Category Archives: Clinical

Personality Disorders: Recognition and Management in a Pain Clinic

by Larry Robins, MD

Introduction

Patients with moderate-to-severe personality disorders (PD) Are frequently seen in medical practices. It is increasingly important to recognize, limit and manage those with aggressive types of PD.  Likewise, it is crucial to recognize those who fit the bipolar spectrum. In particular, the mild end of the spectrum is often missed. The clinical stakes for missing bipolar are enormous, as these patients tend to bounce from antidepressant to antidepressant, with predictably poor results.  This article delves into recognition and management of patients whose pain treatment is complicated by psychological concerns.

Personality Disorders at a Clinic

Consider the following scenario: a 28 year old man, Bill, presents to the pain clinic with severe low back pain.  He seems angry on the first visit and is very demanding with the front office staff.  Bill tells the staff he is mistrustful of physicians.  He openly states to the doctor, “I will go back to work when you give me the right amount of drugs that help take away my pain.” Bill is upset with his last two health providers.

Over the next few months, the clinic staff bends over backwards for Bill, even though at times he is verbally abusive to the staff with a sense of entitlement.  This is demonstrated in instances such as when he calls and tells the staff: “I want to talk to Dr. Smith NOW, put me through!”  The staff, out of fear, jumps and does what he orders.  His behavior is manipulative. The physician feels as though he is in a subservient position, trying to appease Bill and end the confrontations.

When the physician recommends that Bill be evaluated by a psychotherapist, Bill laughs at the idea and refuses. Suddenly, after nine months of treatment, Bill is suddenly blaming the physician and clinic for all of his difficulties including his pain, obesity, and sexual dysfunction.  Bill threatens to sue the clinic and reports the doctor to the state regulatory office.  What happened here?

Bill was subsequently diagnosed with a paranoid personality disorder.  The clinic employees did not recognize him as having that diagnosis and failed to set limits on Bill’s behavior.  The disruptions in the usual activities of the clinic, the increased stress on the staff, and the monopolization of clinician time are difficult to quantify.  In the remainder of this article features of personality disorders that should help with identification are discussed. Optimal care and management of the disorder begins with recognition.

Approximately 10-12% of people in the general population have features of a personality disorder.1 There are a number of personality disorders, and some are more serious and difficult to treat than others.  In general, characteristics of personality disorders include: lack of insight, poor response to psychotherapy or other therapeutic interventions, difficulty with attachments and trust, a sense of entitlement, and chaotic relationships and distress with family, friends and co-workers.  Comorbid personality disorder with substance abuse is common.

Personality disorders range from mild to very severe and patients with such disorders may take on different roles, including victim, rescuer or persecutor.  When the persecutor role is assumed, the person who is the target may be in danger. Seeing a therapist for a long period of time, perhaps 5-7 years, can help to some degree.  However, goals and expectations must be limited.  Considering the plasticity of the brain is important, as some people can improve naturally over time, particularly among younger patients.   The following section describes some of the more severe personality disorder types.  However, many people do not fit neatly into any of these single categories, because they have features of two or three different personality disorders.

Paranoid Personality Disorder.  People who are diagnosed with paranoid personality disorder tends to be non-trusting, suspicious, related to seeing the world as dangerous. They may seem secretive and reluctant to confide in others.  In relationships, they view themselves as being constantly mistreated, doubt the loyalty of everybody around them, and believe they are being exploited or harmed.  Patients diagnosed with this disorder bear severe grudges against others, often, become angry easily and have a sense of entitlement.  People with paranoid personality disorders can become violent and dangerous, with many spree killers being diagnosed with paranoid personalities.  Several notorious world leaders, including Joseph Stalin and Saddam Hussein, were most likely paranoid personalities.2

Antisocial Personality Disorder.  People diagnosed with antisocial personality disorder characteristically have no regard for the rights of others.  In demeanor, they tend to be irritable, impulsive, and exploitative.  They tend to, see themselves as better or superior, and can be very opportunistic in getting what they want.  People with this disorder   have characteristics of being deceitful, stealing from people around them, and often having trouble with the law.  They frequently engage in fraudulent activities and may be successful as scam artists.  For example, a person with this disorder may take on the role of financial savior for a church, then end up stealing everything from the church.  Generally, people with this disorder have no remorse for their actions. Conduct disorder in a child often morphs into antisocial personality disorder.  Examples include fictional character Tony Soprano on the television show, and, in real life, the mafia’s “Dapper Don,” John Gotti.2

Borderline Personality Disorder (BPD).  Characteristics of people with borderline personality disorder are instability of mood, poor self-image, pervasive abandonment fears, identity disturbance and major boundary issues.  People with borderline personality disorders usually demonstrate impulsiveness, and very quick shifts from depression to anxiety to irritability.  They usually have chronic feelings of emptiness or severe loneliness, plus anger volatile tempers and even suicidal behavior. Under stress, they can become somewhat paranoid.  Coexisting problems with substance abuse or other addictive behaviors may occur, as well as sleep disorders with severe insomnia.  People with severe borderline personality disorders will react with high drama and create chaos for everybody around them.  They tend to have a split world view, which is, they see people as wonderful or terrible, with nothing in between. Borderline personality disorders can vary from mild to severe, nd become better or worse over time. Suicide becomes more likely as patients age into their upper twenties and thirties.3 Suicide is also more common within a week of discharge from a psychiatric unit. Examples of people reportedly diagnosed with borderline personality disorder include Adolph Hitler, Marilyn Monroe, and Glenn Close’s character Alex, in the movie, “Fatal Attraction.” 

Narcissistic Personality Disorder.  Narcissistic personality disorder is less common than those previously discussed and is typified by a personality in which the person sees him or herself as superior to others.  People with this personality have characteristics of grandiosity, being vain, requiring admiration, lacking empathy, having a deep sense of entitlement, having strong belief of self-importance and acting to support those feelings of self-importance.  They characteristically have behaviors which are envious, arrogant, exploitative, and can be very angry.  Examples might include General George Patton, Nicole Kidman’s character in the movie, “To Die For,” Michael Douglas’ character, Gordon Gekko, in the movie, “Wall Street.”2

There are a number of other personality disorders which are not as dangerous for the people around them or for health care providers.  Even though PD characteristics may seem extreme, they are often overlooked, and health care clinics may react by reacting to and treating these patients in a dysfunctional manner.  The difficulties begin with not recognizing the personality disorder.

Pain and Personality Disorders

One  study on people with borderline personality (BPD) concluded that BPD comorbidity with migraine is associated with increased disability from the headaches.4  In addition, in that study  those people diagnosed with BPD, were more severely affected by headaches; more inclined to be refractory to treatment; had increase in medication overuse headache; headaches were more pervasive; there was a higher degree of depression; , more unscheduled visits for acute headache treatment; and less chance of adequate response of headache medications..4

Another study indicated the incidence of BPD was increased in migraineurs.5 My recent study of 1000 migraineurs indicated that 5.5% of patients had a moderate or severe personality disorder.6 There is ample evidence that transformed migraine is associated with more prevalent psychopathology, including personality disorder, than is episodic migraine.  BPD can be considered the mental health equivalent of chronic pain.  In my experience, the two most important prognostic indicators for those with PD are impulsivity and substance abuse.

Treatment for those with PD necessitates a caring, but stern, approach.  Limits must be set on clinician contact, including telephone calls. Abuse of staff should not be tolerated.  Referral to other health care providers, particularly mental health professionals, should be suggested.  Psychotherapists and psychiatrists who are experienced with this population are vital if the patient is to be adequately managed.  Many of the PD patients do not do well with traditional, insight-oriented therapy treatment, but are better managed long-term with dialectical behavioral approach.  For a therapy to be beneficial, it must be consistent and long-term.  A psychoeducational approach may also help.  Unfortunately, even with encouragement and support many PD patients will not continue in therapy. Therapeutic goals for the PD patient are relatively modest.

It is easy to become drawn into the drama surrounding patients with PDs, particularly those with BPD.  The patient with BPD may grant the clinician power, but then subvert the therapy.  An example of this would be, “Doctor, you are the greatest, only you can help me.  These headaches ruin my life, ….and I know that nothing is going to work!”  Some clinicians are able to manage working with these patients without becoming involved in the drama and countertransference, but most do not do well working with them.  If there are signs of a dangerous PD (i.e. abuse and anger being demonstrated), during the first visit or phone call to the clinic), rather than becoming enmeshed in the relationship, is better to refer the patient to someone experienced in working with patients with PD.

