Board Certification (ABPMR) in Physical Medicine and Rehabilitation Sub-specialty Board Certification (ABMS) in Pain Medicine Private Practice in Lebanon and Murfreesboro, TN with emphasis on: ◦ Workers’ compensation injuries (acute and chronic) ◦ Electrodiagnostic Testing ◦ IME’s, Record Reviews in Pain Management Assistant Medical Director (part time), Tennessee Division of Workers’ Compensation
Appropriate Pain Management Referrals Psycho-social Aspects of Chronic Pain Physical Therapy and Cases Opioids and Cases Causation and Cases Clinical Pearls Summary
Need to consider primarily objective findings Understand false-positive rates of MRI’s Correlate anatomically with symptoms and signs Understand appropriateness of chronic opioid usage (take into account new pain guidelines in making that decision) Understand appropriate candidates for injections
Don’t be afraid to say: “This makes no sense anatomically—you have to become active in your self treatment and not passively reliant on pills and shots!!!”
“Narcotic seekers” – check state data bases! Chronic lumbar strain with no objective findings Axial spine pain for ESI’s and SCS placements Malingering patients Somatoform disorders
Assimilate all the data and : ◦ Be fair ◦ Be consistent ◦ Be objective ◦ Be Unbiased ◦ Be cost effective ◦ Use evidence based medicine
Recognize poor prognostic signs Document thoroughly Learn and understand causation analysis Understand physiology of the injury and appropriate MMI date Have excellent exam skills, knowledge of anatomy, and take the time to listen and examine the patient
Separate the legitimate “slow-healer” from the “malingerer” Develop a “gut feel” Develop a caring and dedicated office staff Understand appropriate use of UDS’s Don’t over-inject or “narcotic” Communicate, educate, and continually re- evaluate current treatment program
SO… As you can see, correctly practicing pain management in W/C patients takes a lot of time, effort, patience, and the appropriate “team of players”
Source: AMA Guides Newsletter Jan/Feb 2013 Scientific studies have indicated that psychological and social factors are the driving forces behind most chronic benign pain presentations There often is not a causative relationship between structural changes in the spine and serious low back pain
The most important risk factor for chronic pain in these patients appears to be personality disorders (especially, borderline personality disorder) There often is not a legitimate anatomical target as a pain generator in these patients; therefore, surgery and interventional injections often become a major gamble
SO……….. ◦ Does it make more sense, then, to move away from the concept of chronic pain as a “thing” we can surgically remove, inject away, ablate, spinal cord stimulate, or narcotic, and instead: Pay closer attention to the individual presenting with these chronic pain syndromes
Differences in basic and manual based PT (Not all PT’s are equal!!) ◦ Manual needs: Soft tissue restrictions Facet problems True SIJ problems Mixed Etiologies; especially difficult spine cases More important than opioids and injections PT (not PTA) needed in complicated case
Continuity of care is essential Encourage Active approach not Passive Understand where the best PT’s are in each location Know when to stop PT and convert to HEP (ODG Guidelines??) Don’t just order “Eval and Treat” !!
55 yo F employee of a restaurant 20+ years who presented with axial LBP after slip and fall injury 12 weeks before presentation Completed 8 visits of basic PT with no change MRI negative for “structural injury”; + DDD Husband recently been very ill; alot of “stress” 10/10 pain; on narcotics; non-functional Getting worse, not better
Exam: no neuro deficit; tearful; significant Waddell’s signs; very slow gait; took several seconds to rise from the chair Diagnosis– ?Aggravation of DDD, ?Malingering, ?Pyschosomatic Gut Feel: terrible prognosis, will have indefinite pain; “I can’t take another one of these patients!!! Why did I go into medicine as a career???”
