THE PAIN DECADE AND THE PUBLIC HEALTH

1
THE PAIN DECADE AND THE PUBLIC HEALTH

• Rollin M. Gallagher, MD, MPH
• Clinical Professor, Departments of Anesthesiology
  and Psychiatry
• University of Pennsylvania School of Medicine
• Director of Pain Management, Philadelphia VA
  Medical Center
• National Pain Management Coordinating Committee,
  Veteran Affairs Health System
• Editor in Chief, Pain Medicine
• Board of Directors American Academy of Pain
  Medicine and National Pain Foundation
• Immediate Past President, American Board of Pain
  Medicine

2
The Pain Decade and the Public Health

• History
• Conceptualization Lippe, Saper, Ashburn et al,
  1999
• Matriculation SB 3163
• Enrollment October 28, 2000
• Life span 2001 - 2010

3
Pain is a more terrible lord of mankind than
even death itself.

• Albert S. Schweitzer, 1931
• On the Edge of the Primeval Forest.
• New York Macmillan, 1931652

4
Pain MedicineHistory

• Epochs
• Antiquity to 19th Century
• Pain a symptom treated by purgation
• Dichotomy of pain Descartes and Byron
• Physical pain
• Mental pain

5
Pain MedicineHistory

• Epochs
• Late 19th Century to 1980s Age of medical
  science and technology
• Spine surgery and back pain disability
• Psychogenic pain, compensation neurosis and
  behavioral medicine
• John Bonica and IASP
• Gate Theory of Pain (Wall and Melzack)
• Hospice and the treatment of suffering

6
Pain Medicine History

• Epochs
• Late 20th Century to 2007
• Rise of epidemiology
• Failed spine surgery syndrome
• Geographic variation in surgical rates
• National variation in opioid analgesia
• The myth of psychogenic pain and psychiatric
  co-morbidity
• Pain diseases versus chronic pain
• Multi-factorial bio-psycho-social causation

7
DIAGNOSIS There Are Many Painful Diseases and
Pain Diseases
Inflammatory / Immunological Mediation
Nociceptive pain Caused by activity inneural
pathways inresponse to potentiallytissue-damagin
g stimuli
Neuropathic pain Initiated or caused by a
primary lesion or dysfunction in the nervous
system
CANCER PAIN, LBP, CHRONIC FACIAL PAIN (mixed
pain states)
Peripheralneuropathy
CRPS
Postoperativepain
SENSITIZATION
Arthritis
Postherpeticneuralgia
Trigeminalneuralgia
Sickle cellcrisis
Mechanicallow back pain
Neuropathic low back pain
Central post-stroke pain
Diabeticneuropathy
Sports/Exerciseinjuries
Phantom tooth pain
Complex regional pain syndrome.
8
Phenomenological Model of Pain Disease Post
Herpetic Neuralgia
Factors reducing risk for PHN Early anti-viral
treatment, Early amitriptylene, Good pain control.
BPS OUTCOMES
Chicken Pox with Infection, with invasion of
dorsal root ganglion spinal nerves in
childhood
Shingles Activation of virus and disease of
acute herpes zoster
Exposure to Varicella Virus
Post-herpetic Neuralgia
Successful Pain Control


Initial exposure
Risk factors for chronic pain Severity and
duration of acute rash, Pain
severity, Anxiety severity.
Factors enhancing good outcome Access to
appropriate pain treatment Access to
rehabilitation.
Precipitating Factors Acute illness, Stress,
Age, Immuno- Suppression, Cancer.
Predisposing Condition
9
Mismanaged chronic pain is often a personal
catastrophe! .and is a huge
public health problem.
Established effects (by research) of chronic pain

• Quality of life
• Physical functioning
• Ability to perform activities of daily living
  (ADLs)
• Work
• Social consequences
• Marital/family relations
• Intimacy/sexual activity
• Social role and friendships

• Psychological morbidity
• Fear, anger, suffering
• Sleep disturbances
• Loss of self-esteem
• Medical comorbidites consequences
• Accidents
• Medication effects
• Immune function
• Clinical depression

• Societal consequences
• - Health care costs
• - Disability
• - Lost workdays
• - Business failures
• - Higher taxes

Pain causes these problems. These problems reduce
the effectiveness of pain treatment. They must
be managed to obtain good treatment outcomes
10
Depression and Pain Comorbidity
Pain, A condition or symptom that causes or
activates depression
Pain
Remission
Recovery
Response
Relapse
Recurrence
Relapse
Normalcy
Progression to disorder
Symptoms
Syndrome
Continuation
Acute
Treatment Phases
Maintenance
Gallagher Verma, Prog Pain Res Man 2004,
Adapted from Kupfer DJ. J Clin Psychiatry.
199152(suppl)28-34. Dohrenwend BP, et al.
Pain. 199983(2)183-192. Raphael et al Pain 2004
11
Pain MedicineHistory