There are risks inherent in caring for people who are diagnosed with personality disorders. As compared to the general population, those with BPD are at increased risk for suicide, particularly as they progress into middle age.  Identifiable risk factors for suicide among BPD patients include repeated hospitalizations (i.e. five or more), a recent psychiatric hospitalization, and, among adolescents, birth trauma.3 Certain types of PD (i.e. paranoid, narcissistic, antisocial and borderline) are more likely to become angry and vengeful with health care providers working with them; resorting to lawsuits or writing letters to the departments of regulation.  Violence may be threatened.  A patient with PD often presents as a victim, and then rapidly flips into the role of persecutor.  Anger among these patients becomes intently focused, creating a stressful environment for healthcare workers.  Setting limits and keeping careful documentation are important in these situations.

It does take a village to help a patient with a personality disorder, just as it does to adequately treat those with severe pain. It is important to recruit other clinicians, such as mental health providers, physical therapists, biofeedback therapists, etc., to aid in the treatment.

While there are no specific medications indicated for those with PD, the Axis I symptoms are more amenable to pharmacotherapy. Medications, though limited, may be beneficial for the impulsivity, aggression, self-mutilation, anxiety and depression components of PD.7   Antidepressants, mood stabilizers, and antipsychotics may ameliorate symptoms.  Some of these medications may also lessen headache pain as well.  PD patients with severe, chronic pain present additional challenges for treatment. It is important to limit and closely monitor addictive medications.  Particularly with BPD, opioids and benzodiazepines are best avoided.  The diagnosis of a moderate or severe personality disorder alters both goals and approach for pain management.

Conclusion

For patient care, it has become increasingly important to recognize those patients whose psychiatric problems complicate their treatment in a pain clinic. Patients with a personality disorder are more likely to abuse drugs, file lawsuits, or display abusive behavior toward the staff.  With personality disorders, setting limits is vital. 

Treating patients with chronic pain can be complex and challenging enough.  When their patients who live with chronic pain also have psychological comorbidities, it is vital that the psychopathology be effectively attended to, as well as the pain. 

References

  1. Lester G. Personality Disorders in Social Work and Health Care. Nashville: Cross Country University Press; 2002:28-79.
  2. Lester G. Borderline Personality Disorder. Treatment and Management That Works. Nashville: Cross Country University Press; 2005:24-25.
  3. Lester G. Borderline Personality Disorder. Treatment and Management That Works. Nashville: Cross Country University Press; 2005:15-19.
  4. Rothrock J, et al. Borderline Personality Disorder and Migraine. Headache. 2007; 47:22-26.
  5. Hegarty AM. The prevalence of migraine in borderline personality disorder. Headache.1993;33:271.
  6. Robbins L. The prevalence of personality in migraineurs. US Neurological Disease, 2007, Vol.4, Issue I.
  7. Lester G. Borderline Personality Disorder. Treatment and Management That Works. Nashville: Cross Country University Press; 2005:88-91.
  8. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th edition. Washington D.C. American Psychiatric Association: 1994.
  9. Akiskal HS. Classification, diagnosis and boundaries of bipolar disorders. Bipolar Disorder.  Edited by Maj M, Akiskal H, Lopez-Ibor J et al.  London, Wiley, 2002, pp 1-52.
  10. Merikangas KR, et al. Comorbidity of migraine and psychiatric disorders.  Neurol Clin. 1997;15:115-123
  11. Baskin SM, et al. Mood and anxiety disorders in chronic headache. Headache. 2006;46(suppl 3):S76-S87.
  12. Robbins L. Bipolar spectrum in Migraine, Cluster and Chronic Tension Headache. US Neurological Disease, 2007, Vol. 3, Issue II.
  13. McIntyre RS, et al. The prevalence and impact of migraine headache in bipolar disorder: Results from the Canadian community health survey. Headache. 2006;46:973-982.
  14. Low NC, et al. Prevalence, clinical correlates and treatment of migraine in bipolar disorder. Headache. 2003;64:53-59.
  15. El-Mallakh, et al. Antidepressants in bipolar depression, in El-Mallakh R, Ghaem S. Bipolar Depression. Washington DC, American Psychiatric Publishing, Inc.; pp149-153.
  16. Calabrese J, et al. A randomized, double-blind, placebo-controlled trail of quetiapine in the treatment of bipolar I or II depression. AM J Psychiatry. 2005;162:1351-1360.

Medication Overuse Headache: Inaccurate and Overdiagnosed

by Larry Robbins, MD

Medication overuse headache (MOH) is very frequently diagnosed; however, the MOH diagnosis is often overused. Patients are labeled as having MOH when what they actually suffer from are refractory headaches, without medication overuse (MO).   Current diagnostic criteria for MOH only require abortive medication use on 10 or 15 days of each month (depending upon the medication). 1 No evidence is needed showing that the abortive actually causes an increase in headache. MO often occurs among people with frequent headaches.  However, MO does not necessarily lead to developing increased headaches. Diagnosing MOH is not an easy task, and requires a careful assessment of the patient’s medication and headache history.  As the abortive medication was used more frequently, the headaches (usually migraines) should have also escalated in a true MOH situation. In addition, after the offending medication was withdrawn, headaches should have receded. The epidemiologic studies of MOH may not be valid, since they do not differentiate MO from MOH.

A number of years ago all abortives, including nonsteroidal anti-inflammatories (NSAIDS), were implicated in MOH. We now realize that certain medications (NSAIDS and triptans) are less likely to cause MOH than others. Opioids and butalbital compounds are the worst offenders. Although simple NSAIDS usually do not contribute to MOH, they continue to be included in the MOH criteria.

Patients often are given the label of MOH simply because they admit to regularly consuming over-the-counter analgesics or a triptan. Many patients who frequently use these medications do not suffer from MOH. There are a number of variables, including genetics, age, type of drug, etc., that help to explain why one patient suffers from MOH, while the next does not.

For many patients with frequent headaches, behavioral techniques and preventive medications (including Botox) are inadequate. Our current preventives often provide little relief, and frequently cause unacceptable side effects. We do not have any preventives that were initially developed for headache, except for the Calcitonin gene-related peptide-inhibitor  (CGRPinhibitor) injections, which will be available later in 2018.  One long-term study indicated that only about half of migraineurs found any preventive helpful for longer than 6 months. 2, 3  Declining efficacy and increased side effects often lead to discontinuation of the preventive.

Many physicians are quick to blame the patient for causing MOH. The patients are told that they are suffering from MOH due to a particular medication, even though

  1. they have only been taking that medication for a short time, 
  2. the headaches did not increase once they began the medication,
  3. medication withdrawal did not lead to a lessening of the headaches.

Physicians often instruct the patient to only use the abortive 2 days per week. The patient usually responds, “that’s fine, but what do I do the other 5 days? I have to function.” Many headache specialists and neurologists maintain a rigid posture, refusing to allow more than a bare minimum of abortive medication.  The patient either suffers or seeks help elsewhere.

Much of what is written about MO and MOH is confusing, with little basis in fact. These are arbitrary terms, without scientific validation. Of course, we must try to minimize the use of abortives. Patients on frequent abortive medication should be withdrawn for a period of time,  (easier said than done). However, many refractory patients would have zero quality of life without their (frequently used) abortives.

The current criteria conflates MO with MOH. As a result, the term MOH is wildly over-diagnosed.  This is concerning because an inaccurate label of MOH may harm the patient. Patients with the MOH diagnosis often are denied the only medication that is helpful for them.  Two alternatives seem reasonable.  We could re-define MOH, using scientifically validated criteria.  Alternatively, we could drop the term MOH altogether.  

Of course, treating those who do have MOH is never easy. Patients are reluctant to give up their abortive, whether it is Excedrin®, a triptan, or an opioid. If we can convince the person their headaches may improve via minimizing the abortive, we sometimes may succeed. There are various strategies for withdrawal.  Sometimes it “takes a village” to treat a patient with severe headaches, and we recruit other “villagers” to assist in the process. These may be physical therapists, psychotherapists, biofeedback specialists, etc.  In the long-term, at least half of those with MOH do revert back to overuse of their . 4

References

  1. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013;33(9):629-808.
  2. Robbins,L. We Need Better Preventative Medications(Letter). Headache: The Journal of Head and Face Pain. 2001; 41(6): 611-612.
  3. Robbins,L. Efficacy of Preventive Medications for Chronic Daily Headache. Headache Quarterly. 1999; 10(3):135-139.
  4. L.  Letter in Headache, June 2001, Vol. 41, No. 6, pp. 611-612.

