Demanding Better Psychotherapy

Psychotherapy is undergoing a veritable revolution.  And if you're not paying attention, you could miss opportunities to change attitudes, spend less, and save lives.

For nearly a century, the field of psychotherapy (which includes cognitive behavioral therapy and other modalities common in the treatment of chronic pain) has been deemed a subjective and ethereal art based on human relationships, perception of progress, and patient self-reported outcomes. Therapists argued such things couldn't be measured, objectified, or codified.  This feels intuitive to most of us - how can the assessment and treatment of behaviors, thoughts, emotions, and reactions be reduced to mere data points, bar graphs, or pie charts.  Contemporary medical evidence appears to suggest these modalities are efficacious and that's sufficient for most of us to accept the status quo in the field.

The latest issue of The Atlantic Monthly contains an article by Tony Rousmaniere, What Your Therapist Doesn't Know.  Recognize that last name?  Only after reading the article and penning the first draft of this post did it occur to me to reach out to the estimable Peter Rousmaniere to ask if Tony was any relation.  In fact, Tony is Peter's oldest son.  I should have guessed.

In the article, we learn about feedback-informed treatment (or FIT).  In a space where 25 percent of patients drop out of therapy (likely higher among chronic pain cases, but that's just a guess on my part) and 5 to 10 percent of patients actually get worse during the course of treatment, wouldn't it be nice to be able to quantify, and perhaps even predict, patient progress?  Turns out, over 50 different (and, I suppose to some extent, competing) feedback systems have been developed over the past 20 years.  Most involve detailed questionnaires administered to patients and designed not only to measure progress, but also to help therapists identify blind spots (like when a patient might be offering less than truthful feedback directly to the therapist... or about to drop out of treatment... or getting worse).  One such feedback system was able to predict - with 85% accuracy and after only three sessions of therapy - which patients would deteriorate.  

New medical technologies, practice techniques, and methodologies can take a long time to be adopted into every day clinical application.  Rousmaniere discusses the history of the thermometer - at one point, taking a patient's temperature and using that data as a tool in diagnosis was considered heretical and potentially dangerous to the practice of medicine (in that it might make doctors lazy and dull their skills as diagnosticians).

The time has clearly come for injecting data, metrics, and objective performance feedback into psychotherapy.  And since payers are hearing the constant drum beat of "psychosocial... mental health... CBT...", the thought occurs to me that the least we can do, if we're going to pay for this apparently efficacious intervention, is demand feedback-informed treatment for injured workers.  We would demand no less in virtually every other area of medicine.

Why settle here?

Michael
On Twitter @PRIUM1

A Way to Fix a Drug Problem Without More Drugs?

Like many of my colleagues here at PRIUM and acquaintances outside of PRIUM who focus on chronic pain day in and day out, I get all manner of articles forwarded to me from friends about opioids and related medical treatment advances.  There's the spider venom that may hold the key to a more effective non-opioid painkiller.  There's the big-data, molecular-lottery approach that promises to identify medications capable of delivering pain relief without opioid side effects.  There's the on-going debate regarding medical marijuana's potential to stem opioid use.  This is just a sampling of the many studies, articles, ideas, and whims that appear in my inbox on a regular basis.

The theme that sticks out to me is the collective focus we seem to have on fixing a drug problem with more drugs.  

This reminds me of the unsettling moment at last year's National Prescription Drug Abuse and Heroin Summit here in Atlanta when Surgeon General Dr. Vivek Murthy offered some opening remarks prior to the arrival of President Obama at the conference.  In those remarks, he outlined a five-step strategy to combat prescription drug abuse and heroin and the first two steps were medication-based (#1 was expanding access to naloxone and #2 was expanding access to suboxone).  I think highly of Dr. Murthy and applaud his critical efforts to combat addiction in all its forms.  And I'm not even sure his plan isn't exactly what we need.  I was simply struck, again, by this theme of fixing a drug problem with more drugs.  It seems somehow counter-intuitive to me or, at least, not getting at root-cause issues.

So I was intrigued last week when I read about a study out of the University of Utah, Duke University, and Washington University in St. Louis.  The collaborating bioengineers have figured out a way to potentially manipulate our genetic code to suppress chronic pain.  For those rightly uncomfortable with the idea of messing with human DNA, the researchers are not editing or replacing genes.  Instead, they're using something called the CRISPR (Clustered Regularly Interspaced Short Palindromic Repeat) system to modulate the way genes turn on and off in order to protect cells from inflammation and tissue breakdown.  Early experiments point toward the possibility of eliminating the inflammation, cell death, and tissue damage associated with, say, low back pain caused by a herniated disc.  Sounds useful.  