• Epochs
• Late 20th Century to 2007
• Rise of Neuroscience and Biotechnology
• Gate theory
• Molecular biology and neurotransmitters
• Psychopharmacology
• Neuropharmacology
• Neuromodulation
• disease

12
Pain in our wounded warriors (2002-2007)

• 686,306 OIF-OEF veterans
• 229,015 using VA services (33.4)
• 43 have musculoskeletal diseases
• (all cause pain by definition)
• - back pain most common
• 37 have mental health disorders
• Kang et al. Paper presented at War-Related
  Illness and Injury Study Center, 2007.

13
The Polytrauma Challenge

• 65 of OEF/OIF combat injuries are caused by
  improvised explosive devices (IEDs), landmines,
  shrapnel, and other blast phenomena.
• multiple visible injuries (tissue wounds)
• hidden injuries bone and soft tissue damage,
  including nerves
• 60 with symptoms of traumatic brain injury
  (TBI) hearing, vision, cognition, emotional
  control
• Over 95 have chronic pain

14
ANS activation ltltlt Stress ltltlt Pain ltltlt
BRAIN PROCESSING
Spinal cord Damage
Nerve injury

C fiber
Abeta fiber
Limb trauma
Adapted from Woolf Mannion, Lancet 1999 Attal
Bouhassira, Acta Neurol Scand 1999
15
Does early intervention make a difference?
Castillo et al. Pain 124 (2006) 321-329

• 567 severe single extremity trauma patients at 7
  years
• Predictors of poor outcome before injury
  include
• Alcohol abuse 1 month before injury
• Older age, lower education, low self efficacy
  (Gallagher Pain 1989)
• Predictors of poor outcome at 3 months
  post-injury
• Acute pain intensity, anxiety, depression and
  sleep disturbance

16
Opioid protective effect

• Patients treated with opioids for pain at three
  months post-discharge were protected against
  chronic pain..
• despite the fact that these patients had higher
  pain intensity levels and were thus at higher
  risk for chronic pain
• lending support to the theory that
• ..early aggressive pain treatment may protect
  patients from central sensitization and chronic
  pain.

17
Early, Continuous, and Restorative Pain
Management in Injured Soldiers The Challenge
Ahead

• Rollin M. Gallagher, MD, MPH
• Rosemary Polomano, PhD, RN
• Pain Medicine 20067(4)284-286
• John Farrar, MD, PhD
• David Oslin, MD
• Wensheng Guo, PhD
• Chester Buckenmaier, MD
• Geselle McKnight, CRNP
• Alexander Stojadinovic, MD

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19
THE END CPRS Pain Cycle

• Pathology
• Muscle atrophy,
• weakness
• Bone
• demineralization
• -Depression

• Pathophysiology of Maintenance
• Radiculopathy
• Neuroma traction
• Myofascial sensitization
• Brain pathology (loss, reorganization)

• Psychopathology
• of maintenance
• Encoded anxiety
• dysregulation
• - PTSD
• -Emotional
• allodynia
• -Mood disorder

Central sensitization
Acute injury and pain
Disability
Less active Kinesophobia Decreased
motivation Increased isolation Role loss
Peripheral Sensitization Na channels Lower
threshold
Neurogenic Inflammation - Glial activation -
Pro-inflammatory cytokines - blood-nerve
barrier dysruption
20
Mechanism Targets For Neuropathic Pain
Pharmacotherapy
(Adapted from Beydoun 2001)
BRAIN
Modulation by Norepinephrine Serotonin Endogenous
opiates
Tricyclics, SSRIs, SNRIs (Venlafaxine,
Duloxetine), Tramadol, Opiates
Voltage gated Ca channels (L PQ presynaptic)
Gabapentin, Pregabalin
Anti-inflammatory NSAID, Cox 2
Spinal cord
NMDA antagonists Ketamine, Dextromethorphan
PNS
NA channels Lidocaine Patch 5 CarbamazepineOxyca
rbazine Tricyclics Topiramate
?2 agonists Tizanidine Clonidine
21
Pain MedicineHistory

• Epochs
• Late 20th Century to 2007
• Emergence of the specialty of Pain Medicine
• Evolving organizational models of care
• Sequential care model
• Multidisciplinary pain center model
• Managed care model
• Pain medicine and primary care community
  rehabilitation model