Migraine Treatment: A Comprehensive Guide

Migraine is a very common and disabling illness. Picking an agent that is best for each individual patient requires considering the patient’s history, lifestyle, comorbid conditions, and individual preferences.

Migraine headaches are a common cause of disability in the United States, affecting approximately 27 million American adults, or 17.1% of women and 5.6% of men. To help better define migraines, the term classical migraine has been replaced with migraine with aura and non-classical migraine is now referred to as migraine without aura. Chronic migraine, which affects 3.2 million Americans (2%), is defined as having migraine symptoms for at least 15 days per month, lasting at least 4 hours, and for longer than 3 months in duration. This is in contrast to episodic migraine, which causes symptoms on less than 15 days per month. Current treatment for chronic migraine is divided into acute, abortive agents (analgesics, triptans, ergots, etc.) and medications that will prevent migraine onset.

This review will highlight the current definitions of migraines as well as treatment options.

Migraine Characteristics
A recurring headache that is of moderate or severe intensity, and is triggered by migraine-precipitating factors, usually is considered to be migraine. Precipitating factors can include stress, certain foods, weather changes, smoke, hunger, fatigue, hormones, and so on. Migraine without aura is a chronic idiopathic headache disorder with attacks lasting 4 to 72 hours. Status migrainosis applies to migraine headaches that exceed 72 hours. Migraine features often include a unilateral location and a throbbing or pulsating nature to the pain. There may be associated nausea, photophobia, phonophobia, or dizziness. Further characteristics include a positive relationship with menses, decreased frequency during pregnancy, increased pain with physical activity, and history of migraine in first-degree relatives. It has been reported by 70 to 75% of migraine patients that they have a first-degree relative with a history of migraines.

Patients who suffer from migraines often have colder hands and feet compared with controls, and the prevalence of motion sickness is much higher in migraine patients. Although most patients will not have all of these characteristics, there are certain diagnostic criteria that have been established by the International Headache Society for the definite diagnosis of migraine. Distinguishing a milder migraine without aura from a moderate or severe tension headache may be difficult, and it is not surprising when “pure” migraine medications are effective for severe tension-type headaches.

Recurrent, repeated attacks of throbbing or severely aching headache are generally regarded as migraine, whether or not the patient has nausea, dizziness, photophobia, or phonophobia. The patient’s history is used to make the diagnosis of migraine. Physical examination and magnetic resonance imaging (MRI) or computed tomography (CT) scans are helpful only in ruling out organic pathology. Recent-onset headaches need to be investigated with an MRI scan to rule out other organic disorders, particularly brain tumors. In addition to physical exam and imaging, a check of intraocular pressure (IOP) may be warranted. With new-onset headaches, an eye exam is always warranted.

Although the pain is unilateral in 50% of migraine patients, the entire head often becomes involved. The pain may be in the facial or the cervical areas, and often will shift sides from one occurrence to another. Most patients, however, suffer the severe pain on one favored side from attack to attack.

The typical migraine patient suffers one to five attacks in a month, but many patients average less than one (episodic) or more than 10 per month (chronic). The attack frequency varies with the seasons, and many patients can identify a time of year when their headaches increase significantly. Patients with chronic migraine may have 15 days a month of headache, and many even have 30 days/month, 24/7.

The pain of the migraine often follows a bell-shaped curve, with a gradual ascent, a peak for a number of hours, and then a slow decline. Occasionally, the pain may be at its peak within minutes of onset. Many patients with migraine suffer some degree of nausea during the attack, and some experience vomiting as well. The nausea often is mild, and some patients are not bothered by it. Many patients state that the headache is lessened after they vomit. Diarrhea may occur, and is usually mild to moderate. The presence of diarrhea renders the use of rectal suppositories impossible.

Lightheadedness often accompanies the migraine, and syncope may occur. Most patients become sensitive to bright lights, sounds, and/or odors. Between migraine attacks, many patients retain the photophobia, and it is common for migraine patients to wear sunglasses most of the time. Sensitivity to bright lights is a distinctive migraine characteristic.

Pallor of the face is common during a migraine; flushing may occur as well, but is seen less often. Patients do complain of feeling excessively hot or cold during an attack, and the skin temperature may increase or decrease on the side with pain. Patients with migraines often experience tenderness of the scalp that may linger for hours or days after the migraine pain has ceased. This tenderness may actually occur during the prodrome of the migraine. Both vascular and muscular factors contribute to the scalp tenderness. Autonomic disturbances are relatively common, such as pupillary miosis or dilation, rhinorrhea, eye tearing, and nasal stuffiness. These also are symptoms of cluster headache, including the sharp pain about one eye or temple.

Alterations of mood are seen with many patients before, during, and after migraine attacks. Patients are usually anxious, tired, or depressed. They often feel “washed out” after an attack, but a calm or even an euphoric state occasionally is seen as a postdrome to the migraine. Rarely, euphoria or exhilaration may precede a migraine.

Weight gain due to fluid retention may occur, and begins prior to the onset of the migraine. At some point during the migraine, patients may experience polyuria. The weight gain is usually less than 4 lb., and is transient.

Visual Disturbances
Approximately 20% of patients experience visual neurologic disturbances preceding or during the migraine; these auras may be as disturbing to the patient as the migraine pain itself. The visual symptoms usually last 15 to 20 minutes, and most often will be followed by the migraine headache. Most migraine sufferers experience the same aura with each migraine, but occasionally one person may have several types of auras. “The light of a flashbulb going off,” is the description many patients give to describe their aura. The visual hallucinations seen most often consist of spots, stars, lines (often wavy), color splashes, and waves resembling heat waves. The images may seem to shimmer, sparkle, or flicker. These visual occurrences are referred to as photopsia.

Fortification spectra are seen much less often than photopsia. They usually begin with a decrease in vision and visual hallucinations that are unformed. Within minutes, a paracentral scotoma becomes evident and this assumes a crescent shape, usually with zigzags. There often is associated shimmering, sparkling, or flickering at the edges of the scotoma.
Patients may experience a “graying out” of their vision, or a “white out” may occur. Some patients suffer complete visual loss, usually for some minutes. Photopsia may be experienced at the same time as the gray out, white out, or visual loss.

Miscellaneous Neurologic Symptoms
Numbness or tingling (paresthesias) commonly are experienced by patients as part of the migraine. These are experienced most often in one hand and forearm, but may be felt in the face, periorally, or in both arms and legs. Like the visual disturbances, they often last only minutes preceding the pain, but the numbness may continue for hours, and at times the paresthesias are severe. The sensory disturbances usually increase slowly over 15 to 25 minutes, differentiating them from the more rapid pace seen in epilepsy.

Paralysis of the limbs may occur, but this is rare. This is occasionally seen as a familial autosomal dominant trait, and the term familial hemiplegic migraine is applied to this form. With the weakness, aphasia or slurred speech may also occur, and sensory disturbances are seen ipsilateral to the weakness. Vertigo and/or dizziness are often experienced during migraine, and may be disabling. “Migraine associated vertigo” has become a common diagnosis. At times, the dizziness is more disabling to patients than the other symptoms. Ataxia may occur, but is not common. Rarely, multiple symptoms of brain stem dysfunction occur, with the term basilar migraine being applied to this type of syndrome. The attack usually begins with visual disturbances (most often photopsia), followed by ataxia, vertigo, paresthesias, and other brain stem symptoms. These severe neurologic symptoms usually abate after 15 to 30 minutes, and are followed by a headache. This type of migraine often stops over months or years, and the patient is simply left with migraine headaches without neurologic dysfunction.

Workup for Migraine
As noted, when patients present with a long history of typical migraine attacks, and the headaches are essentially unchanged, scans of the head usually are not absolutely necessary. Whether to do any testing at all depends on the physician’s clinical suspicion of organic pathology. Sound clinical judgment, based on patient history and a physical exam, is crucial in deciding who needs which exam.

In addition to the MRI and CT scan, tests that are sometimes useful for diagnosis of headache include lumbar puncture, IOP testing, CT scan of the sinuses, and blood tests. A magnetic resonance angiogram (MRA) allows the detection of most intracranial aneurysms.

The problems that need to be excluded in a patient with new-onset migraine include sinus disease, meningitis, glaucoma, brain tumor, arteritis, subarachnoid hemorrhage, idiopathic intracranial hypertension( or low pressure headache, which is positional in nature: basically almost gone when the patient lies down), hydrocephalus, pheochromocytoma, stroke or transient ischemic attack, internal carotid artery dissection, and systemic illness.