BUT, she had some good prognostic signs: ◦ Worked for same employer over 20 years ◦ No previous claims per adjuster ◦ Had not had hands on therapy ◦ Was under a lot of stress with husband’s illness—was this a big contributor to her “worsening pain”? ◦ She was articulate and had a look in her eyes of “help me please” ◦ MRI was negative and physical exam showed no objective “damage” Did she not deserve one more chance or should I just call it MMI (by the book) and rate her???
Plan: ◦ Discussion about opioids ◦ Counseling about good prognostic signs ◦ Explained CBT concepts: “don’t give into pain” ◦ Local TPI to “facilitate” a manual therapy approach
KEYS: ◦ Refer to the right type of PT: a patient, hands on, soft tissue based therapist who could psychologically “work her through the pain” – 6 visit trial ◦ Minimal emphasis on passive medications (I did prescribe a temporary anti-depressant)
Outcome: ◦ Excellent ◦ Completed 20 visits of PT to include aggressive strengthening ◦ MMI 3 months after I saw her (6 months after injury) ◦ Released with 0% WP IR ◦ She was very happy (we hugged and teared up on the last visit!!) ◦ I learned a lot from that patient (and I have been practicing almost 20 years!)
Take Home Points: ◦ Don’t “cookbook and stereotype” patients ◦ Understand there is a difference in therapy approaches (UR is sometimes wrong!!!!!!!!) ◦ Localized TPI’s can help in the right circumstance (UR is sometimes wrong!!!!!!!!)
Take Home Points: ◦ MMI status needs to be “fluid” ◦ Be careful in interpreting positive Waddell’s signs ◦ Don’t just assume the only treatment is pain pills!! ◦ Communicate and develop a rapport with the adjuster
55 yo M s/p MVA on job with neck pain referring to mid arm 8 months out from injury, no better Had multiple meds, basic non-manual PT, MRI showing multiple disc bulges and HNP at C7-8 PE: normal neurologically, no abnormal illness pain behavior, significantly decreased ROM; + facet load test
Dx: ???? Is that HNP symptomatic? Referred for “pain management”; deferred permanent restrictions to me 7% WP IR given (HNP with NVR symptoms)
Treatment: ◦ Manual PT with facet joint mobilization, minimal non-opioid medications, no injections/rhizotomies Outcome: ◦ Pain free after 10 visits, MMI, regular duty, 0% IR, happy patient and no need for chronic “pain management”!! ◦ BUT, he was a good patient who wanted to improve!
Take Home Points: ◦ Again, not all PT is the same ◦ Just because a patient is no better months after the injury doesn’t mean: He’s “faking” He’ll never get better He needs chronic pain management; he needed and wanted just to be “fixed” ◦ UR certainly would have denied further treatment with “PT” stating patient should be well versed with a HEP at this stage; one has to take it “case by case”
45 yo F working as cashier at grocery store with “repetitive overuse injury” 10 years ago W/U negative but underwent TOS release and no improvement “pain management” Failed good manual therapy with emphasis on facet mobilization, deep soft tissue work, stretching, and strengthening as well as TPI’s Treated with chronic Ultram with so/so success
Had a data base profile problem (honest mistake) BUT: I had had a rough encounter on the patient before her; I went into the room in a terrible mood and overly “chastized” her for her inadvertent mistake; my head nurse scolded me after she left and I felt terrible!!!
Next visit: ◦ Patient told me had it not been for my “sweet nurse”, she would not have come back ◦ Refused more Ultram ◦ Asked for massage therapy approval ◦ I explained nicely my concerns, UR mentality, etc but said I would try to order 6 visits (out of guilt!)
Outcome: ◦ After 15 visits of massage therapy and Yoga (which she went to on her own), she was 80% better and off drugs, working, and felt the best she had felt in 10 years! ◦ On f/u 6 months later, still doing well using Yoga
Take Home Points: ◦ UR would have never approved the massage therapy nor would have private insurance paid for it ◦ Insurance adjuster fortunately approved it ◦ The research studies are not always applicable to every patient! ◦ I WAS WRONG!! (and I admitted it to the patient)
BUT: she was a good patient and wanted to get better without drugs Maybe there is something to this “alternative medicine”!! I’m blessed with good nurses who set me straight if I stray off course!