Three quick observations:
1) This is at least 10 years away from human application.
2) Even then, it's not a panacea.  Surgery may still be required to fix underlying, biological causes of pain (though wouldn't it be nice to isolate that from non-biological, psycho-social contributors to pain?)
3) This work was funded by a National Institutes of Health grant, the likes of which could disappear if the current draft White House budget were to be adopted.

Michael
On Twitter @PRIUM1

We're Skipping the Simple Steps in Chronic Pain Management

"Take deep breaths.  Drink lots of water.  Get some extra sleep."

This is the prescription I tend to apply, at least initially, to all complaints of illness emanating from my three children.  I find it's effective approximately 90% of the time.  For the 10% of the time it's not effective, we escalate to mom... and occasionally from there, we head to the doctor.  Nothing special here, just basic triage for childhood illness.  

The problem I see is that adults often skip a step or two (or three) in this process.  And there's a lot of scientific data to support the reliance on these initial steps in the management of chronic pain.

Take Deep Breaths
There's ample evidence to suggest that relaxation techniques and mindfulness exercises can significantly influence chronic pain management.  This study, among dozens of high quality studies available (and hundreds more of lower quality), showed a >50% decrease in Total Pain Rating Index for 50% of the patients involved in the study.  Granted, small sample... but really compelling results.  Why did I pick this study to highlight?  It was published in April 1982.  This isn't new, folks.
An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: Theoretical considerations and preliminary results.

Drink Lots of Water
The link between dehydration and chronic pain is a little more recent, but still compelling.  A recent study from the journal Psychophysiology linked hypohydration (not as severe as dehydration, but still not healthy... essentially, most of us are walking around hypohydrated) with lower pain sensitivity thresholds.  We also know that the discs in the lower back require proper hydration for optimal functionality.  Getting enough water also effects are immune system response.  We've been told since we were kids to drink lots of water, it's just that none of us actually do that.
A preliminary study on how hypohydration affects pain perception

Get Some Sleep
Sleep hygiene is among the most overlooked elements of chronic pain management.  This topic is admittedly made complicated by the 'chicken and egg' nature of problem - to manage chronic pain, one needs to get more sleep, but sleep is often inhibited by chronic pain symptoms.  This nasty cycle is often addressed by sleep aid medications which are not indicated for long term use (and, as we well know, that doesn't stop them from being used long term).  One way off of this hamster wheel is ensuring that relaxation and hydration are incorporated into daily habits.  Along with mindfulness techniques, one must also incorporate a simple set of sleep management tips that are hard for people to come to grips with: going to bed and waking up at the same time every day, no television or other electronic devices in the bedroom, no alcohol or caffeine assumption.  How many Americans, in chronic pain or not, can pull of that bedtime routine?
Pain & Sleep: Information from the National Sleep Foundation

No, not all chronic pain can be managed by taking deep breaths, drinking lots of water, and getting plenty of sleep.  Some chronic pain has to be escalated to the care of medical professionals and these patients deserve the best, evidence-based care available.  But far too often, chronic pain is diagnosed and immediately treated with surgery and/or medications without an attempt at patient self-regulation based on simple principles of mindfulness, proper diet, and good sleep hygiene - all three of which, when missing, significantly contribute, even exacerbate, chronic pain.

Take deep breaths.  Drinks lots of water.  Get some sleep.

Michael
On Twitter @PRIUM1

Chronic Pain: Do We Even Know What We Don't Know?

My wife is currently training to become a yoga instructor.  Our conversations have begun to revolve around concepts like "being present" and "finding my center."  I'm a somewhat reluctant participant in such conversations and even though I understand all of the individual words being used, I admit the concepts are largely lost on me.  One thing that has resonated with me, though, is the humility that one can derive by recognizing what one does not know.  We can start to develop more rational and realistic responses to life's problems when we step back and question the basis of our views.

Two studies caught my attention recently and reminded me of this important principle.  In the swirl of debate and conjecture surrounding contemporary approaches to pain management, I think it's critical for us to distinguish what we know and what we don't know.