Headache Triggers
With migraine and chronic daily headache sufferers, avoidance of triggers should be emphasized. The most common triggers are stress (both during and after stress), weather changes, perimenstruation, missing meals, bright lights or sunlight, under- and oversleeping, food sensitivity, perfume, cigarette smoke, exercise, and sexual activity. Some foods can be headache triggers, but foods tend to be overemphasized. In general, headache patients do better with regular schedules, eating three or more meals per day and going to bed and awaking at the same time every day. Many patients state that “I can tell the weather with my head”. Barometric changes and storms are typical weather culprits, but some patients do poorly on bright “sun-glare” days.

Regarding stress as a trigger, it is not so much extreme stress, but daily hassles that increase headaches. When patients are faced with overwhelming daily stress, particularly when they are not sleeping well at night, headaches can be much worse the next day.

Psychotherapy is extremely useful for many headache patients with regard to stress management, coping, life issues, family-of-origin issues, and so on. Although psychotherapy may be recommended, it is crucial to legitimize the headaches as a physical condition; headaches are not a “psychological” problem, but rather a physical one that stress may exacerbate. Once one inherits the brain chemistry for headache, these triggers come into play; without the inherited genetics, most people may have stress/weather changes/hormonal changes, but not experience a headache.

Managing stress with exercise, yoga/Pilates/meditation, etc., often will reduce the frequency of headaches. The ideal would be for the patient to take a class weekly, then do the stretches and breathing for 10 minutes a day. Patients may experience some relief from associated neck or back pain. Relaxation techniques such as biofeedback, deep breathing, and imaging also may be helpful for daily headache patients, particularly when stress is a factor.

Many migraine patients have accompanying neck pain and physical therapy may help; acupuncture or chiropractic treatments occasionally help. Certain physical therapists “specialize” in head and neck pain. Massage may be effective, but the relief is often short-lived. Temporomandibular disorder (TMD), with clenching and/or bruxing, may exacerbate migraine; with TMD, physical therapy, a bite splint, and/or Botox may help. It often “takes a village” to help a person with pain, and we recruit other “villagers”, such as physical therapists or psychotherapists.

Caffeine Use
Although caffeine can help headaches, overuse may increase headaches. Whether in coffee, caffeine pills, or combination analgesics, patients must limit total caffeine intake. The maximum amount of caffeine taken each day varies from person to person, depending on sleep patterns, presence of anxiety, and sensitivity to possible rebound headaches. In general, caffeine should be limited to no more than 150 or 200 mg a day. Some migraineurs do well by completely decaffeinating themselves; it often is worthwhile to try this approach.

Foods to Avoid
As noted, food sensitivities are not that common. Patients tend to focus on the foods, as they are a tangible trigger that one can control (as opposed to weather, for example). However, most people are sensitive to only two or three types of food in the diet. If a particular food is going to cause a headache, it usually will occur within 3 hours of eating.

Medications: Abortives
The most common first-line treatment for migraines includes triptans. More than 200 million patients worldwide have used triptans. The most effective way to use triptans is to take them early in the headache—the earlier a patient takes these agents the better the effect. Sumatriptan is an extremely effective migraine-abortive medication with minimal side effects. It is effective for approximately 70% of patients and is the gold standard in abortive headache treatment. The usual dose is one tablet every 3 hours, as needed; maximum dose, two tablets per day. However, clinicians do need to limit triptan use (ideally, 3 days per week) to avoid rebound headaches or medication overuse headache (MOH). See section on rebound/MOH.

Triptans are helpful for moderate as well as more severe migraines. Certain patients tolerate one of the triptans better than another, and it is worthwhile to try several in an individual patient. Triptans are an excellent choice for migraine patients who are not at risk for coronary artery disease (CAD). Patients in their 50s or 60s can use these drugs, but they should be prescribed cautiously, and only in those patients who have been screened for CAD. Over the 23 years that triptans have been available, serious side effects have been few; they appear to be much safer than was previously thought in 1993.

For patients who cannot tolerate triptans, there are a number of other effective non-triptan first-line approaches, including diclofenac potassium powder(Cambia), Excedrin Migraine, naproxen, ketorolac(po/IM/nasal:”Sprix nasal spray”), ibuprofen, and Prodrin (similar to Midrin, but without the sedative). We often combine 2 first-line approaches (a triptan and a non-steroidal anti-inflammatory drug (NSAID) combination, for instance).

In general, drugs containing ergotamine (also called ergots) are effective second-line therapy for migraines. They were the first anti-migraine drugs available, but they have many side effects, and at most, should be used only 2 days per week. Dihydroergotamine (DHE) is the safest ergot derivative. DHE is primarily a “venoconstrictor”, with little arterial effects. This renders it very unlikely to cause cardiac problems. Indeed, since its introduction in 1945, DHE has been remarkably safe. Intravenous DHE is a very effective migraine-abortive agent administered in the office or emergency room. Availability and cost of DHE have been a problem. Nasal (Migranal Nasal Spray) and inhaled forms of DHE (soon to be released) have been found to be safe and effective as well. Barbiturates and opioids have been studied and are effective, but because of the risk for addiction, should be used sparingly. For severe prolonged migraines, corticosteroids (oral, IV, or intramuscular) often are effective. It is important to use low doses of steroids, for only 1 to 3 days per month.

Many patients have 3 to 6 abortives on their shelf: triptan, NSAIDs, Excedrin, an anti-nausea med, and a painkiller (opioid/butalbital). They use each in different situations, for different types and degrees of headache.

A new therapy has emerged, transcranial magnetic stimulation(TMS). The patient uses a hand held device applied to the back of the head, for an acute migraine attack. The first TMS approved(in Dec., 2013) is the Spring TMS. The official indication is migraine with aura. Studies have been positive on TMS devices over a number of years. Time will tell as to the efficacy. The low-dose home TMS appears to be very safe. People rent the unit, and use 3 or 4 pulses twice daily, as a preventive. TMS may also be used abortively, but preventive use is the most promising.

Miscellaneous Approaches

Muscle relaxants (carisoprodol, diazepam) or tranquilizers (clonazepam, alprazolam) occasionally are useful, primarily to aid in sleeping. Intravenous sodium valproate (Depacon) is safe and can be effective. The atypical antipsychotics, such as olanzapine (Zyprexa) or quetiapine (Seroquel), occasionally may be useful on an as-needed basis. In the emergency room, IV administration of antiemetic agents such as prochlorperazine (Compazine, others) or metoclopramide (Reglan) may be useful. Certain preventive medications, such as valproic acid (Depakote), topiramate (Topamax), and also amitriptyline, may be useful on an as-needed basis, utilizing low doses every 4 to 6 hours. The antihistamine diphenhydramine is occasionally useful when administered intramuscularly. At times, patients may have injections for home use: ketorolac, orphenadrine, sumatriptan, diphenhydramine, promethazine, etc.

Medication Overuse Headache(MOH)
Much is written about MOH, with many patients diagnosed with this condition. Often a patient will be overusing abortive meds (medication overuse), but not be suffering “rebound/withdrawal” headaches (medication overuse, but NOT medication overuse headache). Up until recently, all NSAIDS were lumped under “meds that cause MOH”, and this simply is not true. For some patients, opioids, butalbital, and high caffeine containing meds cause MOH. Triptans are occasionally implicated as well. However, for most patients with chronic migraine, they have daily(or near-daily) headaches, the preventives may not be effective, and they use abortives in an attempt to get through the day.

There are more questions in the area of MOH than we have answers. The pathophysiology of MOH is unclear. Some patients will have MOH from 2 Excedrin daily, while others do not suffer from MOH consuming 8 per day. When patients are using frequent abortives, we often withdraw them from that abortive, push preventives, and attempt to minimize analgesics. However, for many chronic migraine sufferers, the preventives are not very effective. For those sufferers, abortives allow them to live with a reasonable quality of life.

Preventive Medications
There is no algorithm to determine who is to go on preventive headache medication. The number of monthly headaches is one factor, along with comorbidities. Patients have to be willing to take daily medication (many do not want any daily meds). There is no absolute rule that applies to headache treatment. For a patient with two headaches a month that are severe, prolonged, and not relieved by drugs, preventive medicine might be used. On the other hand, for the person who has five headaches a month, but can obtain relief from Excedrin or a triptan, preventive medicine may not be optimal. The choice of who qualifies for medication depends on the patient’s age, medical and psychiatric comorbidities, and frequency and severity of the migraine, as well as the patient’s preference. Comorbidities often determine which preventive meds are used. If a patient has HTN, a med for blood pressure will be used. When patients concurrently suffer with anxiety or depression, various antidepressants are utilized for the headache and mood disorder. We want to minimize meds, and treating 2 conditions with one medication is ideal.

