Transcript Chronic Pain: scope of the problem

Chronic Pain in 2010:
Where We Are,
Where We Should Be
Marco Pappagallo, MD
Professor, Dept of Anesthesiology
Director, Pain Research & Development
Mount Sinai School of Medicine, NY
Pain Medicine in 2009
PATIENT
CARE
RESEARCH,
INNOVATION
7/17/2015
EDUCATION,
TRAINING
Marco Pappagallo, MD
2
November 5, 2009: Treating the Pain Epidemic,
By JOHN TIERNEY
“Chronic pain affects more than 70 million
Americans, which makes it more widespread
than heart disease, cancer and diabetes
combined.
It costs the economy more than $100 billion
per year.
So why don’t more doctors and researchers
take it seriously?”
The Mayday Fund : a call to revolutionize chronic pain care in America. Nov 4, 2009
NIH guide: new directions in pain research: I. Bethesda, MD: National Institutes of Health. 1998 Sept 4
IMPACT OF CHRONIC PAIN
• #1 cause of
disability
• Economic
burden in US:
more than
cancer and
heart disease
costs combined
7/17/2015
Marco Pappagallo, MD
4
Chronic Pain in USA
NIH, Dec 2005
• In their life time, about 50% of
people will seek medical help for
pain
• No adequate pain relief in more
than 50% of patients with
moderate to severe chronic pain
7/17/2015
Marco Pappagallo, MD
5
Chronic Pain in America in 1999:
Roadblocks to Relief *
One in four patients have made at least 3
changes in doctors because
• doctors' lack of knowledge and skills
• doctors unwilling to treat chronic
pain (aggressively)
• pain not taken seriously
•
1998-1999 - * conducted by Roper Starch Worldwide Inc. for the American Pain Society, the American Academy of Pain
Medicine, and Janssen Pharmaceutica. The survey was conducted between October and November 1998 and released in
January 1999.
7/17/2015
Marco Pappagallo, MD
6
CHRONIC PAIN IN AMERICA 2010:
Despite its relevance and
prevalence,
chronic pain still remains
one of the weakest fields of modern
medicine
7/17/2015
Marco Pappagallo, MD
7
EXAMPLES OF
CHRONIC PAIN States
• Spine, Bone and Joint Pain
• Headaches
• Neuropathic pain related to peripheral
and/or central nervous system pathologies
• Cancer Pain
• Fibromyalgia
• Vascular (Ischemic, Inflammatory) pain
• Visceral pain
• CRPS/RSD
• Others
7/17/2015
Marco Pappagallo, MD
8
PAIN = COMPLEX END PRODUCT
COGNITION:attention,
MOOD: depression,
distraction,control,
catastrophizing
anxiety
CONTEXT:
beliefs, expectations,
placebo
STRUCTURALBIOCHEMICAL:
dopaminergic
opioidergic dysfunction,
atrophy
genetics
GENETICS
INJURY: peripheral
and central sensitization
Adapted from: Irene Tracey. Imaging pain. British Journal of Anaesthesia 101 (1): 32–9 (2008)
CAUSES
metabolic, infectious, autoimmunitary, trauma, genetics, etc.
MECHANISMS
Transient to long-lasting neurobiological changes related to the processes
of pain transduction, conduction, transmission / modulation, perception,
interpretation, behavior
CHRONIC PATHOLOGICAL PAIN
eg, back pain, CRPS, PHN, PDN, etc
EMERGING PERIPHERAL MECHANISMS
Ectopic activity of injured or uninjured pain neurons related to novel
expression /upregulation of
•
•
•
•
TRP channels (TRPV1-4; TRPA1, TRPM8)
VG Ca Ch subtypes
VG Na Ch (Nav1.8, Nav1.9, Nav1.7)
Others (ASICs,P2x, CB, PAR2, VG K Ch)
Activity initiated or maintained by factors released during
inflammation, metabolic disorders, or nerve injury, such as,
•
•
•
•
Pro-inflammatory cytokines
Growth factors (NGF)
Free radicals
Enzymes (MMPs,Tryptase)
CHRONIC PAIN AS A DISORDER OF
BRAIN STRUCTURE OR FUNCTION
How neuroimaging studies have challenged us to rethink: is chronic pain a
disease? Tracey I, Bushnell MC J Pain. 2009 Nov;10(11):1113-20.