First, from the joint efforts of radiology service provider Spreemo and the Hospital for Special Surgery (HSS), we learned that objective diagnoses for low back pain aren't as straightforward as one might think.  A single patient was sent to 10 different centers to get an MRI of the lower back.  Of the 49 distinct objective findings identified across the 10 centers, not a single finding was identified by all 10 centers.  The study points to a potential diagnostic error rate of up to 43%.  

Next, from the Proceedings of the National Academy of Sciences, we learned that opioids might actually prolong neuropathic pain.  The paper titled "Morphine paradoxically prolongs neuropathic pain in rats by amplifying spinal NLRP3 inflammasome activation" is a technical piece, to say the least and I won't claim to have comprehended all of it.  But here's a snippet from the conclusion of the paper that I did understand (mostly):

In summary, the mechanisms underlying the transition from acute to chronic pain are poorly understood. We discovered that a short course of morphine administered upon expression of neuropathic pain remarkably doubled the duration of CCI-allodynia. This process was dependent upon dorsal spinal microglial reactivity and NLRP3 inflammasomes. These findings comport with prior demonstrations that repeated immune challenges induce a transition from acute to chronic pain, which may also underpin pain comorbidities. An evaluation of the long-term consequences of opioid treatment for chronic pain will identify whether this phenomenon manifests clinically.

It's really astounding to think about how much we don't know when it comes to chronic pain.  For all the time we spend debating the use of opioids for the treatment of low back pain, it's both frightening and illuminating to realize we get the diagnosis wrong almost 50% of the time and the drugs we use to treat it might actually make it worse.  

Long way to go...

Michael
On Twitter @PRIUM1

The Bio-psycho-social Model: Challenges in Application

Hardly a day, a conference, a meeting, or a case goes by without a serious discussion about the need for a 'biopsychosocial' approach to injury resolution.  In fact, I've recently heard griping in some circles that the discussion has run its course.  "We get it... can we talk about something else now?"

Sigh.  We don't get it.  And we still have a lot of work to do.  I offer the following observation as proof of such...

A study hit my desk this past week from the Journal of Occupational and Evironmental Medicine and I'd like to ask for your forbearance as I share the abstract:

"The cost and prevalence of chronic work-related musculoskeletal pain disability in industrialized countries are extremely high.  Although unrecognized psychiatric disorders have been found to interfere with the successful rehabilitation of these disability patients, few data are currently available regarding the psychiatric characteristics of patients claiming work-related injuries that result in chronic disability.  To investigate this issue, a consecutive group of patients with work-related chronic musculoskeletal pain disability (n = 1595), who started a prescribed course of tertiary rehabilitation, were evaluated.  Psychiatric disorders were diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders.  Results revealed that overall prevalences of psychiatric disorders were significantly elevated in these patients compared with base rates in the general population.  A majority (64%) of patients were diagnosed with at least one current disorder, compared with only 15% of the general population. However, prevalences of psychiatric disorders were elevated in patients only after the work-related disability.  Such findings suggest that clinicians treating these patients must be aware of the high prevalence of psychiatric disorders and be prepared to use mental health professionals to assist in identifying and stabilizing these patients.  Failure to follow a biopsychosocial approach to treatment will likely contribute to prolonged pain disability in a substantial number of patients."  

Great study, right?  Isn't that the right message?  And we couldn't ask for a more specific sample set: Work related!  Musculoskeletal pain!  Disability!

Here's the kicker: this study was published in 2002 (J Occup Environ Med, 2002; 44:459-468).

I thought that had to be a typo.  It's not.  Sadly, even in these modern times in which information flows freely and ubiquitously, contemporary healthcare and insurance models still take close to two decades to translate research into clinical practice.  Some see this phenomenon as madness without method.  My own view is that the disconnect is driven not by laziness, lack of awareness, or lack of desire to apply new clinical knowledge.  Rather, the time lag between the establishment of evidence and its clinical application is created by the very hard work of leaping from intellectual recognition to actual clinician behavior change.  We sometimes fall victim to the assumption that chronic pain patients are the only constituency in need of behavior modification.  In fact, all stakeholders must adapt to evolving notions of clinical best practices; adjusters, nurses, claims leadership, doctors, attorneys, service providers, therapists, pharmacists, injured workers, actuaries, underwriters, brokers... all must adapt to both the clinical and economic realities of (what should be contemporary) chronic pain management.

I hear near unanimous intellectual recognition of the need to apply a biopsychosocial model to chronic pain care.  We must now do the hard work of applying this new knowledge.  For knowledge itself is insufficient to solve the problem.  One can know something to be factually true and yet fail to apply that knowledge.  Ever know it's raining... and still forget your umbrella?  Knowledge, when applied, is wisdom.  