In using medication, a realistic goal is to decrease the headache severity by 40% to 70%, not to completely eliminate the headaches. It is wonderful when the headaches are 90% improved, but the idea is also to minimize medication. “Clinical meaningful pain relief” is usually around a 30% improvement. Most patients need to be willing to settle for moderate improvement. Preventives may take 3 to 6 weeks to work, and “educated guesswork” often is used to find the best approach for each patient. In the long run, preventive medications are effective for approximately 50% of patients. The other 50% scramble with various abortives.

As noted, patients should play an active role in medication choice. Preventive medications should be selected depending on the patient’s comorbidities, GI system, medication sensitivities, and the like. Fatigue and/or weight gain are major reasons why patients abandon a preventive medication. Headache patients commonly complain of fatigue, and tend to give up on medications that increase tiredness. A patient’s occupation also may guide the caregiver away from certain medications; for example, an accountant may not be able to tolerate the memory problems associated with topiramate. Side effects are possible with any medication; the patient must be prepared to endure mild side effects in order to achieve results.

First-line Preventive Medications for Migraine

Botulinum Toxin A
Botulinum toxin A (Botox) has been studied extensively in patients with migraines. Nearly 4 million people have had botulinum toxin A injections for headache. Botulinum toxin A has been found to significantly improve quality of life and reduce headache impact.4 Botox is the only botlinum toxin A FDA-approved for treatment of chronic migraine. It is relatively safe and only takes a few minutes to inject. One set of injections may decrease headaches for 1 to 3 months. There also is a cumulative benefit, where the headaches continue to improve over 1 year of injections. Botox may be safer than many of the medications that are used for headache. Botox does not cause the “annoying” side effects that are commonly encountered with preventives.

Natural Supplements and Herbs
Feverfew, Petadolex (butterbur), and magnesium oxide have all proven effective in double-blind studies as migraine preventives. Of these, Petadolex has been the most effective.
Petadolex is a purified form of the herb butterbur and is made of extracted plant certified by the German Health Authority. The herb preparation is commonly used in Europe, and has been found to be successful in preventing migraines in several well-designed blind studies. The usual dose is 100mg. per day, and many increase this to 150mg. daily(all at once, or in 2 divided doses). Earlier concerns about carcinogenesis with this family of herbs have decreased with the use of Petadolex. Patients have occasionally experienced GI upset or a bad taste in the mouth, but Petadolex is usually well tolerated. It is prudent to stop it every three months or so. Petadolex is available by calling 1-888-301-1084, through www.petadolex.com., or at Amazon.com.

Magnesium helps many systems in the body to function, especially the muscles and nerves. It has been shown that magnesium levels in the brain of migraine patients tend to be lower than normal. Magnesium oxide is used as a supplement to maintain adequate magnesium in the body. A dose of 400 or 500 mg per day can be used as a preventive; tablets are found in most pharmacies. However, mild GI side effects may limit use. There are also drug interactions that may occur; as always, consult your physician. There are tablets, as well as powdered versions available.

Feverfew has been demonstrated to be mildly effective in some patients for prevention of migraine headache. Feverfew can cause a mild increased tendency toward bleeding, and should be discontinued two weeks prior to any surgery. The problem with many herbal supplements is quality control. The amount of parthenolide (the active ingredient in feverfew) varies widely from farm to farm; certain farms consistently have better quality than others. The usual dose is 2 capsules each morning; there is a liquid form available. Patients occasionally will be allergic to feverfew, and it should not be used during pregnancy. Miscellaneous herbs/supplements have been used, particularly vitamin B2. CoQ10 and fish oil have also been studied. These occasionally help, but are less effective than Petadolex.

Topiramate is an effective migraine preventive, without the weight gain commonly encountered with the other meds. While usually fairly well tolerated, common side effects include memory difficulties(“spaciness”), and tingling. In higher doses, topiramate increases the risk for kidney stones. Topiramate does decrease appetite, leading to weight loss for some patients. This anorexic effect tends to disappear after several months. The usual dose is 50 to 100mg daily, but some do well on as little as 25mg.. The dose may be pushed to 300 or 400mg. per day, in the absence of significant side effects. Topiramate is primarily used for migraine prevention, but has also been utilized for cluster and tension headache as well. Topiramate may cause a metabolic acidosis, with lower bicarbonate levels(and increased chloride). The acidosis may lead to the tingling, which sometimes is alleviated by increasing potassium-containing fruits/vegetables(or adding potassium).

Valproate, or divalproex sodium, (Depakote) is a long-time staple, popular for migraine prevention. It is usually well tolerated in the lower doses used for headaches, however, the generic may not be as effective. Liver functions need to be monitored in the beginning of treatment. Valproate also is one of the primary mood stabilizers for bipolar disorder. Oral Depakote ER (500 mg) is an excellent once-daily, long-acting agent. As with most preventives, valproate needs 4 to 6 weeks to become effective.

The β-blocker propranolol also is FDA-approved as a preventive agent for migraines. Long-acting oral propranolol (Inderal), for example, is very useful in combination with the tricyclic antidepressant amitriptyline. Dosage begins with the long-acting agent given at 60 mg per day, and is usually kept between 60 and 120 mg per day. Lower doses are sometimes effective, such as 20 mg twice a day of propranolol. Other β-blockers also are effective, such as metoprolol (Toprol XL) and atenolol. Some of these are easier to work with than propranolol because they are scored tablets, and metoprolol and atenolol have fewer respiratory effects. Depression may occur. β-blockers are useful for those migraine patients with concurrent hypertension, tachycardia, mitral valve prolapse, and panic/anxiety disorders. Bystolic (nebivolol) is another β-blocker that may be helpful for the prevention of headaches, and has fewer respiratory side effects than other agents. Bystolic probably has the least amount of side effects among the β-blockers.

As noted, amitriptyline is an effective, inexpensive agent that is useful for the prevention of daily headaches and insomnia. As a preventative agent, amitriptyline is prescribed at low doses and taken at night. Sedation, weight gain, dry mouth, and constipation are common side effects. Other tricyclic antidepressants such as doxepin and protriptyline can be effective for migraine. Nortriptyline is similar to amitriptyline, with somewhat fewer side effects. These also are used for daily tension-type headaches. Protriptyline is one of the few older antidepressants that does not cause weight gain. However, anticholinergic side effects are increased with protriptyline; protriptyline is more effective for tension headache than for migraine. Although selective serotonin reuptake inhibitors (SSRIs) are used, they are more effective for anxiety and depression than for migraine.

Naproxen is a very useful agent for the treatment of daily headaches, as well as for younger women suffering from menstrual migraine. Naproxen is nonsedating, but frequently causes GI upset or pain. Effective as an abortive, it may be combined with other first-line preventive medications. Other NSAIDs can similarly be used for migraine prevention. As with all anti-inflammatories, GI side effects increase as people age, and therefore NSAIDs are used more often in the younger population. Blood tests are needed to monitor liver and kidney function.

Second-line Migraine Preventive Therapy

There are a number of second-line migraine treatments. The anti-seizure medication gabapentin has been demonstrated to be mildly useful in migraine and tension headache prophylaxis. In a large study on migraine, doses averaged approximately 2,400 mg per day, but lower doses are usually prescribed. Some patients do well with very low doses (200 or 300 mg per day). Sedation and dizziness may be a problem; however, gabapentin does not appear to cause end-organ damage, and weight gain is relatively minimal. Gabapentin can be used as an adjunct to other first-line preventive medications. A newer drug, pregabalin (Lyrica), has a similar mechanism of action to gabapentin. Lyrica is fairly safe, but sedation and weight gain often occur.

A safe, non-addicting muscle relaxant, tizanidine is useful for migraine and chronic daily headache. Tizanidine may be used on an as-needed basis for milder headaches, or for neck or back pain. Cyclobenzaprine (10 mg) is helpful for sleeping, and helps some with migraine and chronic daily headache.

There have been a number of studies on the efficacy of using angiotensin receptor blockers (ARB) and the angiotensin-converting enzyme inhibitors (ACE’s) for the prevention of migraine. ARBs are preferred because of minimal side effects. Examples include losartan (Cozaar) and candesartan (Atacand). These may be useful for the patient with hypertension and migraine. Side effects include dizziness, among others, but they are usually well tolerated, with no sedation or weight gain.

Similar to the ARB’s, the calcium channel antagonists have been utilized for migraine prevention. Verapamil ER (extended release) is the most commonly used form, with doses ranging from 120mg daily up to 360mg. per day. Verapamil is probably more effective as a cluster headache preventive.

