Integrative Pain Care: focus on non-opioid modalities Palmer MacKie Integrative Pain Program Eskenazi Health Dept. of Medicine, IUSOM

I wish I could show you, when you are lonely or in darkness, the astonishing light of your own being Hafiz

Objectives View Pain care as social not simply a clinical entity Identify and address all three domains of Pain Polymodal Therapy is optimal: Education(mind), participation(body),creative(spirit) Yoga, CBT, Hypnosis, Acupuncture and oral CAM all have evidence and their place but nothing trumps…. Therapeutic Relationship allows: Education, expectation and engagement

Philosophy and Goals Pain is unavoidable, suffering is modifiable Primary Goals are Two: Reduce pain and suffering Increase functioning Employ poly-modal approach Feelings, beliefs, thoughts and actions We possess ability to use these to create negative feedback loops that entrench pain and suffering. Thankfully, the reverse is true.

Willing, motivated Partner Clin J Pain Vol. 24, No.4, May 2008

Components of Persistent Pain Sensory Evaluative Affective Control not Cure

Only need to exercise on days you eat Treatment Options Co-analgesics Relaxation Response C B T Non-opioid medicine Chiropractic Cranio-sacral Nutrition Yoga /Tai Chi/Qi qong Hypnosis / biofeedback Mindfulness Meditation EDUCATION EDUCATION Progressive Exercise Aerobic Strength Range of motion Rehabilitation Medicine Massage Acupuncture Psychological Heat, TENS, ice Only need to exercise on days you eat

NeuroImage 23 (2004) 392–401

Lumbar instrumented fusion compared with cognitive intervention and exercises in patients with chronic back pain A prospective randomized controlled study For patients with chronic low back pain after previous surgery for disc herniation The success rate was 50% in the fusion group and 48% in the cognitive intervention/exercise group lumbar fusion failed to show any benefit over cognitive intervention and exercises. J.I. Brox et al. Pain 122 (2006) 145–155

Stepped Care for Affective disorders and Musculoskeletal Pain (SCAMP) Randomized Controlled Trial Intervention : 12 wk plus 12 wk Optimize depression then 6 Pain self-management Outcomes: determined at 12 months Hopkins Symptom Check list-20 Pain Severity Global Improvement in Pain Pain Interference JAMA 2009;301(20):2099-2110

SCAMP results > 50 % reduction in depression 37% vs. 16% RR 2.3 > 30% reduction in pain 41% vs. 17% RR 2.4 Global Improvement in Pain 47% vs. 12% RR 3.7 Double success: Depression and Pain 26% vs. 8% RR 3.3

Life-style and pre-diabetic Neuropathy 12 month intervention with N=32 Intraepidermal nerve fiber density (IENFD) Proximal and Distal Michigan Diabetic Neuropathy score Results: IENFD both increased Change in proximal correlated with lower neuropathic pain and sural sensory amplitude Diabetic Care 2012

Knee OA and Acupuncture Ann. Intern Med. 2004;141:901-910

GERAC Chronic LBP Arch Intern Med 2007;167

Hypnosis Pain 146(2009)235-237

Fibromyalgia: Behavioral Therapy Cognitive BT Cognitive BT 6-24 months 50 % reduction in 40-55 % in study Responders: affective distress, low adaptive coping, less catastrophizing, low pain behaviors Cut MD visits, Hospital days, lowers cost Dose response 4 trials showed no response Alter negative feelings, beliefs from dysfunctional thinking Identify harmful/incorrect thoughts disrupting progress Connect these with negative consequences Provide alternative coping and action strategies Internal nidus of control for helplessness Current Rheumatology Reports 2009, 11:443–450

Yoga Interventions: Pain and Disability Meta-analysis 12 randomized and 4 nonrandomized trials 6 trials for back pain 2 trials for headache/migraine Studies reported positive effect sizes SMD for Pain -.74 SMD Overall Treatment -.79 Journal of Pain, 2012 Vol 13, No 1 : pp 1-9

Migraine Prevention Magnesium B2/ riboflavin Butterbur Feverfew CoE Q10 Acupuncture Bio-feedback Trigger Avoidances Clin J Pain Volume 25, Number 5, June 2009 Cochrane Database of Systematic Reviews. (1):CD007587, 2009. Acupuncture for migraine prophylaxis: update of Cochrane Database Syst Rev

“I’m investing less than 7 hours a month on headache prevention and getting next to no headaches”

“The world is full of suffering… Its also full of overcoming it” Helen Keller

Pain Care Paradox Standard Approach, Individual Treatment Tincture of Time Informed and Involved Polymodal diagnosis & treatment Community: More than Par-a-docs Improved outcomes Fewer adverse events

Integrative Pain Program Pain School % change in measure 10/12 1/13 3/13 Fatigue - 28 -17 -24 Pain -13 -14 -14 Aerobic exercise >100 >100 >100 Pain interfering -22 -46 -27 Emotions interfering -22 -36 -28 Non-Rx to control Sxs 31 13 24