And we have work to do.

Michael
On Twitter @PRIUM1

Economic Insecurity and Chronic Pain

Earlier this year, the estimable industry consultant Peter Rousmaniere published a report entitled The Uncompensated Worker: Financial Impact of Work Comp on Households.  In the report, Peter summarizes the realistic impact that workers compensation has on families: "The scenarios [explored in the report] show that a brief work disability often results in a sharp cut in take-home pay, after the deductibles are applied. An extended disability lasting for months can cause many injured workers to struggle to meet their household expenses, forcing these employees to dig into their savings and risk losing their financial cushion."

And in an article last week published on Insurance Business America, Mark Walls, Vice President of Communications and Strategic Analysis at Safety National, noted the economic anachronism that is our current work comp system.  "Today, there are lots of skilled craftspeople who earn more than that [an indemnity cap of $1,100/week].  For anyone who earns a good living, going on workers comp can be a devastating blow, when it should not be."

While the world certainly affords no law to make an injured worker rich, our current system doesn't even appear to allow some injured workers to avoid poverty.  These two pieces came to mind when I saw this headline recently in the Harvard Business Review: The Link Between Income Inequality and Physical Pain.  Researchers from UVA and Columbia hypothesized that there might be a link between fiscal pain and physical pain.

First, they looked at the consumption patters of over-the-counter painkillers among 33,000 US households.  Compared to households in which at least one head of household was employed, those in which both were unemployed exhibited 20% higher spend on OTC painkillers.  Next, researchers asked people how much physical pain they were currently experiencing, but did so after informing the respondent of the unemployment rate in his or her state.  Employment status again proved to be a predictor of physical pain levels and, interestingly, simply living in a state with a high unemployment rate appears to lead to higher reports of physical pain.  They also did a fun experiment involving undergraduates and buckets of ice water, but you can read the article see how that went.

The researchers sum up their findings across studies as follows: "When people encounter economic insecurity, they typically feel a lost of control.  A sense of control is one of the foundational elements of well-being.  When people lose their sense of control, their body goes a bit haywire and responds to stimuli differently - displaying a weakened resilience and a lower pain threshold."

So here's an existential question for you this Monday morning: Might the very system we've devised to address pain resulting from workplace injury actually induce pain instead?  

Michael
On Twitter @PRIUM1

When Opioids Almost Kill You, Chances Are You'll Get More Opioids

I really wanted the first post of 2016 to be positive, uplifting, inspiring... but a study I read over the break was so unnerving, I had to go and ruin "return to work" day, already a day that lives in infamy, with even more depressing news.

Researchers at Boston Medical Center used a national database of prescription information to assess the likelihood of continued opioid prescriptions after a non-fatal overdose.  They looked at prescription information from 3,000 patients who experienced a non-fatal overdose between 2000 and 2012.  These patients were all prescribed opioids for chronic, non-cancer pain. 

Think about this: These 3,000 patients have already overdosed on prescription opioids. They are lucky to be alive. Surely, their healthcare providers will find another way, another mechanism, another approach to managing their pain. The risk here isn't illness or infection or a change in blood pressure... it's death.  

The bad news:

• Over 90% of these patients continued to receive opioids after their non-fatal overdose event
• 50% of these continued to receive the prescriptions from the same doctor
• 7% of the original group experienced a second overdose
• Two years after the first overdose, those with continuing opioid prescriptions were twice as likely to experience a second overdose event compared to those who were no longer receiving opioids. 

Why is this is happening?  

First, our fragmented healthcare system doesn't make it easy for prescribing physicians to discover the clinical events experienced by their patients outside of their immediate purview.  And patients may not want to disclose an overdose event for fear of having their medications discontinued.  I get that.  And it makes we wonder whether PDMPs should also include the ability for inpatient settings to report both fatal and non-fatal overdose events to the database so doctors can see this information whether its reported by the patient or not.  Linking electronic health records to PDMP systems would be a good start down this path.    

The second phenomenon driving these sorry statistics is that doctors are not comfortable weaning opioid (and other) medications.  No one, least of all me, would ever suggest immediate cessation of opioid therapy in light of a non-fatal overdose.  That's clinically irresponsible and potentially dangerous for the patient.  But the necessary steps forward are complicated: If the patient is on multiple medications that require weaning, which should we weaned first?  What titration steps should be used?  Is medication-assisted-therapy (MAT) an option?  Should I refer the patient or try to handle this myself?  These are hard questions and the primary care community, by far the most frequent prescribers of opioids, is currently ill-equipped to handle them.