Polypharmacy is common in migraine prevention. Two first-line medications often are used together and the combination of two preventives can be more effective than a single drug alone. For example, valproate often is combined with an antidepressant. Amitriptyline may be combined with propranolol(or other β-blockers), particularly if the tachycardia of the amitriptyline needs to be offset by a β-blocker; this combination is commonly used for “mixed” headaches (migraine plus chronic daily headache.) NSAIDs may be combined with most of the other first-line preventive medications. Thus, naproxen often is given with amitriptyline, propranolol, or verapamil. Naproxen is employed simultaneously as preventive and abortive medication. Polypharmacy commonly is employed when significant comorbidities (anxiety, depression, hypertension, etc.) are present. Unfortunately, polypharmacy brings the risk of increased side effects.

Venlafaxine (Effexor XR) is an excellent antidepressant, occasionally helpful for the prevention of migraine. Used primarily as an SSRI at lower doses; at higher doses (100-150 mg) norepinephrine also is increased. In fact, antidepressants with dual mechanisms (serotonin and norepinephrine) are more effective for pain and headache. Another similar medication is duloxetine(Cymbalta), with typical doses being 30mg to 60mg daily. Cymbalta has several pain indications, but is probably more effective for moods than for headache.

Conclusion
Migraine is a common and disabling illness. Outside of meds, it is important for migraineurs to watch their headache triggers, and exercise regularly. Physical therapy and/or psychotherapy may be of help (“it takes a village”). There is no good algorithm for determining which medication is best. Each patient is unique, and comorbidities drive where we go with treatment. The goal is to decrease head pain, while minimizing medications. NOTE: This is an updated version of an article that appeared in the July, 2014 issue of Practical Pain Management.

 

References
Lipton RB et al on behalf of the AMPP Advisory Group. Migraine prevalence, disease burden, and the need for preventive therapy. Neurology. 2007;68:343-349.
Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders. 2nd ed. Oxford, England: Blackwell Publishing; 2003.
Gardner KL. Genetics of migraine: an update. Headache. 2006;46(suppl 1):S19-S24.
Lipton RB, Varon SF, Grosbert B, et al. Onabotulinumtoxin A improves quality of life and reduces impact of chronic migraine. Neurology. 2011;77(15):1465-1472.
Mathew NT, Rapoport A, Saper J, Magnus L, et al. Efficacy of gabapentin in migraine prophylaxis. Headache. 2001;41(2):119-128.
Robbins L. Robbins Headache Clinic. http://www.chicagoheadacheclinic.com

In the Spotlight: Geralyn Datz, PhD

I had an opportunity to sit down with Geralyn Datz, PhD, past president of SPS, after her session on “Biopsychosocial Approaches to Treating Chronic Pain and Headache” at our recent meeting in New Orleans.

One of the topics you addressed in your talk was how there has been attention to the overemphasis on medications, particularly opioids, to manage pain. Tell us more about how we can be better at teaching patients how to actively cope with chronic pain?

One of the biggest challenges with using a solitary approach such as pharmacotherapy, including opioid therapy, for the patients living with pain, is that chronic pain is best treated through a multimodal approach. This is because pain affects the whole person. Patients and practitioners need to learn techniques to adapt to and manage the pain, not just take it away temporarily. There is a push to teach active self management strategies, such as sleep restoration, pacing, conquering worry and anxiety, and how to minimize depression in the face of pain. Simply taking a pill is a passive strategy and it is does nothing to teach the patient about the very important mind, body, and behavior connections that exist with chronic pain. Many treatment centers and insurers are including psychologists in the pain treatment conversation because of the understanding that this discipline offers time tested ways of dealing with these issues.

Similarly, the first thing to consider when talking about opioids is that they are designed to be a delivery system, a pharmaceutical, which provides analgesic relief for a certain period of time. As a result, medication is time-limited. When patients deal with a medical problem like chronic pain, they have a constant, day-long, often years-long, process of discomfort and limitations. There will naturally be times where the patient has more or less analgesic effects, and in different people these effects vary widely in duration. Furthermore, the data on opioids for long term pain management and relief in non-cancer pain is rather weak. A Cochrane review showed that in some carefully selected populations, there was relief long term. However, for the great majority of patients, adverse effects and side effects were many, and relief was generally poor, and less than 30%. There is also evidence to suggest that opioids can increase pain when taken long term (opioid induced hyperalgesia), which is obviously completely counterproductive to the goal of pain relief.  As a result, multi-modal approaches that teach coping skills and ways to overcome the impact of pain are crucial.

You shared that the biopsychosocial model of treatment is becoming more recognized by providers and insurers, compared to the biomedical model, which dominated for many years. Can you elaborate on that?

For many years the biomedical model of treatment has prevailed in treating patients living with pain. This model is based on some very early research about acute pain. It basically holds that there is a one-to-one correspondence between the extent of injury and the amount of pain experienced. Therefore, large injuries lead to large pains, and small injuries lead to small pains. This model also assumes that surgery and medications can fix pain.  While this is sometimes true, this model fails to appreciate what we now know about the central nervous system. We know that chronic pain is a complex and dynamic process, and it involves a person’s thoughts, beliefs, experiences; and these all can influence pain for better or worse. In addition, conditions such as depression and anxiety can arise from the presence of pain, and these also can intensify pain through interactions of the brain with the body. 

To address chronic pain effectively, we must address the person’s reactions to it and teach ways to overcome it, including retraining the brain away from the unpleasant pain signals. This is a psychological process involving education, training in thinking and new behaviors, and coaching.

We know that there is a very strong co-occurrence between chronic pain and conditions like depression and anxiety. You spoke about in this in your talk. What can you tell our readers?

Chronic pain is an unpleasant physical and emotional experience. The emotional suffering related to chronic pain, as well as the many changes it can bring about to a person’s life—job loss, financial distress, changes to activities of daily living, limitations, and reliance on other people—all can become very discouraging, frustrating and overwhelming. These circumstances frequently result in the development of clinical depression and anxiety. Co-occurrence rates of depression and anxiety in chronic pain patients are very high.

Another psychological diagnosis that is common to patients living with pain is post traumatic stress disorder. Patients with PTSD actually do experience higher rates of chronic pain and generally will not recover with medical approaches alone. It is worth noting that a person can also have a premorbid psychological diagnosis and then develop pain, and the pain in turn exacerbates the psychological diagnosis. It is extremely important to have psychologists involved in pain treatment for these reasons. Psychologists and specialized mental health professionals are experienced in providing evidence based treatments for depression and anxiety, and these can be adapted for patients with pain. Some of these treatments can be delivered in 8 to 16 sessions and are very effective and inexpensive to deliver.

Can you explain the process of treating pain from a psychological perspective?

I will focus on cognitive behavioral treatment of chronic pain because this approach is considered the gold standard for treating chronic pain. The psychological approach to treating chronic pain involves tailoring treatment to the person with chronic pain who is sitting in front of you. By that, I mean that each person has their own set of thoughts, feelings and behaviors related to managing (or not) their pain. This includes assumptions and fears, such as what to do and what not to do, whether they are willing to experience more pain, and whether they perceive the pain as a signal of harm. In addition, patients with pain also typically have strong feelings of resentment and anxiety about pain, because they perceive it as unnatural and unwanted. In the psychological treatment of pain these thoughts, feelings, behaviors, and assumptions are identified, targeted and modified so that the person experiences less distress related to all of these.

We know that cognitive behavioral treatments (CBT) create quantifiable changes in the brain, and that these changes are distinct to CBT. These effects are lasting and result in long term success. Ideally the psychological and medical perspectives work together. They really shouldn’t be independent. The best results are achieved through collaborative care.

In your talk, you discussed Biopsychosocial Laws and other changes in the healthcare landscape. What do you see as essential health care delivery system changes in the treatment of chronic pain?

I see that we need big changes in insurance and reimbursement practices in health care delivery. These will enable better collaboration between medicine and psychology. It should be easier to refer to psychologists and mental health than it is. We need to remove barriers that slow down this process. In addition, mental health is subject to higher copays and deductibles and a greater financial burden to patients. Also, the reimbursement for medical psychology type services should reflect the specialized training that must occur to deliver these types of treatments, and be reimbursed at a higher level. Finally, the stigma of referring to mental health should be addressed. Some providers are hesitant to refer to mental health due to fears of being misunderstood by their patients. Other providers are still ignorant of what psychology can do to help them and their medical patients. Finally, patients themselves are fearful of being labeled or being judged as crazy or weak for attending psychotherapy. These stigmas need to be addressed systematically through education and collaboration. In our clinic, while many people may hesitate to be referred, once they arrive and have an opportunity to be heard, and hear how ‘normal’ what they experience really is, the relief and healing that occurs is truly amazing to watch. We need more approaches that are personalized, and tailored to patients’ needs and presenting problems, because that is the basis of true rehabilitation.