• Functional neuroimaging:
– Thalamic CBF drop off (thalamic asymmetry)
– Descending facilitatory system activation
– Resting state networks disruption
• Anatomical neuroimaging:
– Gray matter loss (e.g., prefrontal cortex, thalamus)
• PET studies:
– Opioid and dopamine receptor availability reduction
(forebrain)
7/17/2015
Marco Pappagallo, MD
12
Chronic (Pathologic) Pain =
Chronic Illness Paradigm
It is a
Symptom
7/17/2015
It is a
Disease
Marco Pappagallo, MD
13
Examples of Field Complexity
• Comprehensive evaluation due to multiple
diagnoses and co-morbidities
• Subjectivity, individual variation,
multidimensional aspects of pain
• Multidisciplinary diagnostic skills,
multimodal therapies, multiple treatment
trials
• Prevention, education of patient,
coordination of care among multiple
specialists
• Assessments of function and pain over
time
7/17/2015
Marco Pappagallo, MD
14
MANAGEMENT OF CHRONIC PAIN
• Goals:
– 1. alleviating pain
– 2. restoring function
• Long-term assessment
of symptoms and
treatment effects
• Multimodal
• Interdisciplinary
7/17/2015
Marco Pappagallo, MD
15
Examples of Analgesics and
Co-analgesics
NSAIDs,
musclerelaxants
• Opioids
• Mixed
opioid +
NE-TEDs
Gabapentinoids
Topical
agents
7/17/2015
Marco Pappagallo, MD
16
EXAMPLE OF MANAGEMENT COMPLEXITY:
TRIAL OF OPIOID THERAPY
• Moderate to severe pain may
warrant a trial of opioids
• Long-term opioid treatment is
complex, and often based on an
even a more complex physicianpatient relationship
• Such a management requires
dedicated health care
professionals
7/17/2015
Marco Pappagallo, MD
17
EXAMPLE OF MANAGEMENT COMPLEXITY:
TRIAL OF OPIOID THERAPY
•
•
•
•
•
•
•
•
•
•
Education
Realistic treatment goals
Agreement; discuss exit strategies
Obtain consultations and diagnostic studies
Short-acting vs. long-acting opioids
Titrate
Manage side effects; opioid rotation
Reassessment & documentation
RISK EVALUATION - MITIGATION (recognize /
manage potential cases of abnormal
behaviors, addiction)
Continue Tx vs. exit strategy
7/17/2015
Marco Pappagallo, MD
18
Chronic Pain
• High utilization of care
• High cost of care
7/17/2015
Marco Pappagallo, MD
19
CHRONIC PAIN:
HIGH UTILIZATION OF CARE
PATIENTS with back pain (N=807)and
headaches (N=831) utilized and
required health care services almost 2
times more frequently than age-sex
matched controls due to symptoms
worsening, ill-defined conditions, and
low complexity mental health care
issues
–
Von Korff M, Lin E, Fenton J, Saunders K. Frequency and priority of pain patients' health care use. Clin J Pain. 2007;23:400–408.
7/17/2015
Marco Pappagallo, MD
20
Economic burden of illness
for employees with painful conditions.
White AG et al. J Occup Environ Med 47:884-892, 2005
• A 2005 insurance-claims analysis
(database of approx 600,000 insured lives)
found that total annual healthcare costs
were about 3 times higher for the group of
employees with chronic pain than for a
random sample (“average employee”)
group (P < 0.01).
• Of note, pain medication costs accounted
less than 20% of the total costs
7/17/2015
Marco Pappagallo, MD
21
Patients
with chronic pain
Primary Health Care
Provider
Current Role
7/17/2015
Marco Pappagallo, MD
22
Burden of care
Primary Health
Care Provider
Pain Specialist
7/17/2015
Medical and Surgical
Subspecialists
Marco Pappagallo, MD
23
GROWING REALITY
1. At present, most primary health care
providers do not have the
– Expertise
– Time
– Support
– Resources
to serve patients with chronic pain (or patients
with life-threatening illnesses)
2. Current system of reimbursement
disincentives Coordination of Care,
Cognitive Care, Prevention, Wellness
Approach (Integrative Medicine)
7/17/2015
Marco Pappagallo, MD
24
Who trained the PCP in Pain Medicine?
1. Pain Medicine Education Not
Standard in Medical School, trivial
during medical residency
2. Post-graduate education limited to
traditional meetings, conferences,
lectures, webinars, etc
3. No accredited pain fellowships for
PCPs
4. No innovative systems (e.g., pain
mentorship, educational and support
programs) currently available for
PCPs
7/17/2015
Marco Pappagallo, MD
25
Collaborative Care for Chronic Pain in Primary Care: a Cluster
Randomized Trial. Dobscha et al. JAMA 2009;301(12):1242-1252
• PCPs (N=42) randomized to the “assistance with pain ” group
or to the “treatment as usual” group
• Assessment of chronic pain–related outcomes, including
depression, in 401 patients with musculoskeletal pain,
moderate or greater pain intensity, disability > 12 weeks
• Assistance: team (psychologist, internist), workshop sessions;
ongoing feedback and support to clinicians.
