Integrative Pain Management for Optimal Patient Care
The Pain Practitioner November December 2017
Annual Meeting 2017
+
Nutrition, Inflammation, and Pain Musculoskeletal Pain Management
3.5 3
2.91
2.8
2.77
2.65
2.5 2
9
8.81
Hospital Anxiety and Depression Scale p<0.001
8.5 8 7.5 7
6.89
6.5
6.42
6.24
6.16
6 5.5
Baseline Week 1
Week 2 Week 3
Week 4
5
Baseline Week 1
Week 2
Week 3
Week 4
Pi sburgh Sleep Quality Index p=0.055
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Mean Insomnia Scores
Brief Pain Inventory p=0.013
3.74
Mean Anxiety Scores
Mean Pain Scores
4
INCREASED SLEEP TIME
DECREASED ANXIETY 9.5
10.5
10.23
10 9.5
8.7
9 8.5
8.4
8 7.5 7
Baseline
Week 2
Week 4
DECREASED DEPRESSION 6.5
Mean Depression Scores
PAIN REDUCTION
6 5.5
6.36
Hospital Anxiety and Depression Scale p=0.024
5.67 5.27
5
5.34 4.97
4.5 4
Baseline Week 1 Week 2
Week 3
Week 4
The Pain Practitioner NOVEMBER/DECEMBER 2017
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4 NOTES FROM THE FIELD Defining Integrative Pain Management By Bob Twillman, PhD, FAPM, Executive Director 5 EDITORIAL Progress and Promise By W. Clay Jackson, MD, DipTh, Editor-in-Chief PAGE 6
6 ANNUAL MEETING/EDUCATION Annual Meeting 2017: Communication, Education, Empathy, Empowerment, and Collaboration By Christine Rhodes, MS 8 ADVOCACY AIPM’s Policy Powerhouse Convenes 50+ Leaders to Advance Integrative Pain Care By Amy Goldstein, MSW, Director of the State Pain Policy Advocacy Network
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10 Nutrition, Inflammation, and Pain By Christine Rhodes, MS 13 Talking with ASH: Perspectives on Non-pharmacologic Management of Musculoskeletal Pain By Debra Nelson-Hogan
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ACADEMY BOARD OF DIRECTORS President W. Clay Jackson, MD, DipTh Past President Joanna Katzman, MD, MSPH Vice President Paul Christo, MD Secretary Michael Kurisu, DO Treasurer Kevin T. Galloway, BSN, MHA, Colonel, US Army (Retired) Directors-at-Large Lynette Cederquist, MD George D. Comerci, Jr, MD, FACP John Garzione, DPT Joseph Matthews, DDS, MSc Roger Mignosa, DO Liaison to the Board Maggie Buckley
STAFF AND CONSULTANTS Executive Director Robert Twillman, PhD, FAPM Director of the State Pain Policy Advocacy Network (SPPAN) Amy Goldstein, MSW Assistant Director of Education Cathleen Coneghen Director of Legislative and Regulatory Affairs Katie Duensing, JD Member Services Manager Whitney O’Donnell Account Manager Rosemary LeMay Professional Development Project Manager MacKenzie Davis Content Consultant Debra Nelson-Hogan
THE PAIN PRACTITIONER STAFF AND CONSULTANTS Editor-in-Chief W. Clay Jackson, MD, DipTh Editor Debra Nelson-Hogan Advertising and Sales Leslie Ringe Managing Editor Cathleen Coneghen Clinical Editor Christine Rhodes, MS Art Director Peter McKinley, Pak Creative Copy Editor Rosemary Hope
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The Pain Practitioner is published by the Academy of Integrative Pain Management, P: 209-533-9744, Email: aapm@integrativepain.org, website: www.integrativepainmanagement.org. Copyright 2017 Academy of Integrative Pain Management. All rights reserved. Send correspondence to: Debra NelsonHogan at dhogan@integrativepain.org. For advertising opportunities, media kits, and prices, contact: sales@integrativepain.org or 209-533-9744. The Pain Practitioner is published by the Academy of Integrative Pain Management solely for the purpose of education. All rights are reserved by the Academy to accept, reject, or modify any submission for publication. The opinions stated in the enclosed printed materials are those of the authors and do not necessarily represent the opinions of the Academy or individual members. The Academy does not give guarantees or any other representation that the printed material contained herein is valid, reliable, or accurate. The Academy of Integrative Pain Management does not assume any responsibility for injury arising from any use or misuse of the printed material contained herein. The printed material contained herein is assumed to be from reliable sources, and there is no implication that they represent the only, or best, methodologies or procedures for the pain condition discussed. It is incumbent upon the reader to verify the accuracy of any diagnosis and drug dosage information contained herein, and to make modifications as new information arises.