◦ In 2011, TN had the second highest per capita RX rate for opioids in the US ◦ Unintentional overdose deaths increased more than 250% from 2001 to 2011, exceeding deaths due to motor vehicle accidents, homicide, or suicide in 2010 ◦ The number of babies born dependent to drugs who suffered from Neonatal Abstinence Syndrome grew 10 fold from 2001 to 2011(over 900 cases in TN last yr) ◦ Worker’s compensation programs have seen the number of people treated for substance abuse increase five-fold in 10 yrs
◦ Chronic pain is a significant health problem: 116 million US adults (> than heart disease, DM, and cancer combined) ◦ Acute/chronic pain one of most common reasons for physician visits ◦ 16% of W/C medical costs in TN are related to drugs (in US: 11%); 20-30% are opioids (#1: Hydrocodone) ◦ Risk of overdose/death increases with higher dosages, especially if taking benzodiazepines ◦ 75% of drug overdose deaths are unintentional!!
◦ Goal of Pain Intensity Decrease: 30% decrease in pain scores 4/10 on VAS ◦ Why the Love for Hydrocodone? Can reduce anxiety, boredom, emotional pain, and increase self esteem There is an “on and off” reward system that can backfire Maybe this is why patient doesn’t want to stop the drug even when reported pain level is 8/10!!
Use of opioids for chronic cancer pain is clear cut Use of opioids for non-malignant pain is not No studies have shown long term use has reliably decreased the magnitude of pain or improved overall health and function Studies have shown the many potential adverse effects and risks
On >100 mg MEDD ◦ Adverse effects risk increases 9X ◦ 80% of overdose deaths On >200 mg MEDD ◦ Mortality rates increase 5X Overall addiction rates vary from 3% to 30% My biggest battle is not with addiction, but tolerance
Positives: ◦ “I feel better” ◦ Some patients have improvement in quality of life and function Negatives: ◦ No research support for long term use ◦ Addiction, tolerance, dependency ◦ Opioid Hyperalgesia ◦ Side effects: respiratory, sexual/endocrine, GI, urinary, itching, cognitive, emotional, legal, oral ◦ Costs to the system and “society”
Facts: ◦ As the number of prescriptions increase yearly, so do the numbers of adverse events (including unintentional overdose deaths), addiction/abuse, disability rates, and costs in healthcare ◦ There is no data to support overall improvement in the long run of quality of life or function
Legitimate Questions: ◦ Are these patients really better off with these drugs? ◦ Is their function truly better? ◦ Are the risks really outweighed by the benefits? ◦ What are the costs to the “system”? ◦ Are these patients really happy and content people????????? Do they “look” like they are happy?
Why do DRs not want to wean patients off opioids? ◦ Patients are reluctant because of fear of pain and may not get them back if they agree to stop ◦ DRs feel patient okay on these “if they help” ◦ DRs don’t know how to taper and are afraid of potential withdrawal ◦ DRs too busy to go thru “hassle”—a lot easier to “just write the prescription” and go to next patient
Keys in Treatment: ◦ Must have objective basis for pain ◦ Must see improvement in pain levels ◦ Must see improvement in function ◦ Must continually reassess benefit vs risk ratio ◦ Must assess aberrant behavior, monitor for abuse
Keys in Treatment: ◦ “Hold back the reins”!!! ◦ “Don’t let the horse get out of the barn”!!! ◦ “Treat for the marathon, not the sprint”!!! ◦ “Rotate, not escalate”!!!
