrine systems
2. Psychological stress and myocardial ischemia
3. Plays key role in patient’s perception of pain
4. Isolation and autonomy main factors in creating negative stress

4. Hypnosis

1. Can treat pain in acute situations
2. Fractures, Surgery

5. Acupuncture (NIH consensus statement)

1. Postop dental pain
2. HA, fibromyalgia, myofascial pain
3. Conflicting meta-analyses in chronic pain
4. May not be effective in nonspecific chronic low back pain, but existing studies felt to be poor

6. Manipulative Therapy for LBP

1. Agency for Health Care Policy and Research supports it
2. 1998 study
3. 321 acute with chiropractor and physical therapy
4. small but significant improvement compared with minimal intervention
5. New study suggesting massage may be as good or more effective than acupuncture or state of the art self care
6. Osteopathic manipulation

7. Other Approaches Utilized but not Well-accepted

1. New research
2. Writing about emotionally traumatic experiences reduces symptoms in
3. Rheumatoid arthritis
4. Asthma
5. Magnetic Therapy
6. Animal models show blockade of dorsal root ganglion neurons
7. Extensive article in PM & R, August 1999, reviewing criteria/research utilizing magnetic therapy
8. Strong evidence for EMF in bone, neurologic, pain and sleep disorders. 
9. 26 of 33 double masked studies showed beneficial effects. 
10. Caution re: non-scientific claims that abound
11. TENS/Pulsatile EMF (PEMF) established modalities for bone and orthopedic injuries
12. Big “Cottage Industry” at present
13. Aromatherapy
14. Early clinical trials in process
15. Uncertain and varied mode of action
16. Placebo, parasympathetic response to touch/smell, pharmacokinetic potential of drug by oils or pharmacologically active ingredients all proposed
17. Massachusetts State Board of Nursing has accepted it as part of holistic nursing care

US Department of Health and Human Services Clinical Practice Guidelines for Acute Pain Management

1. Ia – Evidence obtained from meta-analysis of randomized controlled trials.
2. Ib – Evidence obtained from at least one randomized controlled trial.
3. IIa– Evidence obtained from at least one well-designed controlled study without randomization.
4. IIb – Evidence obtained from at least one other type of well-designed quasi-experimental study.
5. III – Evidence obtained from well-designed descriptive studies, such as comparative studies, correlational studies, and case studies.
6. IV – Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities.

Simple Relaxation

1. Jaw relaxation, progressive muscle relaxation, simple imagery
2. Good meta-analyses
3. Time 3-5 minutes
4. Simple Relaxation (music)
5. Controlled trials

Complex Relaxation

1. Biofeedback
2. Controlled trials
3. Time skilled personnel/ special equipment
4. Imagery
5. Controlled trials
6. Skilled personnel

Education/Instruction

1. Good meta-analyses
2. Time 5-15 minutes

TENS

1. Good meta-analyses
2. Needs skilled personnel, special equipment

New standards for pain management in hospitals
Joint Commission of Accreditation of Hospitals (JCAHO), July 2001
JCAHO Standards

1. Patient has the right to appropriate assessment and management of pain
2. Assess existence, nature and intensity of pain
3. Assure staff competency at assessing and managing pain
4. Establish policies that support appropriate prescription of effective meds
5. Educate patients and families about effective management
6. Assess patient needs for symptom management at discharge
7. Recognize recently publicized issue of  ADR and deaths due to prescription drugs
8. Era of new oversights and regulations dawning

Pharmacologic Classes Available

1. Analgesics

1. Acetaminophen
2. Caffeine

2. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

1. Many classes
2. Worth trying one from several before moving on
3. New COX-2 inhibitors useful adjuncts with decreased GI effects

3. Muscle relaxants

1. Cyclobenzaprine
2. Methocarbamol
3. Carisoprodol (Soma)
4. Metabolized to meprobamate (Miltown)
5. Risk of habituation, addiction
6. Benzodiazepines

4. Antidepressants

1. Tricyclics - especially with neurogenic pain
2. Pain relief before antidepressant activity
3. Receptors unknown
4. Improve sleep
5. Significant ADRs
6. SSRIs
7. Increasing experience suggest worth trying
8. As effective as TCAs but with faster onset
9. Fluoxetine (Prozac) most commonly used in class
10. Trazodone (Desyrel)
11. Maprotiline (Ludiomil),
12. Bupropion (Wellbutrin)