Functional Restoration: Use, Value & Structure – Newsletter

by Geralyn Datz, PhD

The Opioid Epidemic has forced providers and insurers to re-evaluate the way chronic pain is treated both short and long term. As a result, there has been a renewed interest in non-medical based treatments that restore pain patients, particularly injured workers, to health and optimal function.

Chronic pain is a common presentation in work injury. Functional restoration, or Interdisciplinary Pain Rehabilitation (IDPR) is a non-medication based option that can restore patients with pain to higher function and return to work. This is an intensive treatment that occurs during a full day, and typically for 20 consecutive days (programs may vary slightly in their duration).  The programs are coordinated by a group of skilled healthcare providers, all of whom have experience in treating patients with pain.

As Director of a functional restoration program in Mississippi, a question I am often asked is, “Does it really work?” And, “more importantly, Is it worth it?” Treatments are all about value and return on investment (ROI). And if there is no perceived value, why would insurance pay for something that is fairly expensive compared to a single, stand alone treatment?

The use of chronic opioid therapy for all patients with pain is a good example of high expense and low return on investment.   While opioids can be appropriate in some circumstances, the consensus is that they are currently overprescribed as the only therapy for pain by physicians and are overused by patients. In addition, they can be easily obtained by non-medical users https://www.cdc.gov/drugoverdose/data/prescribing.html .

In the case of non-specific low back pain, neck pain, or “whole body” (musculoskeletal) pain, for example, opioids are not the recommended first line treatment, but are nonetheless often used as the only treatment. Extended use of opioids can contribute, ironically, to greater physical pain (in a process called opioid induced hyperalgesia), and reduced activity level, depression and greater disability. Opioids have been under scrutiny for contribution to addiction and overdose risks, and death.

These challenges all translate to poorer care of injured workers, increased time off work, and increased costs and difficult claims handling for employers and insurers.

With respect to cost, expenses related to opioid prescriptions per claim continue to grow in the United States.  The National Council on Compensation Insurance (NCCI) indicates that medical costs are now approximately 59 to 60 percent of workers’ compensation claims costs.  Opioid prescriptions account for at least 25% percent of these costs. 

As problematic as medication-only approaches are, at least they are familiar. For some insurers, and providers, the ‘Devil they know is better than the Devil they don’t know’, to borrow from an old saying. For some, it became “comfortable” to prescribe opioids as a sole therapy for chronic pain, as other treatments were either not known, understood, nor appreciated. We now know that no one treatment is best for pain. Using a multimodal or biopsychosocial approach, where the whole person is addressed, leads to the best recovery from pain.

When I speak to carriers and employers about functional restoration, this thinking style and their discomfort with change is often obvious.  Their initial confusion is related to wondering how could a treatment last ALL DAY, when we are “simply talking,” (or worse, “watching movies”, or “coloring”, also fears I have heard) for 20 consecutive days in a row. What a rip off!!  If that were what functional restoration was, I would have to agree.

However, true functional restoration could not be more different. True functional restoration is the combination of two highly skilled services: Cognitive Behavioral Therapy (CBT), a type of specialized psychotherapy, and intensive Physical Therapy (PT). Note the word “intensive”, because ordinary, 1 hour a day, run-of-the-mill PT won’t pass muster in a functional restoration program. On Day 1 of our program,  we tell patients, “You WILL have a flare up in this program. If you don’t, we are doing something wrong.” Amazingly, the majority of our patients go from barely moving to walking the equivalent of walking five miles a day  at program’s end.  It is not unusual for patients to also increase their strength by 500%. Now that’s PT!

Here’s some straight talk on what functional restoration is and isn’t.

Characteristics of Functional Restoration

  1. Functional restoration reduces medication intake, in particular opioids. This is perhaps the most important feature of functional restoration. Rule of thumb: If a patient’s medications did not change during a functional restoration program, you definitely just wasted a lot of money.

Functional restoration is about reducing reliance on medication and teaching patients to self manage pain. Some patients need to be treated prior to program enrollment to wean medications, either inpatient or outpatient.  It is not unusual to reduce patients from 400mg of opioids a day or more to zero opioids at the end of these types of program. This is done through appropriate weaning or detoxification, counseling, coordination with prescribers, and lots of coaching and education.

Many patients would prefer not to be on the medications they are on, and are yearning for a solution that restores their previous way of living.  However, with few choices and alternatives, they fear change. When given an alternative for a fuller, restored, healthier and more active life, many patients will jump at that chance.

  1. Functional restoration is very focused on Return to Work and Activity. If return to work or former job is not feasible, then it’s about Return to Life. As the name implies, these programs are about restoring function.

Effective programs spend time teaching patients about Return to Work (RTW). The literature shows that functional restoration has 75 to 88% RTW rates. This is because the program is designed to help patients overcome the mental and physical obstacles that prevent their recovery. Research shows if the employer is willing to work with the client, there is more success in returning the client to their original position, or some modified version of it.

  1. Functional restoration is an alternative to surgery, particularly when a patient doesn’t want, or doesn’t qualify for surgery. Many studies have shown that functional restoration is an effective alternative to spine surgery and other surgical procedures, and can produce greater benefits.

 Spine surgery is far more costly than functional restoration, and while it is often touted as an effective means to RTW, the data do not support this. Several well-performed studies have demonstrated that RTW rates after spinal fusion are relatively poor. In a 2011 Ohio Work Comp cohort, only 26% of those who had surgery RTW, compared to 67% of patients who did not have surgery. Of the lumbar fusion subjects, 36% had complications, 27% required another operation. Even more troubling, the researchers determined there was a 41% increase in the use of painkillers, with 76% of surgery patients continuing opioid use after surgery.

 One very interesting study allowed injured workers to enter a functional restoration program for 10 days, even despite being elective spine surgery candidates. After 10 days in the program, they could either continue the program, or quit it and have surgery. After 10 days, a whopping 74% of the enrollees voluntarily decided to stay with functional restoration and declined surgery.

 What this and other studies keenly show is that when people are given other options, more often than not, they will take them. Injured workers have no idea how to rehabilitate themselves. But when shown how to do so, this is when true recovery is possible.

 Typical functional restoration programs have a team of highly qualified providers. These providers deliver up to 3 hours of physical therapy a day, in addition to 3 hours of cognitive behavioral therapy a day, plus another one to two hours of other adjunctive treatments like yoga, meditation, mindfulness and self massage. The team should have meetings about patient progress, and should be available for consult. Many programs use a combination of Physical Medicine Physician (DO), clinical pain psychologist (PhD), Doctor of Physical Therapy (DPT), Physical Therapy Assistant (PTA), Licensed Clinical Social Workers (LCSW), certified yoga therapists (RYT), licensed massage therapists (LMT), and sometimes nutritionists (RD).

That’s a lot of people and there’s definitely no time for coloring!

  1. Functional restoration facilitates claim closure.

In the past functional restoration has been primarily used on tail claims, as a last resort. However functional restoration can be used at any time (early, middle or late) in the claim cycle, but is most beneficial for RTW within the first 8 months of injury. One study showed that the average cost savings of using functional restoration early in the claim cycle, total economic cost savings was $170,000. This translated to cost savings of 64% and productivity loss savings/disability savings of 80%.

In functional restoration, patients are taught to refocus their mind on recovery, return to life and return to work. Work gives us purpose, resources, and makes us feel worthwhile. Psychotherapy techniques used in these programs help empower patients to reclaim their lives from pain.

Incidentally, beware of functional restoration programs that, at discharge, immediately refer for other medical treatments, like spinal cord stimulators, spine surgery, or medication, and report that the program “didn’t work.” While there are some exceptions, these should be rare, and functional restoration is not designed to become a referral program for surgeries or other interventions.  The goal of functional restoration is to stabilize the patient, improve their mental and physical functioning, and make them LESS reliant on the medical system and more reliant on themselves.  Hopefully more insurers will be open to referring for multidisciplinary approaches as the tides change in pain treatment.

Geralyn Datz, PhD, is a licensed clinical health psychologist in Mississippi and Louisiana, and immediate past president of the Southern Pain Society. She is the Clinical Director of the Pain Rehabilitation Program as well as the President of Southern Behavioral Medicine Associates, PLLC, in Hattiesburg, MS.