50 yo F referred for IME with “CRPS” diagnosis General body pain with “traveling RSD” X 10 yrs Failed extensive treatment—multiple blocks (still undergoing these), PT, medications, spinal cord stimulator and peripheral nerve stimulator, CBT in-patient program On 720 mg MEDD without misuse/abuse Pain levels 7-8/10 and minimal function 15 surgeries on one foot, 2 on other
Exam: ◦ No objective signs of CRPS (no more than 1 or 2 documented in all the records to support dx) ◦ Very pleasant and no signs of symptom magnification ◦ Was not oversedated or ill-appearing
Legitimate Questions: ◦ Did she really ever have true CRPS? ◦ Does she need continued sympathetic blocks? ◦ What does one do with this patient? ◦ Is it appropriate to continue to use opioids and potentially escalate? ◦ Do the benefits outweigh the risks?
Legitimate Questions: ◦ Is she even opioid sensitive? Does she have hyperalgesia? ◦ Is she addicted to opioids? ◦ Should we worry about her being found dead some morning from unintentional overdose? (also on Soma, Valium, Prozac, and Ambien) ◦ Are the concerns over the cost of the case important to consider? ◦ My Opinion …
40 yo F with chronic neck pain, hx of 1 level fusion 10 years ago; not working but functional Never had problems with profiles, UDS’s, pill counts Low opioid risk assessment scores Always stable on Oxycontin 10 mg BID She never felt she could do without it Exam negative except myofacial tenderness
Insurance company expressed concern over chronic opioids and asked me to wean Outcome: ◦ I agreed to do so but “fussed about it to my nurses” ◦ Had “gut feeling” it would not work ◦ RESULT: No change in pain off med ◦ I WAS WRONG!!!!! ◦ I learned a valuable lesson
Take Home Points: ◦ Maybe there is something to this UR business!!! ◦ Maybe the studies are correct ◦ Maybe it is worth the “hassle” ◦ Maybe it is the “right thing” to do!!!! ◦ BUT, again, it takes the right kind of patient to have success!!!!!!!!!
25 yo M with history of failed back surgery and severe “nerve damage”; 90% leg pain Exam: definite objective nerve damage Failed PT, ESI’s, SCS, multiple non-opioid medications On chronic opioids, not working, fairly functional; mood becoming more irritable UDS problem X 2 Weaned off MS Contin 30mg BID, MSIR 10 mg BID
Outcome: ◦ Initially: Walked out cursing “I’ll never be back” “You just work for the insurance company!” ◦ Ultimately: 6 months later came back smiling; hugged all of us Working full time job; functional with kids; off opioids “I still hurt like hell, but I feel the best I’ve felt since the injury. Thank you for saving my life”
40 yo M with history of 5 back surgeries and chronic back and leg pain Failed PT, ESI’s, non-opioids Still working and very functional on initially 160 mg MEDD Low risk assessment, no abuse problems, “good guy” Stable dosages without escalation and pain levels 4/10
UR requested weaning citing various reasons Weaned from 160 MEDD to 90 MEDD successfully but he said “I can’t come down anymore and work” We’ve weaned very slowly using adjunctive meds, “the weather”, and a lot of “blood, sweat, and tears”
Take Home Points: ◦ He trusted me or we couldn’t have done it ◦ We weaned slowly and spent a lot of time explaining the risks and rationale of weaning ◦ He was a smart guy and processed what I said
Take Home Points: ◦ I disagree that he should come down further in this case as long as he: Continues to have appropriate pain levels and function Has appropriate UDS’s, profiles, risk assessments, pill counts, lack of aberrant behavior And we continually reassess his “situation”
The patient where opioids do not work or are contraindicated (but patient has objective pathology) OR, UR has denied use of opioids AND, UR has denied other treatment options What is one to do??!! Discharge? CBT? Formulated creams? OTC meds? More injections?
