1. Is Persistent (Chronic) Pain a Preventable Disease Ruben Halperin, MD MPH May 31, 2014

2. Conflict of Interest Disclosure Ruben Halperin, MD MPH Has no real or apparent conflicts of interest to report.

3. Objectives Understand the: – Current paradigm for treatment of persistent pain – New biopsychosocial paradigm for evaluation and treatment and maybe predicting and preventing persistent pain – Risks and benefits of opioid treatment Public health & individual health

4. Chronic Pain Treatment? How Did We Get Here?

5. The Old Cartesian Model

6. Risks vs. Benefits Public Health Individual Health What do we know about the risks and benefits of chronic opioids?

7. Risk vs. Benefit What is the benefit we are seeking? – Better function? – Decreased suffering? – Improved Quality of Life? What risks are we willing to take? 100,000,000 people in the US have Chronic pain. An effective treatment might be worth some risk......if that treatment worked

8. Risks of Opioids to Individuals are Well Known Dependence Addiction Overdose death Ventilatory Impairment/ Central sleep apnea Narcotic Bowel Syndrome Opioid endocrinopathy Opioid induced hyperalgesia

9. A 30 Year Public Health Experiment

10. Unintentional Opioid Overdoses National Vital Statistics System 2008, Centers for Disease Control and Prevention

11. Death is Not the Only Issue

12. 2010 Cost of Non-Medical Use of Opioids

13. Do Opioids Improve Function, Decrease Suffering and Improve Quality of Life? “Ask your doctor if taking a pill to solve all your problems is right for you.”

14. Danish Epidemiologic Study N=1906 : opioid users vs. matched controls Opioid use significantly associated with physical activities levels of employment self-rated health self-rated QOL by SF-36 self-reported severe pain Eriksen et al. Pain 2003

15. Kaiser NW Study Longer duration of opioid use associated with: Depression Anxiety PTSD Substance Abuse Sedative-hypnotic use Escalating doses of opioids Deyo et al. JABFM 2011

16. CON sortium to S tudy O pioid R isks and T rends Group Health + KP Northern CA For > 100 mg HR 8.87 (3.99 – 19.72) for all overdose events

17. VA/Univ. of Michigan Opioid Prescribing and Overdose

18. Cochrane review 2013 31 studies, 1237 subjects, – 10 different opioids Short term studies: – lasting up to 1 day Intermediate studies – – Up to 12 weeks – Median 28 days ( 8 – 70) 1˚ Outcome ≥ 30 or ≥ 50% ↓ pain from baseline Short term – no difference Intermediate term – Opioids better than placebo for pain reduction ≥ 30% and 50% – No difference in physical functioning

19. Efficacy of Opioid Withdrawal + Pain Rehabilitation Mayo Clinic N = 373 213 taking opioids, 160 not taking – Mean pain duration 9.4 years 3 week intensive outpatient interdisciplinary program + opioid withdrawal Follow-up post treatment and at 6 months Townsend et al. Pain 2008

20. Outcome variablePretreatmentPosttreatment6 months OpioidsNo opioids OpioidsNo opioids OpioidsNo opioids Mean (SD) Depression* 29.3 (12.4) 24.8 (12.5) 16.3 (11.7) 14.7 (10.7) 17.8 (13.4) 16.9 (11.6) Catastrophizing* 28.3 (11.5) 25.3 (13.1) 12.9 (11.0) 12.1 (12.3) 13.9 (11.4) 13.1 (11.2) Pain severity* 49.3 (8.6) 46.2 (10.3) 40.0 (12.9) 37.2 (13.8) 39.1 (14.5) 38.2 (14.7) Activity level* 52.0 (8.9) 52.7 (9.5) 58.4 (10.3) 57.9 (9.9) 58.2 (10.6) 57.7 (10.5) Health perception* 34.8 (12.7) 36.5 (12.7) 42.4 (12.7) 43.0 (11.6) 41.3 (12.3) 39.7 (12.9) Physical functioning* 28.2 (13.9) 30.4 (14.9) 39.7 (12.2) 41.2 (12.3) 37.8 (13.6) 38.9 (14.7) *p<00.1 pre to post treatment

21. It’s Time to Move Beyond Opioids

22. A New Paradigm If opioids aren’t the answer, then what? PAIN IS AN OUTPUT FROM THE BRAIN ALL PAIN IS REAL PAIN PAIN ≠ HARM TISSUE DAMAGE (nociception) IS NEITHER NECESSARY NOR SUFFICIENT FOR PAIN

23. Fear Avoidance Model Vlaeyen (2000) Sympathetic Tone, Cortisol

24. Catastrophizing

25. The Keele STarT Back Screening Tool AgreeDisagree 1 My back pain has spread down my leg(s) at some time in the last 2 weeks □□ 2 I have had pain in the shoulder or neck at some time in the last 2 weeks□□ 3 I have only walked short distances because of my back pain□□ 4 In the last 2 weeks, I have dressed more slowly than usual because of back pain □□ 5 It’s not really safe for a person with a condition like mine to be physically active □□ 6 Worrying thoughts have been going through my mind a lot of the time□□ 7 I feel that my back pain is terrible and it’s never going to get any better □□ 8 In general I have not enjoyed all the things I used to enjoy□□ 9 Overall, how bothersome has your back pain been in the last 2 weeks? not at allslightlymoderatelyvery muchextremely © Keele University 01/08/07 Total score (all 9): __________________ Sub Score (Q5-9):______________

26. Pain Catastrophizing Scale PCS Total _______

27. PCS Implications 30 is 75 th percentile - normal distribution sample of injured workers in Nova Scotia who filed work-comp claim At a score > 30 – 70% remain unemployed one year post injury – 70% describe themselves as totally disabled – 66% scored > 16 on Beck Depression Index (moderate depression)

28. Fear and Catastrophizing in the Development of Persistent Pain Self-Perceived disability, but not pain intensity at 2 months predicts disability at 6 and 12 months 1 Psychological factors and opioid use predict disability 2 mos. after skeletal trauma 2 Catastrophizing was the sole independent predictor of disability at 5-8 mos. 2 Severity of injury and extent of surgery did not predict disability at 2 mos. Or 5-8 mos. 2 1 Epping-jordan et al. Health Psych 1998 2 Vranceau AM et al. J Bone Joint Surg Am. 2014 Feb

29. Catastrophizing Pain Catastrophizing associated with Pain intensity Pain related activity interference Disability Depression Alterations in social support networks Severeijns et al Clinical J Pain, 2001

30. Catastrophizing Predicts Poor Surgical Outcomes Pre- TKA, ↑ catastrophizing associated with: post- op pain rating 1,2,3 increased disability 1,2,3 increased opioid usage 2 increased length of hospital stay 3 1Riddle D et al. Clin Orthop Relat Res. Mar 2010 2Forsythe ME et al. Pain Res Manag. Jul-Aug 2008 3 Vitvwrow E et al. Knee Surg Sports Traumatol Arthrosc 2009

31. Changing Beliefs Changes Function 141 patients, 3 week multidisciplinary pain treatment (UW) ↓ catastrophizing, ↓ belief that pain = harm, ↓belief that one is disabled self-report disability, pain intensity depression Jensen MP et al. Pain 2001 Jensen MP et al. Pain 2007

32. Catastrophizing and fear avoidance can be treated Engaged, activated patient Multidisciplinary team Behavioral health intervention Pain education / cognitive change of faulty beliefs Return to activity/pacing Self-management/self-soothing techniques

33. More Importantly Identifying Catastrophizing and Fear early can help us predict who is at risk for developing persistent pain