Welcome to 2016.  Once more unto the breach, dear friends.  

Michael 

On Twitter @PRIUM1  

Mental Health and Addiction: What if We Had What We Really Need?

Consider several seemingly unrelated articles that all ended up in my stack of "articles to read" just in the last three days:

First, a report from the Proceedings of the National Academy of Sciences that found that the death rate among white, middle-aged Americans has grown since the 1990s, while death rates among the same age cohort within other ethnicities and countries has continued to decline.  From the report: "Rising midlife mortality rates among non-Hispanics were paralleled by increases in midlife morbidity.  Self-reported declines in health, mental health, and ability to conduct activities of daily living, and increases in chronic pain and inability to work, as well as clinically measured deteriorations in liver function, all point to growing distress in this population."  The researchers speculated that relatively easy access to opioid pain killers may be linked to the rise in incidence of mental illness.  While I think they have the cause and effect backward, there's little doubt in my mind that the two are related.

Second, a report from WESH in Orlando on a US government study that estimates there are 4 million baby boomers struggling with addiction.  "Baby boomers," the group of Americans born within the 19 year period following WWII, are now in their 50s and 60s and they're suffering from drug and alcohol addiction at a rate that rehabilitation and recovery services cannot accommodate.  "It's hard to imagine grandma with a heroin problem," says Dr. Heather Luing, medical director at Recovery Village, "but that's the reality we sometimes see."

Third, there was a lot of international coverage of a controversial paper from the United Nations Office on Drugs and Crime (UNODC) that suggested UN-member countries should consider "decriminalizing drug possession for personal consumption."  The paper was retracted by UNODC leadership with an explanation that it was written by a mid-level policy person simply expressing a viewpoint and was never sanctioned or adopted as a formal UNODC position.  This public policy approach, however, has been tested, perhaps most notably in Portugal.  Despite warnings of potentially dire consequences, Portugal decriminalized the simple possession of all drugs back in 2001.  Since that time, Portugal has seen overall drug use fall, it has the second lowest overdose death rate in all of Europe, and HIV infections among drug users are dramatically lower,  The resources formerly focused on arresting and prosecuting simple drug possession were instead poured into mental and behavioral health, education, and job training/placement programs.  And if you think such a program wouldn't be possible in the US, check out what Worcester, MA is doing.  

What are the common themes here?

1. People are dying.  That much is statistically evident.  
2. These deaths appear to be correlated with chronic pain, drug use, mental illness, and addiction. 
3. Efforts over the last three decades to deal with the issue from a criminal justice standpoint appear to be at least ineffective and at most counterproductive.  
4. The current supply of mental and behavioral health resources in the US is nowhere near sufficient to meet demand.  

So if the demand is there, why don't we have the mental/behavioral health resources we need? Because we've never devoted the reimbursement dollars necessary, either public or private, to ensure such programs were economically viable.  But now, with the Affordable Care Act's parity provisions, we have legislatively mandated reimbursement policies around mental health coverage offered by private insurers.  The resources haven't yet caught up to the demand, but billions of dollars of private equity investment is being poured into the sector.  Hopefully, it's just a matter of time before the number of trained professionals and the facilities and technologies they need to practice are in place.

And that leads us to an interesting thought experiment: What if we did have the mental and behavioral health infrastructure we so desperately need? Could we fundamentally change how we approach drug abuse in our society?

Michael
On Twitter @PRIUM1
 

Effective Chronic Pain Treatment: An Overview

[Part 2 of 2 from PRIUM's Medical Director, Dr. Pamella Thomas]

Divergent Treatments for Chronic Pain

As I described in the previous post, chronic pain initially begins, appropriately, as acute pain – a biological event in response to noxious stimuli.  However, as time progresses, social, psychological, and cultural factors impede and complicate recovery.  These psychosocial factors become complicit in exacerbating the pain and disrupting pain management. 

Unless underlying triggers are recognized and addressed early on, the treating clinician is left to treat the symptomology of the patients’ pain, often with repeated surgeries and ever escalating doses of narcotic analgesics.  Such treatments may not be addressing the real pain generators.  More often than we’d like, surgeries are treating MRI results.  As many as 30% of these diagnostic screenings are potentially inaccurate. MRIs may return false positives that hint at physiological incongruences that are only potentially associated with the patient’s pain pathology.  Often the patient’s medical file tells a treatment story of narcotic analgesics in large doses for multiple years.  The present reality is that the patient is now both physically and emotionally dependent on these medications. 