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NOTES FROM THE FIELD
Defining Integrative Pain Management By Bob Twillman, PhD, FAPM, Executive Director
Comprehensive integrative pain management includes biomedical, psychosocial, complementary health, and spiritual care. It is person-centered and focuses on maximizing function and wellness. Care plans are developed through a shared decision-making model that reflects the available evidence regarding optimal clinical practice and the person’s goals and values. At the end of the AIPM’s 28th Annual Meeting in San Diego this October, an invited group gathered for the inaugural Integrative Pain Care Policy Congress. This Congress, co-sponsored by AIPM, The PAINS Project, the Integrative Health Policy Consortium, and the Alliance for Balanced Pain Management, brought together more than 70 participants representing more than 50 organizations from across the stakeholder spectrum. Patient advocates, professional associations, public and private insurers, researchers, and policy makers all participated. Task No. 1 for this august group was to reach consensus on a definition of “integrative pain management.” Given that we are the Academy of Integrative Pain Management, you could be forgiven for thinking we already had a clear definition, and the truth is that we did, but it needed some polishing. So, starting with a definition of “comprehensive/integrative pain management” proposed in a 2015 policy brief (found at http://bit.ly/2zJU1Hh) from The PAINS Project, we set to work crafting a definition that we felt could garner consensus of a wide-ranging group. The final definition is found at the top of this article. I want to take this opportunity to deconstruct it and tell you what it means to me. “Comprehensive integrative pain management includes biomedical, psychosocial, complementary health, and spiritual care.” We have always endorsed the notion put forth in the Institute of Medicine’s report, Relieving Pain in America, that the best and most effective plan of pain care will be one
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that arises from a conception of chronic pain as a biopsychosocial phenomenon. I sometimes have deconstructed the term “biopsychosocial,” pointing out that it has not three, but eight distinct components. Each component should be assessed in a comprehensive pain assessment, and each is a potential treatment target. “Bio-” refers to three components: cell and organ system physiology, anatomy, and mechanics; “psycho-” refers to cognition, emotion, and behavior; and “social” refers to societal and cultural factors that affect the pain experience. Based on my clinical experience, however, I’ve always felt that one additional factor was missing: spirituality. I believe that one’s attribution of meaning to his or her pain experience has a tremendous impact on that experience, and, to me, meaning is an issue of spirituality. Complementary health interventions are specifically listed because they often are what set integrative pain care apart from purely biomedical pain care. It is important to note that treatments aimed at one component of the biopsychosocial-spiritual model may affect multiple components. For instance, opioid analgesics are primarily aimed at affecting cellular physiology, but we know that they also can affect, sometimes profoundly, cognition and emotion—and, in these times of heightened concern about opioid use, perhaps even social factors. It is the combination of these treatments, with their net effects on all eight subcomponents of the model, that produces a synergistic benefit. “It is person-centered and focuses on maximizing function and wellness.” Integrative pain management always has the person with pain as the most important team member. The person with pain plays a key role in treating pain through self-management techniques, and, as we will see in the next sentence of the definition, it is the person with pain who helps define the goals of care. In contrast to the biomedical model, which emphasizes identifying pathology and removing it, the integrative approach has a positive orientation, aiming to restore wellness and maximize function through the interventions carried out with the cooperation of the person with pain.
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“Care plans are developed through a shared decision-making model that reflects the available evidence regarding optimal clinical practice and the person’s goals and values.” All integrative pain care plans reflect the result of discussion between clinicians and the person with pain. Both parties participate in defining the goals of care, and those goals are informed by existing evidence regarding what might be the most effective treatments and by what the person with pain values as an outcome. Neither the person with pain nor the clinician has absolute authority to create the care plan, and it is necessary for all parties to reach agreement on the plan before treatment can proceed. This is the essence of the person-centered model first mentioned in the definition’s second sentence. Participants at the Policy Congress were asked to reach consensus that these key definitional elements represent what is meant by “integrative pain management.” While there were some who raised concerns about a word or two in the definition, consensus was achieved. Participants were asked to take this definition back to their organizations for official endorsement, and we are hopeful that all will agree to provide that endorsement. Having a common definition is just the first step, but it is an important one because it keeps Congress participants focused on the kind of care we are asking payers and policymakers to make more readily available for everyone with chronic pain. The road is long, but as Lao Tzu said, “The journey of a thousand miles begins with one step.” We’re off and running—join us on our journey by supporting our advocacy efforts! ❏ Bob Twillman, PhD, is the executive director for the Academy of Integrative Pain Management. Dr. Twillman is responsible for overseeing federal and state pain policy developments and advocating for those supporting an integrative approach to managing pain. He also serves as Chair of the Prescription Monitoring Program Advisory Committee for the Kansas Board of Pharmacy.
EDITORIAL
Progress and Promise By W. Clay Jackson, MD, DipTh, Editor-in-Chief
Keynote speaker Colonel Greg Gadson captivated meeting attendees with his personal story of trauma and recovery. Hundreds of the nation’s brightest scholars and most dedicated clinicians gathered in San Diego in October for the 28th Annual Meeting of the Academy, and from the very start of the program, the energy and excitement of joining together with supportive colleagues was palpable. In a time when our country is grappling with what Executive Director Bob Twillman has called the “dual public health crisis” of the overprescription of opioids and the undertreatment of chronic pain, it is inspiring to see our members rise to the challenge of education, research, and practice improvement that was reflected in the meeting agenda from start to finish. In the preconference portion of the meeting, Paul Cristo, MD, and his co-faculty led an outstanding training course on how to utilize opioids in a safer, more effective manner. On the non-pharmacologic end of the therapeutic spectrum, the course by Robert Bonakdar, MD, and Nancy Cotter, MD, on the role nutrition can play in battling the inflammatory aspects of chronic pain (and thus promoting wellness) was packed. Jack Ginsberg, PhD, Ron Gharbo, DO, Melanie Berry, MS, and Aubrey Berry, BS, ABT CP-TLP, CES, CHP, also held an outstanding hands-on workshop demonstrating how autonomic self-regulation and heart rate variability can reduce pain and give patients a feeling of empowerment.
The keynote address by Colonel Greg Gadson brought the immediacy of a patient’s perspective to attendees that was unlike anything I’ve witnessed at a professional meeting. As Greg shared his story of trauma, courage, pain, despair, support,
I’ve never been prouder of our Academy. Together, we are improving the experience of persons who suffer from pain. and recovery, you could have literally heard a pin drop in the main ballroom, as a thousand ears took his message of hope (and challenge) straight to the hearts of every practitioner sitting on the edge of every seat. As we’ve come to expect over three decades of excellence, the scientific program was full to the brim with informative, current, and novel talks from experts in a variety of disciplines. I was taken aback, though, by the feeling in the hallways this year. The engagement of learners and faculty extended beyond the
prescribed times of the sessions, and the interesting conversations among colleagues regarding advances in care spilled over into break times, around the coffee stands and snack bars. That stimulating conversation turned into engaging work on Friday and Saturday morning, when our multiple special interest groups laid out plans to help the Academy grow in their areas of expertise in 2018. From a policy and advocacy perspective, the capstone of this year’s meeting was the inaugural Integrative Pain Care Policy Congress, which took place Saturday evening and Sunday morning. A diverse group of delegates, representing over 55 separate organizations in the chronic pain space, gathered to hammer out a consensus definition for comprehensive integrative pain management, to identify barriers in providing it, and to prioritize next steps to enhance research, outcomes reporting, and payment reform to support next-level care for patients. I’ve never been prouder of our Academy. Together, we are improving the experience of persons who suffer from pain. Each of us seeks to do so incrementally, one patient at a time, and we should certainly continue to do that important work. But by combining our efforts at the organizational level, we are beginning to see transformative change— and it’s for the good. Don’t be discouraged by the naysayers. It’s a good time to be a clinician. It’s a good time to be in the helping professions, improving the lives of those who experience pain. And it’s a great time to be a member of the country’s foremost professional organization dedicated to providing topflight integrative care—the Academy of Integrative Pain Management. ❏ W. Clay Jackson, AIPM board president, is clinical assistant professor of family medicine and psychiatry at the University of Tennessee College of Medicine in Memphis, Tennessee, where he maintains a private practice in family and palliative medicine. He is also the medical director of Comprehensive Primary Care, and of Methodist Hospice and Palliative Services. Dr. Jackson is the associate fellowship director of palliative medicine at the University of Tennessee College of Medicine.