The doctor must utilize his/her past clinical experience and understanding of anatomy and pathophysiology Must determine mechanism of injury and correlate with symptoms Is the association plausible biologically, clinically, and physiologically? Must know the “causation” literature (Dr. James Talmage’s book)
43 yo M who complains of axial LBP with referral down RLE to knee after turning to pick up a part weighing 3# at work Exam shows L3 sensory deficit MRI shows L2-L3 HNP to right Has been treated thru system as “injury” Referred to me for IME with causation questions after “front line” doc referred to a surgeon (basic PT/NSAID hadn’t helped)
I opined legitimate pain with L3 sensory radiculopathy that matches well with MRI Recommended conservative treatment with an ESI since he is not improving I opined this was not a work related “injury”; a surgeon who subsequently saw him stated it was “work related” Just because “the pain began at work” doesn’t mean “work caused the pain”
Interventional Injection KEYS: ◦ Do not overinject ◦ Do not shotgun injections – use the Hx and PE ◦ Use injections to facilitate PT ◦ Explain potential risks and benefits; decide together ◦ Remember the placebo effect ◦ Primary goals of injections: Back to work and off the drugs!!!!
MRI’s in Low Back Pain: ◦ 25% of HNP’s resolve within 6 weeks ◦ 67% of HNP’s resolve within 6 months ◦ Most HNP’s are at L5-S1 (then L4-L5) ◦ Per JAMA 2013 article, more than 50% of MRI’s for LBP are ordered inappropriately (50% by spine surgeons!)
Opioid Induced Low Testosterone ◦ LA opioids have 5X chance vs SA opioids ◦ Especially present on >100 mg MEDD ◦ Males are more susceptible ◦ Effects reversible within a few weeks of treatment ◦ Symptoms: Decreased libido, osteopenia on x-ray, fatigue, decreased muscle mass, weakness, depression, poor pain control, hyperalgesia, increased fat deposits
NSAIDS have definite risks: ◦ GI, renal, CV (HTN, MI, CVA) ◦ 1 in 5 patients have endoscopic ulcers (no pain) ◦ 1 in 70 patients have symptomatic ulcers ◦ 1 in 150 have clinical bleeds ◦ In especially the older population, are they safer than opioids?
Drug Interactions: ◦ Hydrocodone metabolism can be impeded by use of Sertraline and Paroxetine ◦ Hydromorphone may be preferred in renal impairment over Morphine ◦ Don’t use Tizanidine and Ciprofloxacin together ◦ Don’t use Hydromorphone if have sulfa allergy ◦ Don’t use Duloxetine with Phentermine
CRPS ◦ Remember the rarity of the diagnosis ◦ Use objective, not just subjective, especially in medico- legal cases ◦ TPBS best obtained around 6 months after diagnosis to improve sensitivity and specificity ◦ Don’t forget biphosphonate trial ◦ Strong opioids usually ineffective ◦ Worse outcome if cold extremity and sensory deficit ◦ Weakness and stiffness usually persist whereas other objective signs often improve over time
All treatments of acute and chronic LBP are much less effective than natural history and non-specific factors The association of chronic LBP with DDD is weak and is much more associated with: psychological and social distresses, legal disputes, altered pain sensitivity, and drug dependency and abuse issues
Concept of Cognitive Behavioral Therapy ◦ “Internal” focus vs “External” focus ◦ Pain catastrophizing is linked to fear avoidance ◦ Fear avoidance leads to “disuse syndrome” which further worsens the pain problem ◦ Depression and disuse decreased pain tolerance promotes “pain experience” and worsening muscle activity viscious cycle/chronic pain syndrome
“Pain Management”, as you see, is much more complicated than just injections and narcotics! Emphasize not just “Is the pain better?” but instead evaluate objective findings, opioid risk assessment tools, aberrant behavior, risk:benefit ratio, functional gains with use Are these patients after all this “pain management” really happy people????????
The essence of chronic pain management, in my opinion, is best summarized by the following quotes:
“The good physician treats the disease” “The great physician treats the patient who has the disease” “It is more important to know the patient who has the disease than about the disease the patient has”