The question then is what to do with injured workers with complicating psychosocial factors which can range from adverse childhood events (ACE) to more recent post-traumatic stress disorder (PTSD).  Selected treatments should account for a patient’s psychosocial and behavioral complications.  As an industry we are faced with a myriad of options and limited guidance as to how best to choose between them.  However, the focus should be on providing carefully selected interdisciplinary care and referring the injured worker for modalities that can simultaneously address a patient’s pain while building endurance and addressing the psychosocial drivers of chronic pain.

Assessment

The probable starting point is to identify the goal of treatment and the disposition of the patient.  It may not be possible to return the injured worker to a pre-injury state, but treatment should be geared towards restoring the patient to maximum medical improvement. The goal of this treatment should be to facilitate the worker’s return to some form of employment - even if that is at a restricted duty level.  

For patients with longstanding chronic pain Motivational Interviewing (MI) is commonly a good starting point to assess the patient.  It is a patient-centered treatment modality meant to engage the patient and assess ambivalence and anxiety.  This also provides a screening opportunity.

You may find that understanding an injured worker’s chronic back pain, ongoing for 10 or more years, may be attributed to nothing more than age progression degenerative changes. The spine begins to lose its water content in the early 30’s which increases the risk of bulges, herniations, and even annular tears.  These degenerative changes impact almost everyone, even without symptoms.  Studies show disc degeneration in about 37% of all asymptomatic 20 years-olds, 80% of asymptomatic 50 year-olds, and 96% of all asymptomatic 80 year-olds.

Or you may also find as part of an initial screening of the patient, a history of a more traumatic event.  Significant diagnoses such as PTSD can occur in instances such as rape, traumatic brain injury, gun point robbery, severe motor vehicle accidents, veterans returning from combat, or employees witnessing a shooting incident or murder.  These individuals need to be referred to a specialist who can provide the necessary interventions recommended by the American Psychological Association issued in their “A” list included in the published 2008 guidelines.

Frequently you will find the injured worker’s status can be improved through referral to multiple modalities addressing pain, function, and comorbid conditions as well as addressing smoking and weight issues. 

Choosing between Coordinated Interdisciplinary Care and a Functional Restoration Program

Without engagement, a patient chronically treated with narcotic analgesics, now likely dependent, will be resistant to change and unlikely to achieve any progress of either their pain or function.  It is critical however that the delivery of care be improved.  Common options include referring the patient to a Functional Restoration Program (FRP) or by coordinating analogous care by referring to multiple modalities in an integrated system, inclusive of motivational counseling such as cognitive behavioral therapy (CBT).

Functional Restoration Programs

A FRP is a rehabilitation program aimed at increasing physical functioning, improving pain-coping skills, and returning the patient to a productive lifestyle at home and at work.  These treatment programs will be inclusive of multiple provider types, commonly including physical therapists, addictionologists, psychiatrists and/or psychologists, orthopedists and others.  These programs excel at providing coordinated care through treatment teams that jointly assess and construct treatment plans weaving multiple modalities together.

However, FRP programs cost anywhere from about $40,000 on the low-side to upwards of $90,000 on the higher end.  Unfortunately, due to their size and volume, a number of these programs do not have peer reviewed, published, prospective, randomized controlled studies to support their published claims of outcomes.  While there are fantastic programs available, they come at significant cost and with refutable evidence of their program's ability to produce improved functionality, pain control, medication management, or return to work.

When considering the incredible cost of these programs, it is important to also account for patients who are poor candidates for such a program.  Patients who are retired, or who will never return to work in any function, would not be good candidates for referral.  Additionally patients with comorbidities that would prevent full participation in all the modalities of an FRP (e.g., suicidal ideations, unstable heart conditions, uncontrolled hypertension, asthmatics, exertional dyspnea etc.) would not be good candidates.  Other poor candidates include patients who have previously failed CARF accredited programs, have unrealistic expectations of treatment such as immediate cure, or patients who are depressed or not motivated to fully participate.  Those who are already dependent on narcotics with existing neurobiological changes may not recover as expected.

There is no advantage for the payer, physician, patient or anyone else to refer a patient for therapy that will not provide efficacy for that individual patient.