THE PAIN PRACTITIONER
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ANNUAL MEETING/EDUCATION
Annual Meeting 2017: Communication, Education, Empathy, Empowerment, and Collaboration By Christine Rhodes, MS
The 28th Annual Meeting of the Academy of Integrative Pain Management was held at the Hilton San Diego Bayfront Hotel on the waterfront of sunny San Diego, California, between October 19 and 22, 2017. As always, hundreds of pain professionals from across multiple disciplines gathered to attend 50 thought-provoking sessions dedicated to integrative pain management.
catastrophizing, Dr. Darnall and her colleagues found that a single two-hour class could reduce pain catastrophizing for several weeks. Her message to AIPM attendees: Educate patients on developing a positive mindset, and use behavioral medicine as a first-line treatment, not a last resort, particularly when planning surgery or other intensive treatments. W. Clay Jackson, MD, DipTh, AIPM
The stigma of mental illness is so great, however, that physicians will go to great lengths to avoid detection, including self-treating with medication samples and seeking treatment outside one’s own community. Clinicians who do commit suicide most likely do so because of professional stressors, and not because of any interpersonal issues or financial or legal problems. According to Dr. Jackson,
A FEW HIGHLIGHTS
board president and clinical assistant professor of family medicine and psychiatry at the University of Tennessee College of Medicine in Memphis, presented a littlediscussed topic, “Wounded Healers: Preventing Clinician Suicide,” to a packed auditorium of rapt listeners. Greater stress and burnout, social isolation, access to powerful drugs, and barriers to getting treatment and the associated stigma are noted as reasons for clinician suicide. For women, greater role conflict and, yes, sexual harassment are also cited as factors. Statistics from a 2015 Physician Lifestyle Report point to a loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment—all signs of burnout—in half or more of critical care, emergency medicine, family medicine, internal medicine, general surgery, and HIV/ infectious diseases clinicians. Depression among physicians is increasingly common, especially in those at the start of their internships.
burnout must be openly and actively addressed as it plays a role in the high rates of physician suicide. The risk can be minimized by staying connected, practicing self-care, and cultivating meaning and purpose in life. “The Science, Politics, and Medicine of Cannabis to Treat Chronic Pain” was a topic of great interest for many attendees. Mark S. Wallace, MD, professor of clinical anesthesiology at the University of California in San Diego, discussed the controversies and regulatory issues surrounding medical marijuana and the use of cannabinoids for pain relief. Although 34 states and the District of Columbia currently allow medical marijuana, it is still viewed by some as a gateway to drug abuse and may never meet FDA criteria for approval. Nevertheless, a survey of hospital discharges between 1997 and 2014 claims no changes in marijuana dependence or abuse discharges, but a 23% reduction in opioid dependence or
In an inspiring keynote presentation, Beth Darnall, PhD, former co-chair of the Pain Psychology Task Force, American Academy of Pain Medicine, and clinical associate professor of pain medicine at Stanford University, presented her thoughts on “Changing Mindsets to Enhance Pain Treatment Effectiveness” as well as research showing the bidirectional relationship between pain and psychological disorders. This relationship is mediated through a set of complex shared mechanisms incorporating individuals’ expectations and mindset, which can be visualized on brain imaging studies as changes in the neural activity in brain regions involved with the coding of pain intensity. For example, pain catastrophizing, by shaping the brain and priming the nervous system, actually sets the stage for chronic pain to develop. While multiple sessions of cognitive behavioral therapy can help overcome the effects of pain
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ANNUAL MEETING/EDUCATION
abuse discharges and a 13% reduction in opioid pain reliever overdose discharges, all related to cannabis use. Cannabis use is clearly associated with decreased opioid use: A retrospective cross-sectional survey of patients with chronic pain shows cannabis users report a 64% decrease in opioid use, along with decreased medication side effects and an improved quality of life. Studies show that cannabis has a low abuse potential and a good safety profile. Dr. Wallace presented results of several studies, including a systematic review of trials of cannabinoids for the treatment of chronic non-cancer pain that concluded there is evidence that cannabinoids are safe and modestly effective in neuropathic pain with preliminary evidence of efficacy in fibromyalgia and rheumatoid arthritis.
brain injury. Also new to the board is Lynette Cederquist, MD, clinical professor in the internal medicine group at the University of California, San Diego, and director of clinical ethics at the UCSD Health System, who presented a talk and a case study on integrative approaches to fibromyalgia treatment. Small fiber neuropathy was the topic in a didactic presentation and a case study session given by Charles E. Argoff, MD, professor of neurology at Albany Medical College and director of the Comprehensive Pain Center at Albany Medical Center in New York. As always, early morning exercise sessions led this year by Dr. Mignosa and Nadia Linda Hole, MD, a QiGong master, allowed attendees to start their day with movement and meditation.
POSTER
WINNERS Winning posters at the 2017 meeting were selected from each of the following categories: • Original Research • Basic Science/Review/Case Study • Student Abstracts In the Original Research category, we had a tie between Thomas J. Romano MD, PhD, FACP, FACR, DAAPM, ABIM, with a study of DEHA Deficiency in Fibromyalgia and Lata Handiwala, PharmD, with a study of Real World Experience of Flavocoxid Use in Pain Management.
