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

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

3. 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

4. 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.

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

6. Components of Persistent Pain
Sensory
Evaluative
Affective
Control not Cure

7. 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

8. NeuroImage 23 (2004) 392–401

10. 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

11. 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):

12. 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

13. 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

14. Knee OA and Acupuncture
Ann. Intern Med. 2004;141:

15. GERAC
Chronic LBP
Arch Intern Med 2007;167

17. Hypnosis
Pain 146(2009)

18. Fibromyalgia: Behavioral Therapy
Cognitive BT
Cognitive BT
6-24 months
50 % reduction in % 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

19. 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
SMD Overall Treatment -.79
Journal of Pain, 2012 Vol 13, No 1 : pp 1-9

20. 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

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

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

23. 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

24. Integrative Pain Program Pain School
% change in measure 10/ / /13
Fatigue
Pain
Aerobic exercise >100 >100 >100
Pain interfering
Emotions interfering
Non-Rx to control Sxs