Cognitive Behavioral Therapy

Depending on diagnosis, CBT when used in conjunction with other treatment modalities (such as needed physician consults by orthopedist, psychiatrist, psychologists etc.) biofeedback, physical therapy (PT), aqua PT, or other PT modalities such as Alexander or McKenzie’s protocol which may help to centralize or relocate the pain, can restore patients to function in a shorter time than putting them through all the sessions of the FRP.  It can often be even more beneficial as FRP programs often require the patients be housed near the campus which silos the patient away from their family and support systems. 

Utilizing this integrated coordinated outpatient delivery of care, the patient can also be taught protocols to be done at home after they are mastered in the facility ,allowing the injured worker better continuity of care.  Including a dietitian can also help the patient by reconstructing their diet around anti-inflammatory foods, limiting sugars, fats, sodium intake and introducing more plant-based fibrous foods into their diets.  This has the added advantage of addressing other elevated medical risk-associated with raised BMI levels.

All of this can be provided for the patient while keeping them at or close to home at a much lower cost to the payer.

Evidence for Coordinated Care

When coordinate care delivery programs are utilized in a hospital facility, various specialty providers have weekly group strategy meetings focused on each patient's needs.  The team sets treatment goals for each patient and each team member then coordinates their intervention to achieve the team goal.

Other team members like an addiction specialists, nutritionists and a vocational rehabilitation provider, can also be brought in as needed, to help address patient detox, weaning, medication management, and return to work.  This often includes the assistance of a psychotherapist with associated lifestyle goals such as weight reduction and return to work with necessary modifications.  In this setting a PM&R specialist sometimes act as the team coordinator.

In 2007 G. Roche et al., published a comparison of an FRP intervention and an active individual therapy (AIT) intervention post five-week study period(1).  The included a study groups included the FRP program  utilized fort 25 hrs/wk, versus active individual physical therapy group utilizing 3 hrs/wk for patients with chronic low back pain.  The objective of this randomized controlled trial was to compare short term outcomes of each intervention.

The study was conducted within two Rehab Centers and private ambulatory PT facilities. There were a number of outcome measures including flexibility and endurance, daily activities, reports of work ability, resumption of sports and leisure activities.  The results showed all outcome measures improved except the endurance in the active individual PT group. There was inter- group difference in pain intensity or Dallas Pain Score, daily activities or work and leisure activity scores. However, better results were observed in FRP for the other outcome measures.

Low cost ambulatory AIT is effective. The main advantage of FRP is improved endurance. They speculated that this may be linked to better self-reported work ability and more frequent resumption of sports and leisure activities.  Personally, I would think being at a facility 25 hours per week as opposed to 3 hours would lend itself to more availability of other aerobic sport and leisure activities to build endurance, this can be done just as well in a community gym etc.

 

Conclusions

Treatment of chronic pain starts with careful assessment of the patient.  This in turn relies strongly on an engaged treating physician and solid patient-physician relationship.  When coordinating the delivery of interventional care it is critical that the right care be selected to achieve the greatest impact for the patient with the least wasted expense.  Not all care is equally effective, and not all patients of similar diagnoses will be similarly impacted by identical care.  Leading with a motivational assessment is a good place to start when choosing between care delivery models.  While integrated and collaborative care delivery as is provided in hospital settings and intended to be provided by FRPs is the gold standard when it comes to chronic pain interventions, finding such a program close to a patient's home, with the necessary modalities, with objective outcomes, and at an acceptable cost is often an impossible task.  In many cases these hindrances to care outweigh the benefits that may be obtained.  Analogous, low cost care can be provided through carefully integrated and coordination for each injured worker with multiple modalities.

Dr. Thomas

1.            Roche G, Ponthieux A, Parot-Shinkel E, et al. Comparison of a functional restoration program with active individual physical therapy for patients with chronic low back pain: a randomized controlled trial. Arch Phys Med Rehabil. 2007;88(10):1229-1235. doi:10.1016/j.apmr.2007.07.014.

Where Does Pain Come From?

[Part 1 of a two part guest post from Dr. Pamella Thomas, PRIUM's Medical Director]

What is Pain?

Chronic pain initially begins, appropriately, as acute pain – a biological event in response to noxious stimuli.  However, as time progresses, social, psychological, and cultural factors impede and complicate recovery. 