The approach to medical marijuana followed by the UCSD Pain Clinic includes referral to a naturopathic doctor and consideration of cannabis before prescribing chronic opioids. For those already on chronic opioid therapy, the protocol is to wean first before considering cannabis, but in some patients, cannabis may be used to ease the weaning process.
A RANGE OF TOPICS The Annual Meeting brought together an array of speakers and topics, including Donna D. Alderman, DO, medical director of the Hemwall Centers for Orthopedic Regenerative Medicine in California, who spoke of the low risk and high success achieved with prolotherapy for osteoarthritis. Roger Mignosa, DO, a physical medicine and rehabilitation physician in San Diego and new AIPM board member, gave an excellent talk on restoring neuroplasticity in traumatic
This year the sessions were particularly inspiring, with reports of hugging, tears of joy, and life-changing experience. Based on attendees’ overwhelming acclaim, I would say these emotions exemplified the mood of the entire meeting! ❏ Christine Rhodes received her MS in Nutrition Science from Columbia University’s Institute of Human Nutrition and is a Certified Holistic Health Coach. She serves as clinical editor of The Pain Practitioner and is a New York City-based medical writer.
Beth L. Dinoff, PhD, presented, Pain May Predict Traumatic Stress in Persons With Cancer BH, which won for the Basic Science category. Her co-authors were M. Lindsey Jacobs, PhD, and Emily Venezia, BGS. The winning student poster on Effects of Mindfulness on Anxiety & Academic Goals in Medical Students was presented by Jennifer Golden, OMS-IV. Her co-authors Michael Blahut, MS, OMS II, Alexandra Collado OMS II, Deborah Schmidt, DO, Mitchell Dandignac, MS, Lance Ridpath, MS. The abstracts are housed on the AIPM website.
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ADVOCACY
AIPM’s Policy Powerhouse Convenes 50+ Leaders to Advance Integrative Pain Care By Amy Goldstein, MSW, Director of the State Pain Policy Advocacy Network
The Academy of Integrative Pain Management has been a leader in pain policy since 2010 when (now Executive Director) Bob Twillman joined the organization as its first Director of Policy and Advocacy. Since that time, two more full-time policy and advocacy staff have been added—Amy Goldstein as Director of the State Pain Policy Advocacy Network (SPPAN) and Katie Duensing as Director of Legislative and Regulatory Affairs. This team has tracked, analyzed, commented on, testified about, and rallied collective efforts around thousands of bills and proposed regulations that affect people with pain and clinicians caring for them. Despite these efforts, people with life-changing pain continue to struggle to find clinicians who use a comprehensive integrative approach to address complex pain conditions. Insurance policies often continue to approach these complex issues with a one-size-fits-all approach, ignoring the decades of evidence that point to the benefits of a biopsychosocial approach to pain care. We need safe, effective, evidence-informed treatments for people with pain and with substance use disorders, a health care system designed to provide comprehensive integrative pain care, investments in pain research, and appropriate training to enable health care professionals to provide this type of care.
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Additionally, the growing number of well-intentioned pain management guidelines and policies—both state and federal—impact the health care that is available to those in need of acute and chronic pain management. The expertise, effort, and resources required to develop effective plans to address the public health crises of inadequate pain treatment and opioid-related harms are far beyond the capacities of any one organization. It is essential that we find ways to work together to develop areas of consensus and strategies for collaboration. Earlier this year, AIPM decided it was time to bring together high-level representatives from key stakeholder organizations to discuss this matter. No organization was going to be able to make the necessary changes alone—it was necessary to gather leaders who could get to the root of the issues, find common ground, and build consensus around future action steps.
THE INAUGURAL INTEGRATIVE PAIN CARE POLICY CONGRESS The Integrative Pain Care Policy Congress was born with a vision of collective action to advance comprehensive integrative pain management. As AIPM’s SPPAN Director began talking with key stakeholders about this concept, it didn’t take long to see that this was a shared
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vision and that other organizations’ leaders also believed it was absolutely necessary. Everyone strongly agreed that insurers must be part of the conversation, and that we must bring together all key provider groups under the umbrella of evidence-informed comprehensive integrative pain care. This kick-off, invitation-only, meeting brought together approximately 75 leaders from more than 50 organizations representing the full scope of licensed and certified health care professionals involved in pain care, along with insurers, regulators, people with pain, researchers, and policy experts. It began on Saturday evening, October 21, 2017, and continued through Sunday morning during AIPM’s Annual Meeting in San Diego. This inaugural Policy Congress connected key stakeholders in discussion to: • Achieve consensus on the definition of comprehensive integrative pain care. • Review the evidence base for this approach to pain management and identify gaps. • Explore payment models that take into account the intersections among pain management, addiction, and behavioral health. • Develop meaningful outcomes for post-Congress action among the participants and other interested organizations.
IMPORTANT WORK—BEFORE, DURING, AND AFTER After months of planning meetings, a pre-Congress survey, and individual phone interviews with those invited, areas of potential agreement had been identified and the inaugural Integrative Pain Care Policy Congress was about to start. And all of that extensive preparation meant that this meeting was unlike many, at which participants come together, talk about issues and ideas, and then return back to “normal” life without a clear plan for next steps. Because of this thoughtful approach to ensuring that each voice was considered during the planning process, there was a clear sense of belonging and connectedness around a greater mission before the meeting even began.