22
The tertiary, sequential care model
1
1
INJURY/SYMPTOM
Emergency Services
TIME
1
Primary Care
2
2
(5)
4
Specialty Office 1
(6)
3
TREATMENT FAILURES
Specialty Office 2
3
4
ALTERNATIVE TREATMENTS
Specialty Office 3
3
5
CHASING THE SYMPTOM THROUGH A REDUCTIONISTIC,
BIOMEDICAL MODEL
Specialty Office 4
4
Gallagher RM. Med Clin N Am 83(5) 555-585,
1999.
23
The multi-disciplinary, biobehavioralpain center
model
INJURY/SYMPTOM
time
1
Emergency Services
Primary Care
1
1
5
3
Specialty Offices, Alternative Care
Treatment Failure
Treatment Success
2
2
Multidisciplinary Pain Center MD, PT, OT, Behav
Med, Voc Rehab
4
24
The managed primary care model
DOES NOT WORK FOR PATIENTS OR POPULATIONS
time
INJURY/SYMPTOM
Emergency Services
Primary Care Office
1
1
(4)
3
2
JUST SAY NO!!
Specialty Offices
Treatment Failures
(3)
6
2
5
INSURANCE LOSS
JOB LOSS

• Gallagher RM. Med Clin N Am 83(5) 555-585,
  1999.

25
Cost vs. Quality
(From W. Brose, MD)
Resource
Excess care
Best practice
Quality of care (outcomes)
26
The pain medicine and primary care
community rehabilitation model

• A systems model for pain management that is
  based on three core principles
• 1) empowerment by education of and support for
• primary care provider, patient and
  community
• 2) outcomes focus evidence based, quality
• improvement approach
• 3) shared responsibility for outcomes amongst,
  
• patient, providers, health care system, and
  payers
• 4) Easy access for early intervention
• 5) Evidence-based rational polypharmacy imbedded
  
• in goal-oriented, stepped, selectively
  multi-modal treatment (e.g., PT, behavioral,
  social)
• Gallagher RM. Rational polypharmacy in
  integrated pain treatment. Am J Phys Med Reh
  2005(S)84(3)S64-76

27
Pain medicine and primary care community
rehabilitation model
INJURY/SYMPTOM
Multidisc- iplinary Pain Center
7
1
Emergency Services
PrimaryCare ClinicalAlgorithms
Community Support Services (PT, OT,
Voc, behavioral, pharmacy)
2
Sub-specialty Eval. mgmt.
Recurrent or persistent pain impairing function
(4)
3
5
Integrated Pain Medicine Eval Services Med.
trials, PT, Blocks, Behavioral mgmt.
6
3
Treatment Failure
6
Gallagher RM. Med Clin N Am 83(5) 555-585,
1999. .
28
Algorithm for Medication Selection in Chronic
Pain With and Without Comorbid Depression
Neuropathicpain
Nociceptivepain
Pain condition depression
Secondary depression
Primary D.
Secondary sleepdisturbance
Evaluate risks
Persists afteradequateanalgesia
Evaluate risks
Persists afteradequateanalgesia
NSAIDs,Cox-IIs,opioids, lidocaine p.? doxepin
cr.?
SSRI trial
Evaluate risks
Evaluate risks
Lidocaine patchgabapentin other AED (Ca
Na channels) alpha 2 agonists
(tizanidine, clonidine)opioids
SNRIs venlafaxine, duloxetine
Antihistamine,zolpidem,etc.
Trazodone Low-doseTCA
Titrate TCAs (Na channels and SNRI)
desipramine, nortriptyline,
Adapted from Gallagher RM, Verma S. Semin Clin
Neurosurgery. 2004. This information concerns
uses that have not been approved by the US FDA.
29
The Opioid Renewal Clinic A structured approach
to managing opioids for pain in primary care
Wiedemer N, et al Pain Medicine 2007Bair M,
Pain Medicine 2007Aberrant Behavior Categories
over one year
30
OUR CONUNDRUM

• Growing societal awareness of
• 1. the prevalence of inadequately treated
  chronic pain
• 2. its impact on society
• 3. the need for access to effective pain
  treatment
• vs
• Growing societal awareness of
• 1. The rapidly increasing rate of use of opioid
  prescriptions
• 2. The increasing rate of prescription drug
  abuse
• 3. The increasing rate of prescription drug
  abuse deaths

31
Balanced Pain Policy Initiative Center for
Practical BioethicsKansas City, MO

• American Academy of Pain Medicine
• American Pain Society
• American Society of Addiction Medicine
• DEA
• FSMB
• National Association of Attorneys General
• Wisconsin Pain Policy Center
• Wisconsin Department of Regulation Licensing