Pain, generally, is defined by the IASP Task Force on Taxonomy, 1994, as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.¹  The individual’s experience of pain is mediated by the brain; pain is always subjective.  Commonly the experience of pain is due to physical injury; however, it may also be caused or intensified due to emotional stress: anxiety, depression, exhaustion. The prefrontal cortex of the brain’s frontal lobe plays an important role in interpreting and mediating both types of pain perception.

Role of the Brain

Our understanding of the brain’s role in pain perception has advanced significantly.  For example, we now understand that one's prior experience involving pain, its consequences, and associated moods and stressors, plays an important role in a person’s experience of pain.   One hypothesis is that early adverse experiences and early-onset mental disorders may contribute to a chronic imbalance in hormonal and neurotransmitter mediators linked to neuronal stress response pathways.²  This in turn has been linked to a range of adverse metabolic, cardiovascular, immunological and cognitive effects.^3,4 

Adverse Childhood Events

Additionally we know that adverse experiences with pain occurring prior to age 18 heavily influence our ultimate perception of pain.  Adverse experiences such as abuse, neglect, poverty, parental death, divorce, drug use, and incarceration have been shown in numerous studies to have profound effects on a child’s temperament and psychological and physiological development.

Studies from the Centers for Disease Control and Prevention (CDC) and international surveys from the World Health Organization (WHO) provide mounting evidence and weight to the theory that Adverse Childhood Events (ACEs) predispose a person to poor health as an adult.  Of note, ACEs causing anxiety and/or depression in childhood were positively correlated with chronic pain in adulthood.  Most interestingly, these emotional stressors from childhood are directly correlated with physical disease states in adulthood. Individuals with a history of three or more ACEs were more likely to be diagnosed with each of the six physical conditions measured by the WHO: heart disease, asthma, diabetes, arthritis, chronic spinal pain, and chronic headache.  Those individuals who had suffered from childhood physical abuse had an even longer list of adult chronic disease.

These results suggest that early onset mental disorders may function as endogenous psychosocial stressors that can be associated with poor physical health in adulthood caused not only through increased risky health behaviors, but also through direct biological mechanisms.

Authors KM Scot et al., found in their study, “These results are consistent with the hypothesis that childhood adversities and early onset mental disorders have independent broad spectrum events that increase the risk of diverse chronic physical conditions later in life.”⁵

Anecdotal Experience

As a former medical director overseeing an onsite employer clinic, I had specific insight into the chronicity of some of the workers’ compensation patients filing claims.  Some employees had charts over two inches thick with frequent claims and follow-up visits. I affectionately referred to them as my frequent flyer work comp club members. Given their frequent visits and extensive charts, I began to interview some of these employees and ask questions about their work environment and about their childhood up until 18 years of age. I wanted to see if there were any common experiential themes amongst this population.

I heard frequently from the employees that they had issues with their supervisors or others in authority.  Similarly they had disagreements with those they interacted with at home.  I also frequently heard anecdotally that these employees suffered through poor in-home security, lower socioeconomic status, and circumstances that caused frequent fear and anger in their homes from an early age.

The Doctor-Patient Relationship

Though I likely missed a great opportunity to reproduce the results found in the ACE study, I found that just by taking the time to engage these injured workers in conversation, addressing factors outside those reported as part of the injury, that some seemed to have fewer ongoing problems going forward.  Being heard and validated proved therapeutic for these oft troubled employees.  Actively listening to patients may help prevent chronic pain and its complications from certain treatments. It is my conclusion that the physician-patient relationship should be seen as the critical piece in treating workers’ compensation claims, especially for workers that display a particular subset of characteristics that I will detail in a follow-up post.

1.            Merskey H, Bogduk N. Classification of chronic pain, IASP Task Force on Taxonomy. Seattle, WA Int Assoc Study Pain Press available online www iasp-pain org). 1994.

2.            McEwen BS. Protective and Damaging Effects of Stress Mediators. N Engl J Med. 1998;338(3):171-179. doi:10.1056/NEJM199801153380307.

3.            Miller GE, Cohen S, Ritchey AK. Chronic psychological stress and the regulation of pro-inflammatory cytokines: A glucocorticoid-resistance model.

4.            Chrousos GP, Kino T. Glucocorticoid action networks and complex psychiatric and/or somatic disorders. Stress. 2007;10(2):213-219.

5.            Scott KM, Von Korff M, Angermeyer MC, et al. Association of childhood adversities and early-onset mental disorders with adult-onset chronic physical conditions. Arch Gen Psychiatry. 2011;68(8):838-844. doi:10.1001/archgenpsychiatry.2011.77.