ADVOCACY
On Saturday evening, the group of leaders came together for a dinner program. Each table was designed to include leaders with varying backgrounds and viewpoints on the topic of comprehensive integrative pain management. For example, at one table were leaders with expertise in painrelated research, policy, primary care, orofacial pain, integrative health, addiction and behavioral health, and the Veteran’s Health Administration, as well as patients with pain and a commercial payer. The meeting’s facilitators, W. Clay Jackson, MD, DipTh, AIPM’s board president, and Kevin T. Galloway, BSN, MHA, Colonel, US Army (retired) also an AIPM board member, did a masterful job balancing the need for structure, discussion, and vision toward common goals. On Saturday evening, table discussions centered around the consensus definition and answering the following questions: • What other stakeholders should be included in this coalition? • What future tasks/activities might the Congress consider to advance a common understanding and expanded utilization of comprehensive integrative pain care? • What would you like to see this Congress consider as action items for greatest impact? • What are some strategies for the Congress that might assist those trying to provide, pay for, or research comprehensive integrative pain care? Importantly, the Congress also developed a consensus definition for “comprehensive integrative pain management”: Comprehensive integrative pain management includes biomedical, psychosocial, complementary health, and spiritual care. It is person-centered and focuses on maximizing function and wellness. Care plans are developed through a shared decision-making model that reflects the available evidence regarding optimal clinical practice and the person’s goals and values. Many ideas for collective action were generated through discussions and these ideas are currently being collated into a plan of action for the coming year. Examples of ideas generated include: advocating for specific rule changes with the Centers for Medicare & Medicaid Services; coordinating pilot programs and data collection; and exploring the use of alternative payment
models to improve access to comprehensive integrative pain management.
COMPREHENSIVE INTEGRATIVE PAIN MANAGEMENT’S ROLE IN MITIGATING THE OPIOID OVERDOSE CRISIS The opioid overdose crisis was officially declared a national public health emergency in October 2017, but it is unclear whether that declaration, with its focus on substance use disorder treatment and prevention, will do anything to advance access to improved pain care. However, it was clear from Congress participants that advancing comprehensive integrative pain management is regarded as an essential solution to address the opioid crisis. “During this inaugural Congress, there was strong agreement that in order to actively address the opioid overdose epidemic while providing quality care for people with high-impact pain, we must align efforts to promote quality care focused on function and wellness, not care guided only by what payers are covering. We must continue discussions with payers and researchers to review and enhance the existing evidence in service of expanding payer coverage of safe and effective pain treatments,” said Dr. Twillman. Following up on these comments, Dr. Jackson added, “This Congress created,
for the first time, an opportunity for leaders representing the full scope of health care providers, payers, and patients, to discuss how we can change the status quo. There was strong agreement that lasting solutions require a culture change and payment reform in health care, with a deeper understanding of the interplay among pain management, behavioral health, and addiction.”
MOVING FORWARD TOGETHER Congress participants said the sheer number of organizations and stakeholders participating in the Congress was monumental. This Congress was a giant first step, bringing together diverse participants to discuss how we can advance integrative pain care. Soma Wali, MD, representing the American College of Physicians, commented that “Advancing evidence-based treatment for pain is a high priority for our organization, and the strength of this collective group was extremely motivating. We all have the same common goal—to provide the best care to our patients and to continue to save lives.” A full report on the outcomes of the Integrative Pain Care Policy Congress will be released by the end of this year. For more information, please contact Amy Goldstein at: agoldstein@integrativepain.org. ❏
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THE PAIN PRACTITIONER
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Nutrition, Inflammation, and Pain This article is based on the Nutritional Pain Management workshop held at the 28th Annual Meeting of the Academy of Integrative Pain Management Meeting on Thursday, October 19, 2017, given by Robert A. Bonakdar, MD, and Nancy A. Cotter, MD. To earn their Certificate in Nutritional Pain Management, the session attendees completed six hours of instruction and a post-session examination. By Christine Rhodes, MS
Research shows an irrefutable connection between inflammation and pain. Exactly how one’s diet can influence pain generation is the result of several factors, one of the most common being obesity. In addition, nutrient deficiencies limit the rate of key chemical reactions, thereby lowering the body’s defenses against damage from free radical initiated oxidation. How does inflammation go on to cause pain? Our Total Western Diet (TWD), composed of processed foods containing added fats and oils, added sugar, and refined grains, is considered to be pro-inflammatory and can decrease the diversity of the microbiome within a very short period of time. In a study designed to investigate the functional and physiologic consequences of poor diet, researchers fed mice a version of the Total Western Diet for 13 weeks and found that prolonged exposure to poor diet quality resulted in altered acute nociceptive sensitivity, systemic inflammation, and persistent pain after inflammatory pain induction(1). The Total Western Diet, also known as the Standard American Diet, or SAD, includes low levels of fruits, vegetables, and fiber, and
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high levels of processed food, additives, and inflammatory fats, which promote pain, inflammation, and obesity. Individuals on such a diet tend to eat more mindlessly, consuming highcaloric meals, high-glycemic foods, and a significant number of liquid calories. They eat on the go, drink too much caffeine and alcohol, and end up in a pro-inflammatory state with accompanying dysbiosis. An analysis of more than 15,000 participants in the National Health and Nutrition Examination Survey showed significant associations between systemic inflammation, as indicated by high levels of C-reactive protein (CRP), and low back pain, especially in those who are obese(2). In older adults, the association between pain and inflammation is especially strong in women(3). These effects are partially mediated through changes in the microbiome. Studies have shown, for example, that as diets become more Westernized, a loss of microbial diversity occurs, including organisms able to ferment fiber-rich dietary components(4). These changes occur extremely rapidly— within one day of consuming a