• At 12 mo, 22 % of intervention patients vs. 14 % of usual care
patients demonstrated > 30 % reduction in the Roland-Morris
Disability Questionnaire. Also, intervention patients with
depression showed significantly greater improvements on the
Patient Health Questionnaire-9
Marco Pappagallo, MD
26
Patients
with chronic pain
Pain Specialist
Current Role
7/17/2015
Marco Pappagallo, MD
27
ACGME Accredited
Pain Fellowship Programs
• interventional based,
• accessibility essentially limited to
anesthesiologists
• at present 1-year programs,
inadequate to form well-rounded
pain physicians
• conducive to interventional pain
practice, but not to comprehensive
care
7/17/2015
Marco Pappagallo, MD
28
U.S. board-certified pain physician practices:
uniformity and census data of their locations.
Breuer B, Pappagallo M, Tai JY, Portenoy RK. J Pain. 2007 Mar;8(3):244-50
• US board-certified pain physicians
(N=2,502) represent approx 6 boardcertified pain physicians per 100,000
adult patients with chronic pain.
• if children are included, ratio of 4
pain physicians per 100,000 patients
7/17/2015
Marco Pappagallo, MD
29
The procedure-oriented
pain specialist
• Reimbursements highly incentivize
technical interventions
• “Block shop” or “pain injection” based
practice is lucrative
• Often inadequate, short-lived
treatment outcome
• At intervention completed, a frustrated
patient often returns to a helpless
referring PCP
7/17/2015
Marco Pappagallo, MD
30
LOST IN THE
HEALTH
CARE
SYSTEM:
in search of a
medical home
for chronic
pain (and
other qualityof-lifethreatening
illnesses)
AAMC 2009
MEDICAL HOME CONCEPT GAINS MOMENTUM
•
•
•
•
•
•
•
•
Model of care delivery that includes
Accessible, ATC
Patient-centered, Personalized Care,
Community-based,
Promoting patient education,
responsibility, prevention
Coordination across subspecialties,
hospitals, etc
Primary Care Focused
Collaboration W/other Health Care
Professionals (Secondary Care)
Advanced information system, EHR
7/17/2015
Marco Pappagallo, MD
32
THE MEDICAL HOME CONCEPT
Adults who have as their main health
care provider a primary care physician
rather than a specialist
– had 33% lower costs of care and
– were 19% less likely to die at a given age
compared with a matched cohort.
Franks P, Fiscella K. Primary care physicians and specialists as personal physicians: health care expenditures and mortality experience. J
Fam Pract. 1998;47:105–109. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83:457–
502. Shi L, Macinko J, Starfield B, Wulu J, Regan J, Politzer R. The relationship between primary care, income inequality, and mortality in US
states, 1980-1995 J Am Board Fam Pract. 2003;16:412–422
7/17/2015
Marco Pappagallo, MD
33
Chronic Pain : Call for a change
in Patient Care
PCP , HCP
Pain Mentor,
Support
7/17/2015
Medical Home
Cost
containment;
better care
PCP / Pain
Generalist
Concept of
Medical
home for
chronic pain
Marco Pappagallo, MD
34
HOSPITALS ?
7/17/2015
Marco Pappagallo, MD
35
HOSPITAL CARE AND PAIN
MANAGEMENT
In the first US national survey
(2008), patients give low scores to
hospitals on pain management
and discharge instructions
Ashish K. Jha et al. Patients' Perception of Hospital Care in the United
States The New England Journal of Medicine, October 30, 2008,
359;18
7/17/2015
Marco Pappagallo, MD
36
ACADEMIC HOME for pain
research in 2009?
• The field remains orphan, fragmented
among departments and programs
• Current situation in many institutions is
unsatisfactory, facing many challenges,
not conducive to the growth of competitive
translational pain research programs
7/17/2015
Marco Pappagallo, MD
37
PAIN RESEARCH in 2009?
• Less than 1% of the NIH budget was
devoted to pain research in 2008
• NIH budget for pain research has declined
sharply (10%) between 2004 and 2007
7/17/2015
Marco Pappagallo, MD
38
CHRONIC PAIN: Where are we?
where an increasing number of patients
• Fall between the cracks of the health care
system, and remain in an endless cycle,
seeing multiple providers and many
specialists
• Endure often inadequate treatments,
unnecessary or unproven procedures with
no long-term impact on comfort and
function
• Have more hospital admissions, longer
stays, and unnecessary trips to the ED.
7/17/2015
Marco Pappagallo, MD
39
CHRONIC PAIN: Where should we be?
where
• PAIN MENTORING AND SUPPORT
PROGRAMS should be available to train an
• Adequate number of health care providers,
help them evolve to become de facto primary
pain specialists , or “PAIN GENERALISTS”
and build a
• Sufficient number of community-based
MEDICAL HOMES for patients with chronic
pain (and life-threatening illnesses) and
capitalize on better care and cost containment
7/17/2015
Marco Pappagallo, MD
40
““We are born and die
in a time of pain, and
along the way, we are
likely to suffer from a
form of chronic pain”
Anonymous 2009