• Limited experience
4. Anticonvulsants

1. Carbamazepine (Tegretol) - most commonly for neuropathic pain
2. Gabapentin (Neurontin) most commonly used now in this class
3. Analog of GABA
4. Remarkably few side effects
5. Lamotrigine (Lamictal)
6. Phenytoin
7. Valproic acid

6. Narcotics

1. Previously felt to be inappropriate in chronic pain management
2. Now becoming more accepted aspect of management
3. Expectation of physicians to treat pain; consequences for failure to do so
4. Current studies reassuring about efficacy, and not creating addiction
5. Suggest one can
6. Avoid toxicity,
7. Aberrant behavior,
8. Mental debility
9. Provide pain relief

Addiction

1. Physical dependence is the development of abstinence symptoms
2. Focus is on symptom relief and return to function
3. Addiction is characterized by
4. Loss of control
5. Compulsive use
6. Preoccupation with getting and using the medication
7. Continued use despite harm
8. Inducing addiction with use of narcotics is rare
9. Aggressive demand for narcotics is not predictable indicator of addictive potential
10. Incomplete treatment or PRN approach does create “pseudo-addictive” behavior
11. Demands for med
12. Anger, strong emotion
13. Focus on medication itself

Recommendations for Use of Narcotics

1. Have clear approach to assessing and managing chronic pain
2. Follow protocols consistently
3. Document very clearly
4. Narcotics rarely appropriate as sole approach to pain control
5. Use long-acting agents on scheduled basis
6. Can use shorter-acting for breakthrough
7. Decision to use is
8. Made mutually by the patient and physician
9. Common ground negotiated
10. Narcotic use is not a right or privilege

Candidates for Narcotics

1. Have established diagnosis consistent with pain syndrome
2. Be reliable and willing to accept their responsibility in plan
3. Have failed other approaches
4. Not using illegal drugs currently
5. Hx of previous addiction  increases risk of failure

Narcotics Contract – (Ethics)

1. List diagnosis
2. List functional goals and expectations
3. Discussion of risks and benefits of narcotic
4. Agreement to participate in integrated approach to pain management
5. Agreement to take meds exactly as prescribed
6. Agreement to get prescriptions from only one physician
7. Designation of one pharmacy for medications
8. Understanding that lost/stolen meds will not be replaced, and that early requests for refill will not occur
9. Signatures of patient and physician with date
10. Each visit should review whether functional goals obtained, and explore for signs of habituation or tolerance
11. Early dosage adjustments to reach therapeutic levels should not be viewed as habituation
12. Tolerance to Adverse Drug Reactions usually occurs within one to two weeks, but does not reflect occurrence of tolerance to analgesia

Options – Morphine Sulfate

1. Has active metabolites, morphine 3 & 6 glucuronide
2. Comes as sustained and immediate release
3. Once a day version available
4. Onset of sustained release slow
5. Some stigma, but generally acceptable

Options – Oxycodone (Percocet)

1. Has sustained and immediate release, with onset about the same
2. No active metabolites
3. One to one conversion to MS
4. No stigma

Options – Methadone

1. Inexpensive
2. Potent
3. Requires more regular dosing
4. Significant social stigma (heroin detox) may limit utility

Dosing Guidelines

1. No maximum or predictable dose for any one patient
2. Correct dose is
3. The one that controls the pain
4. Improves the function
5. With tolerable side effects
6. Adverse Drug Reactions (ADRs)
7. Tend to decrease within 1-2 weeks
8. Analgesic properties maintained
9. Constipation

Putting it into Practice

1. Patient centered Process

1. Individualized by patient, diagnosis
2. Identify approaches patient has utilized, expectations
3. Identify coping skills and support system
4. Discuss evidence-based versus anecdotal support
5. Negotiation of  functional (and realistic) goals

2. Develop treatment plan with goals listed

1. Involve patient at each step in their care plan

3. Address

1. Patient Education
2. Behavioral and Lifestyle Choices
3. Pharmacologic including prescriptions and OTC
4. Non-Pharmacologic approaches
5. Relaxation
6. Sleep