Westernized diet. Such loss of microbiome diversity has been associated with irritable bowel syndrome, chronic prostatitis, and chronic pelvic pain syndrome. In addition, persistent activation of mast cells and neurogenic activation results in immune reactions that can affect the brain and cause microglial hypersensitivity and central sensitization(5). Magnesium plays a leading role in the development of inflammation and pain. Elevations in CRP are more likely to occur in adults who consume less than the RDA of magnesium, and serum concentrations of magnesium were identified as an independent risk factor in migraine attacks, increasing the odds of migraine 35 times when magnesium was below normal levels(6). Other deficiencies linked to pain include those of vitamin B1, vitamin B2, folate, calcium, amino acids, coenzyme Q-10, omega-3 fatty acids, and zinc. Obesity and pain are associated in the United States, and the link grows stronger in older age groups(7). The proposed interrelationships between inflammation, obesity, and pain are shown in Figure 1(8). As systemic inflammation increases as a factor of inflammatory and systemic mediators, against a backdrop of comorbid conditions and baseline characteristics, pain and obesity increase as well. For example, in a longitudinal study of 900 individuals followed for 20 years, poor glycemic control, a cardiometabolic mediator, was found to be an independent risk factor of severe osteoarthritis and progression to joint replacement(9). Another study showed that obesity-related pro-inflammatory adipokines predicted patient-reported shoulder pain(10). This is one of the reasons that obesityrelated pain has been linked not only to weight bearing joints but to a diverse number of pain conditions(8) (see Table 1). Pain and food intake are also linked regardless of obesity. One study
FIGURE 1: Obesity-related pain: A proposed framework related to systemic inflammation(8) PAIN Inflammatory mediators Cytokines and adipokines (secreted by adipocytes) • IL-1, IL-6, IL-8 • TNF-alpha • Leptin • Adiponectin • Resistin
Acute-phase proteins • C-reactive protein
Cardiometabolic mediators • • • • •
Comorbid conditions
SYSTEMIC INFLAMMATION
Insulin Glucose Low-density lipoproteins Triglycerides Plasminogen activator inhibitor-1 (PAI-1)
• Depression • Insomnia • Sleep apnea • Fatigue • Physical deconditioning • Mechanical overload • Mal-alignment
Baseline characteristics
• Genetic predisposition • Environmental factors: · Trauma · Stress · Diet · Activity · Family dynamics/ coping
Deficiency states • Vitamin D • Testosterone
showed that back pain correlates with activity in the ventral striatum and medial prefrontal cortex, areas known to mediate the palatability and enjoyment of food. As back pain increases, individuals crave higher amounts of food, especially high-fat and high-carbohydrate foods, and they eat more because their satiety signals have been disrupted(11). Perhaps the admonition to eat slowly has an inflammatory basis: Faster eating, especially in obese individuals, leads to increases in interleukin-1β (IL-1β) and IL-6 concentrations, even accounting for caloric intake and body mass index (BMI)(12). In addition, faster eating increases the odds ratios for high glucose and low HDLcholesterol levels, particularly in men, even adjusting for BMI(13). A high saturated fat meal also increases inflammatory markers compared to a high oleic sunflower oil meal, but increased stress increases the inflammatory markers to the same degree and overrides these effects(14). Pain promotion occurs through an inflammatory imbalance, an oxidative imbalance, or an allergy or sensitization reaction. Inflammation is associated with the most pain and is generally determined by poor nutrition and other lifestyle factors. Cytokines are responsible for multiple aspects of the inflammatory process, including the initiation and persistence of pain. These proteins, which may be directly affected by food, can activate nociceptive sensory neurons, contribute to central sensitization, and influence the development of hyperalgesia and allodynia. Interleukin-1β and IL-6 are pain generators, while IL-10 is an antiinflammatory mediator that can shut off the immune response. Prostaglandins sensitize peripheral nociceptors, while leukotrienes increase vascular permeability. Chronic inflammation induces oxidative stress, or the body’s inability to protect against cellular damage caused by foreign
OBESITY*
substances and free radicals. Certain nutrients, such as magnesium and zinc, are cofactors in key enzymatic reactions that dismantle free radicals. Others, such as vitamins C and E and coenzyme Q10, serve as dietary antioxidants. When co-factors and co-enzymes are deficient, oxidation increases just as rust corrodes metallic substances. Oxidative stress is also caused by the exaggerated spikes in blood glucose and lipids that occur after a SAD meal. The transient increases in free radicals produced by such a meal triggers atherogenic changes including inflammation, endothelial dysfunction, hypercoagulability, and sympathetic hyperactivity. Such postprandial dysmetabolism is an independent predictor of future cardiovascular events even in nondiabetic individuals, but improvements in diet can have profound and immediate changes. A diet high in minimally processed, high-fiber, plantbased foods, such as the Mediterranean diet, will significantly blunt the post-meal increase in glucose, triglycerides, and inflammation. Postprandial dysmetabolism is also positively affected by lean protein, caloric restriction, weight loss, exercise, and moderate alcohol intake(15). Oxidative stress and inflammation are also promoted by the formation of advanced glycation endproducts (AGE) from nonenzymatic reactions between sugars, proteins, lipids, and nucleic acids(16). Although AGEs are part of normal metabolism, their formation is exacerbated by high-heat cooking. They bind with cell surface receptors and proteins, altering their structure and function. In the kidney, for example, AGEs are implicated in diabetic nephropathy. AGEs are generally formed after high-heat cooking of animal products, and can be reduced by using shorter cooking times, lower heat, and the inclusion of acidic ingredients, such as vinegar, in cooking.
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REFERENCES
TABLE 1: Pain conditions associated with obesity(8).
• Carpal tunnel syndrome • Connective tissue disorders (e.g., rheumatiod arthritis) • Fibromyalgia • Gastrointestinal disorders* • Gout • Low back pain • Migraine and headache • Neuropathy* • Osteoarthritis: multiple sites (e.g., knee, hip, hand) • Plantar fasciitis • Rotator cuff tendonitis *Refers to subtypes of the condition.
Robert A. Bonakdar, MD, is director of pain management, Scripps Center for Integrative Medicine, and assistant clinical professor, UCSD School of Medicine. He is the Past President of the Academy of Integrative Pain Management. Nancy A. Cotter, MD, is clinical associate professor, PMR, Rutgers NJ Medical School, and clinical director, Whole Health VANJ, Clinical Champion, Office of Patient Centered Care. Christine Rhodes received her MS in Nutrition Science from Columbia University’s Institute of Human Nutrition and is a Certified Holistic Health Coach. She serves as clinical editor of The Pain Practitioner and is a New York City-based medical writer.