32
Physicians Charged with Opioid Analgesic
Prescribing Offenses

• Goldenbaum, Donald M., Ph.D. Christopher, Myra
  Gallagher, Rollin M., M.D., M.P.H. Fishman,
  Scott, M.D Payne, Richard, M.D. Joranson,
  David, MSSW
• Edmondson, Drew, J.D. McKee, Judith, J.D.
  Thexton, Arthur, J.D., M.A.
• Author Affiliations
• Center for Practical Bioethics (Goldenbaum and
  Christopher)
• AAPM Philadelphia V.A. Medical
  Center/University of Pennsylvania (Gallagher)
• AAPM U. California, Davis (Fishman)
• Duke University Divinity School (Payne)
• U. Wisconsin (Joranson)
• Attorney General, State of Oklahoma (Edmondson)
• National Association of Attorneys General (McKee)
• Wisconsin Department of Regulation Licensing
  (Thexton).

33
PRINCIPLES OF TREATMENTSummary

• Primary prevention
• avoid injuries and diseases
• Secondary prevention
• When injuries or diseases occur, prevent or
  minimize nociception or neural activation of pain
  pathways, improve coping and adaptation, and
  restore and maintain function
• Risk management
• Tertiary prevention
• manage perpetuating factors, control pain and
  restore function and quality of life

34
Decade of Pain Control and Research

• Goals To Promote Pain Medicine
• Research
• Education
• Clinical Practice
• Advocacy Policy Development
• How are we doing after 6 years?
• A snapshot

35
Growth in the Number of Published Articles on
Pain over the Past 30 years. (Source June 10,
2003, Pub Med search with keyword pain)
Fishman S, Gallagher RM, Carr D, Sullivan Pain
Med 2004
36
Growth in the Number of Published Articles on
Nociception over the Past 30 years. (Source
June 10, 2003, Plumbed search with keyword
nociception)
Fishman S, Gallagher RM, Carr D, Sullivan Pain
Med 2004
37
Growth in the Number of Published Articles
related to pain over the past 3.5 years.
(Source August 2, 2004, Plumbed search with
keywords pain, neuropathic, nociception)
No. Published Articles ---------------------
---------------------- Search 1995-99 2000-04
Term (5 years) (3.5 years) increase Pain 59,
749 72,018 gt 21 Neuropathic 1,527 2,481 gt
62 Nociception 831 1,220 gt 47
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Journal proliferation

• Concomitantly rapid rise in numbers of journals
  devoted to pain
• 2 new academic journals started in 2000 indexed
  recently by the National Library of Medicine for
  MEDLINE, Index Medicus and Pub Med.
• - Pain Medicine indexed 2003 Imp F. 2.477
• Increased to six issues yearly in 2005
• Increased to eight issues in 2007
• Increase to twelve issues in 2009
• - Journal of Pain indexed in 2004
• Neuromodulation, likely to follow.
• Growth of review pain journals (Pain Practice,
  Pain Physician, J Opioid)
• Multiple special supplements to other specialty
  society journals (Family Practice, Neurology,
  Psychiatry, JAMA, Internal Medicine,
  Neurosurgery)
• Multiple sponsored articles and throw away
  journals

39
NIH Research Initiatives

• Pain is much more prominent in RFAs from several
  institutes.
• Challenge
• Capps-Rogers 2007 HR 2994
• The National Pain Care Policy Act 2007
• National Cancer Institute
• Challenge
• Will pain and palliative care become a
  pre-requisite in evaluating CA clinical trials?

40
VA-military Initiatives

• Senator Akaka (D-HI) introduces bill to enhance
  VA and military pain care and research
• Promoting Improvements in Treatment of Veterans
  Suffering from Chronic and Acute Pain
• Provide research funding for studies of pain in
  military and in VA
• October 15, 2007

41
Transition to Community Care
MILITARY HOSPITAL, USA MILITARY BASE CLINIC,
USA
Pain Medicine and Mental Health Services
COMMUNITY HEALTH SYSTEM
VETERANS HEALTH SYSTEM
COMMUNITY SUPPORT SYSTEM
42
SOCIETAL INTEREST

• Non-profit advocacy organizations
• American Chronic Pain Association
• National Pain Foundation
• www.nationalpainfoundation.org
• American Pain Foundation
• www.painfoundation.org

43
The future?

• Pain Medicine as a Specialty
• Standardize training
• Create qualified teachers of all doctors
• Medical schools
• Residencies
• Pain Fellowships
• Promote important research
• Societal Awareness for Advocacy and Policy Change
• Organization of health care
• Performance-based medicine
• Pain Medicine and Primary Care Community
  Rehabilitation Model
• Integrated medical record
• Risk management