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1. Totsch SK, Waite ME, Tomkovich A, Quinn TL, Gower BA, Sorge RE. Total Western Diet Alters Mechanical and Thermal Sensitivity and Prolongs Hypersensitivity Following Complete Freund’s Adjuvant in Mice. J Pain. 2016 Jan;17(1):119-25. 2. Briggs MS, Givens DL, Schmitt LC, Taylor CA. Relations of C-reactive protein and obesity to the prevalence and the odds of reporting low back pain. Arch Phys Med Rehabil. 2013 Apr;94(4):745-52. 3. Eslami V, Katz MJ, White RS, Sundermann E, Jiang JM, Ezzati A, Lipton RB. Pain Intensity and Pain Interference in Older Adults: Role of Gender, Obesity and High- Sensitivity C-Reactive Protein. Gerontology. 2017;63(1):3-12. 4. David LA, Maurice CF, Carmody RN. Diet rapidly and reproducibly alters the human gut microbiome. Nature. 2014;505):559–563. 5. Aich A, Afrin LB, Gupta K. Mast cell-mediated mechanisms of nociception. Int J Mol Sci. 2015;16:29069-29092. 6. Assarzadegan F, Asgarzadeh S, Hatamabadi HR, Shahrami A, Tabatabaey A, Asgarzadeh M. Serum concentration of magnesium as an independent risk factor in migraine attacks: a matched case-control study and review of the literature. Int Clin Psychopharmacol. 2016;31:287-292. 7. Stone AA, Broderick JE. Obesity and pain are associated in the United States. Obesity. 2012;20:1491-1495. 8. Bonakdar RA. Targeting systemic inflammation in patients with obesity-related pain: Obesity- related pain: time for a new approach that targets systemic inflammation. J Fam Pract. 2013 Sep;62(9 Suppl CHPP):S22-S29. 9. Schett G, Kleyer A, Perricone C, et al. Diabetes Is an Independent Predictor for Severe Osteoarthritis- Results from a longitudinal cohort study. Diabetes Care. 2013;36:403-409. 10. Gandhi R1, Perruccio AV, Rizek R, Dessouki O, Evans HM, Mahomed NN. Obesity-related adipokines predict patient reported shoulder pain. Obes Facts. 2013;6:536-541. 11. Geha P, Dearaujo I, Green B, Small DM. Decreased food pleasure and disrupted satiety signals in chronic low back pain. Pain. 2014;155:712-722. 12. Mochizuki K, Misaki Y, Miyauchi R, et al. A higher rate of eating is associated with higher circulating interluekin 1beta concentrations in Japanese men not being treated for metabolic diseases. Nutrition. 2012;28:978–83. 13. Lee KS, Kim DH, Jang JS, et al. Eating rate is associated with cardiometabolic risk factors in Korean adults. Nutr Metab Cardiovasc Dis. 2013;23:635-641. 14. Kiecolt-Glaser JK, Fagundes CP, Andridge R, et al. Depression, daily stressors and inflammatory responses to high-fat meals: when stress overrides healthier food choices. Mol Psychiatry. 2017;22:476-482. 15. O’Keefe JH, Gheewala NM, O’Keefe JO. Dietary strategies for improving post-prandial glucose, lipids, inflammation, and cardiovascular health. J Am Coll Cardiol. 2008;51:249-255. 16. Uribarri J, Woodruff S, Goodman S, et al. Advanced glycation end products in foods and a practical guide to their reduction in the diet. J Am Diet Assoc. 2010;110:911-916.
Talking with ASH: Perspectives on Non-pharmacologic Management of Musculoskeletal Pain By Debra Nelson-Hogan
Musculoskeletal pain, such as neck and back pain, traumatic injuries, and arthritis, impacts more than half of all adults in the U.S. and nearly 75% of individuals age 65 and over. It is the most common reason for long-term pain and disability. Moreover, JAMA reports estimated direct health care costs for musculoskeletal pain are $183.5 billion annually(1). With current concerns about appropriate use of opioid analgesics to treat chronic pain, clinicians and payers alike are looking for non-pharmacological, non-invasive (NPNI) treatments to provide safe and effective pain management options. We recently spoke with Douglas Metz, DC, executive vice president and chief health services officer, and Denee Choice, MD, PT, vice president and medical director of American Specialty Health (ASH) about ASH’s history of, and commitment to, coverage for NPNI therapies for managing musculoskeletal pain. Both were participants in a panel presentation at the AIPM’s Annual Meeting in San Diego on the “Realities of Insurance Coverage for Integrative Pain Care.” “ASH has provided services for more than 30 years that are delivered across a continuum of NPNI interventions, from chiropractic care to acupuncture to massage therapy,” said Dr. Metz. “Our services cover 43 million Americans, many of whom seek treatment for some type of acute or chronic musculoskeletal pain.” Dr. Metz explained that with their programs, “The goal is to help people with pain understand that managing their condition is not
just about an intervention. It’s about each individual understanding the value of owning his or her care. So, although they may feel they are being governed by their pain, they own their life and their intervention. Unfortunately, often people in pain are unsure of the best intervention for their situation and they drift from one treatment to the next without the help of a coordinated care system and appropriate education about the options available to them.” He mentioned a comment heard at the AIPM meeting that he felt was telling: “Look at the evidence for many of the NPNI services. The evidence shows that most of them are effective, but there is no evidence that shows that one is necessarily better than the other.” “We need to help patients as they navigate the system to know what options they have and how to work with their health care practitioner to evaluate the options and the outcomes they are experiencing,” said Dr. Metz. “Ultimately, the patient has to choose, but he or she will most likely need help deciding what is best for the current situation,” he said. ASH recently launched a new program that aims to help patients navigate their many pain options, guided by a care coordinator, or coach, who is trained to help with that process. The EmpoweredDecisions!™ program created by ASH combines provider delivery systems, fitness and exercise products, education about self-care, and cognitive behavioral training, which is administered by registered nurse coaches. The resulting program provides an ecosystem that helps guide the patient through evidence-based pain solutions. The program also includes digital engagement, which Dr. Metz called the fourth leg of their chair. “With digital engagement tools, patients have smartphone access to real-time information that can help them think about their pain management options and self-care at the point that they need it,” said Dr. Metz. “For example, for a pain patient, getting in and out of a car appropriately is critical. You can irritate and reinjure your back repeatedly with each transition if you are not careful.” ASH is building a product that links to a phone’s GPS system that identifies the user’s location and movement. “So if you are a pain patient and the GPS identifies that you are driving, the application can send you a notice that says, ‘When you get out of your car, remember to do the following...’ The app user receives real-time useful instructions. We also have an app that knows when you are in a gym and how long you stay there. We remind you that you need to be there for at least 30 minutes to get the full benefit.” Dr. Metz emphasized that the essential functional ingredients of the ASH NPNI programs have operated for more than 30 years. “We know how to deliver evidence-based chiropractic, physical therapy, and other types of NPNI MSK [musculoskeletal] services that are evidence-based and guideline supported.” ASH sells its products to payers across the U.S. and currently contracts with more than 140 health plans and nearly 70,000 providers.
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Table 1: Evidence and Guideline Supported Non-pharmaceutical/Non-invasive Interventions(2) EDUCATION AND SELF-CARE
MOVEMENT, EXERCISE, AND FITNESS
PROVIDER-DELIVERED CONSERVATIVE SERVICES
Cognitive Behavioral Therapy (CBT)Based Training and Education Medication Management Education Mindfulness-Based Stress Reduction Mental Imagery Relaxation Skills Biofeedback Posture and Ergonomics Training Safe Movement and Exercise Superficial Heat Acute Pain First Aid Injury Prevention and Recovery Lifestyle Factors: Health promoting diet Weight loss Smoking cessation Sleep Hygiene Stress Management
General (aerobic and resistance training) exercise and fitness Therapeutic exercise Aquatic exercise Core stabilization exercise Postural exercise Activity pacing Mindful movement Yoga, tai chi, pilates, qui gong Motor control exercises Functional fitness
Acupuncture Spinal manipulation Joint mobilization Soft tissue mobilization Therapeutic massage Ergonomic intervention Multidisciplinary rehabilitation Supervised therapeutic exercise Return to work/activities of daily living (ADLs)
“Payers should know that if they want to move people away from first-line use of opioids for MSK pain, they should encourage them toward treatment options that are quality-managed in order to get the best outcomes,” said Dr. Metz. He noted that some payers cover treatments without appropriately managing the benefit or measuring outcomes. “However, we can demonstrate that, on average, 94% of patients report resolution of chief complaint for the patients that access providers in our networks. Our program offers a managed, supported, intervention as an option for first-line MSK condition management.” ASH recently published a white paper called “The Solution: Non-Pharmaceutical/Non-Invasive Interventions for Musculoskeletal Pain(2),” which includes an evaluation of the evidence and guidelines that support various treatment options for those with MSK conditions (See Table 1). The company also has created an integrative evidence guide that evaluates effectiveness and safety for 40 different interventions for eight major categories of back pain. For example, Dr. Metz said, “There is pretty strong evidence for using acupuncture for localized back pain, but less for pain radiating down the limb. Physical therapy has better evidence for that condition. Patients need to know this in order to discuss options with their health care practitioner as they make their decisions about treatment options.” Dr. Choice adds, “We don’t want to demonize the need for surgery, injections, or drugs. These are necessary and valuable tools in the armamentarium of health care providers, but we recognize that they are being used more frequently than necessary.” “A key component,” Dr. Metz said to addressing resolution of chronic pain, “is a spiritual value proposition that we can simply call ‘purpose.’ We ask: ‘Why are you here? What would you like to do with your life to be more fulfilled and have more fun if you were able to manage your pain?’ When I had my practice, one man came into the office complaining about back pain and I asked him what he would he like to do if he was able to do more
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than he could today? He wanted to play with his grandkids. So I taught him to do exercises that allowed him to get on the floor and back up off the floor without hurting his back. He was elated. His pain didn’t go away, but he had improved function and had a better life as a result. Sometimes we providers get so focused on the treatment service that we want to provide, we forget about the patient and what they really want to accomplish.” Overall, Dr. Metz said ASH programs evaluate functional outcomes, pain interference, mobility, and movement when reviewing non-pharmaceutical and non-invasive health care utilization. “Basically, we want to improve the patient’s function and reduce overutilization of the health care system,” he added. Dr. Choice said that ASH programs help people select evidence-based treatment options consistent with their values and preferences, and tailored to meet their goals. “EmpoweredDecisions!™ is a new product for ASH that integrates all of the pieces—self-care, physical exercise and movement, cognitive reframing, and provider-delivered pain treatment services into a new ecosystem,” she said. This product is delivered in a manner that can be scaled for national health plans and employers. “We tell the carrier that we will manage their members with musculoskeletal pain in a comprehensive, coordinated program,” said Dr. Metz. “We help people navigate within a large network of providers, understand how to work effectively with their health care providers, and select the preferred and appropriate services, movement activities, and self-care activities as they learn to manage their pain. This is where we start.” REFERENCES 1. Dieleman JL, Baral R, Birger M, et al. US spending on personal health care and public health, 1996-2013. JAMA. 2016 Dec 27;316(24):2627-2646. 2. THE SOLUTION; Non-Pharmaceutical/Non-Invasive Interventions for Musculoskeletal Pain. Carmel, Indiana: American Specialty Health;.
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Authors
Supercharge Yourself!
In this new clinician book, the authors dive into the neuroimmune science of pain further than ever before. Gain applicable knowledge to care for your patients with 238 pages on the neuroimmune biology of pain, educational science and conceptual change theory, and over 100 ready-to-use clinical metaphors and therapeutic narratives.
David Butler BPhty MAppSc EdD lecturer, educator, and author, has written and co-written many publications, blending manual therapy skills with neurobiological evidence and clinical decision-making skills for the management of acute and chronic pain states. Lorimer Moseley PhD, FACP is Professor of Clinical Neurosciences, Foundation Chair in Physiotherapy and NHMRC Principal Research Fellow at the University of South Australia. He is the author of over 200 articles and several books, and is also a Fellow and Honoured Member of the Australian Physiotherapy Association.
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➊ Document your knowledge and use of best practices in pain care. ➋ Demonstrate your extensive experience treating people with pain. ➌ Show your patients and peers you’ve gone above and beyond to provide safe and effective pharmacologic pain care.
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