Dr Datz has authored scientific articles and book chapters on the topics of health psychology, pain treatment, the mind-body connection, and treatment of injured workers. She can be reached at drdatz@southernbmed.com

 

20 Years of the Integrative Healing Arts Network – Newsletter

by Michele Erich, MM, CCLS, MT-BC and Ann Quinlan-Colwell, PhD, RN-BC, AHNBC, DAAPM

News reports are replete with stories about the problems of opioid use disorder (OUD) and over dose deaths [1,2].  A reasonable approach to addressing this health care crisis is managing pain with a multi-modal approach rather than with opioid mono-therapy.  A multi-modal approach includes a variety of medications including appropriate use of opioids, non-opioid analgesics, co-analgesic agents and non-pharmacologic interventions [3].  Many people may be interested in non-pharmacologic interventions but don’t know much about them, don’t know where to find practitioners or can’t afford them. In addition, they are almost always thought of as interventions for chronic pain and not part of acute care or acute pain management.  One hospital in our region has shown leadership in offering non-pharmacologic interventions in the acute care arena.

This year New Hanover Regional Medical Center, a not for profit community hospital, celebrates the 20th anniversary of their Healing Arts Network (HAN) which has brought non-pharmacologic interventions to patients for the last two decades.  HAN originated as a vision to bring awareness to the use of complementary therapies and to open communication between patients and their physicians in regard to the different complementary therapies patients were considering incorporating into their plans for health and wellness.  The HAN also educated the public about appropriate qualifications of the therapist/practitioners who provide complementary therapies.  After a year or two as part of growth the HAN changed from referring to services as Complementary therapies to Integrative therapies.  The change emphasized the integration of HAN therapies into the medical model of care in both the acute care inpatient setting and outpatient setting.  Physician referrals and assessments are required and primarily address pan management, anxiety, depression, trauma and coping with a new diagnosis/prognosis or change in prognosis of a chronic illness.     

Interventions currently offered by the HAN are expressive therapy, music therapy, child life, massage therapy, therapeutic touch, tai chi/qi gong, yoga, craniosacral therapy and pet therapy.  These services are primarily offered to patients, but during the past year a plan was developed to offer stress relief to the employees of the medical center through chair massage and brief yoga and music therapy relaxation sessions.  Exploration is underway to expand services to further help employees take care of themselves by incorporating Integrative therapies into their own plans for health and wellness.  Expressive Therapy is provided by a Licensed Professional Counselor with a master’s degree in Expressive therapy.  Through Expressive therapy patients can begin to deal with their emotions related to the illness, injury or pain.  She often helps the patients find ways to relax and deal with the stress of their health conditions and hospitalization.  Imagery, breathing techniques, drawing and journaling are all introduced to patients teaching them some coping skills to take home after discharge and use as needed whenever stressed, in pain or anxious.   

Music Therapy is provided by a nationally board-certified therapist with 30 years of experience.  Through music therapy she can find ways to connect with patients who are in crisis, emotional distress or struggling with a diagnosis, treatment or unfamiliar experiences.  The connection between music, therapist and patient provides a safety net allowing the patients to confront their pain, fears or anxiety and begin to cope with their present situation.  Once an adult patient said, “Can you come home with me and play that music so I can relax?”  This patient had participated in breathing exercise with music and imagery to deal with his acute abdominal pain and was able to find relief during the music therapy sessions.  After one music therapy assisted procedural support with a pediatric patient the nurse said, “He actually fell asleep during that procedure.”.  “The music really helped.”    

Child Life offers support to children and families during their hospitalizations and outpatient treatments.  Through the use of music, imagery, art and play Child Life Specialist offer a positive outlet when a child is sick and hospitalized.  They also offer redirection and support during scary or painful procedures using music, breathing techniques, bubbles, Virtual Reality headsets, etc. Massage Therapy is provided by four licensed massage professionals who work on a contractual basis.  They provide full body and partial massages.  The focus is on pain management, relaxation and anxiety reduction and is tailored to the individual’s needs.  The massage is modified to work along with any limitations due to medical conditions, injuries, or medical equipment such as propping a pregnant woman with pillows, or avoiding massage to surgical sites, or modified positioning for a patient on a ventilator with limited mobility.  Partial massages are offered one to two times each week during treatments in the Chemotherapy/Infusion area as well as for patients in the inpatient oncology unit.

Therapeutic Touch (TT) is provided by trained individuals and can be incorporated into standard nursing care by those trained in TT.  Therapeutic touch is not as familiar as some of the other services in the HAN but patients report just as much relaxation and pain management benefits.  TT is a bit of a misnomer since generally the clinician never actually touches the person but rather works in the energy field surrounding the body. For patients dealing with extremely intense pain who can tolerate very little touch or movement It can be  preferred and can often help them to tolerate treatments.  TT has been used with patients from the NICU to palliative care.  Frequently, HAN is consulted by the wound care nurses to use TT to help patients having painful procedures or dressing changes.  Often the patients request TT intermittently between procedures to help with pain control as well.

Tai Chi/Qi Gong is offered by a middle-aged woman who was described by a young man as “that lady is very special; the coolest person I ever met.”  She teaches even patients who are confined to bed the basic techniques of Tai chi.  In addition to the benefit patients derive from Tai Chi in the hospital, they learn a technique that they can continue to use after discharge.  Another young man who lives with a chronic illness reported that he uses the Tai Chi he learned at NHRMC at home.  When he is re-hospitalized, he uses it with the “Relaxation Channel” on the television in his room and looks forward to learning more techniques.

Yoga is taught by two yoga practitioners with over 22 years combined experience and multiple specialty trainings including pregnancy yoga, restorative yoga and gentle yoga.  Sometimes patients who have “always wanted to try yoga” take the opportunity to do so.  Other times people who never thought of yoga, are willing to try it while in the hospital with the time and privacy to do so at no cost to the patient or their insurance.  One professional deep sea fisherman said that he would try anything to ease his pain and later reported that not only did the yoga help but that he would continue to use it to manage his pain.   They usually provide individual sessions but have offered yoga groups for women diagnosed with gynecologic cancers and adults hospitalized with mental health issues.  Both groups have been very well received.

CranioSacral Therapy (CST) uses light touch to release restrictions in the body and create balance.  A special process in CST called somatoemotional release can help relieve the lasting effects of trauma and illness.  A woman receiving treatments for cancer received CranioSacral Therapy and was so profoundly impacted by the reduction in her pain level, stress and tension as well as improved mood and overall well-being that she independently wrote a letter to the CEO of the medical center praising this service and the medical center.  She was also eager to participate in a local television news story to promote the Healing Arts Network and inform other patients of these services and benefits.

Pet therapy is “staffed” by volunteers who bring their specially trained and credentialed dogs.  The dogs must have completed the rigorous pet therapy certification training.   Their owners must go through the NHRMC volunteer training program and commit to bringing their dogs to the medical center at least 30 hours per year.  It is very impressive to observe the response that patients and families have to the special dogs.  One woman later reported that when one of the dogs visited it was the first time she had forgotten her head pain in over 30 years.  Another dog brought a young woman and her mother together sharing an interlude of smiling, giggling and petting the dog just days before the young woman died.

With Music Therapy, Expressive Therapy, Tai Chi/Qi Gong and Yoga patients are introduced to a variety of pain management and relaxation techniques.  Patients can learn the basics, expand upon them and continue to use them to manage pain and cope with challenges of life.  Patients are encouraged to explore resources in the community to further their use of these non-pharmacologic interventions as they strive for health and wellness.

Most recently, HAN joined with the Code Outreach Safety Team (COST) (see SPS issue Winter 2017) working with patients who are hospitalized for six to ten weeks for intravenous antibiotic therapy for serious infections resulting from IV SUD.  A challenge is that due to funding limitations, currently patients can have Tai Chi or yoga or massage once per week and must choose one.  While massage feels good, clinicians encourage the patients to at least try and learn a bit about Tai Chi and yoga because they can continue to use either or both integrative therapies to manage pain and cope with challenges after discharge.  The HAN is currently working with the COST to arrange weekly group yoga and Tai Chi.

The HAN Co-Founder (Michele Erich) not only coordinates the various activities and clinicians but she provides the Music Therapy and Child Life services as well as develops and updates policies and procedures, and complies with the Human Resource department requirements for maintaining all contracts with the HAN contractors.  She worked with the Electronic Medical Record team to create EMR documentation for herself and other HAN providers.  She also coordinates interactions with community groups who offer donations and activities.  Last month she coordinated “Christmas in July” with the local Parrothead fan club, bringing Santa in his sunglasses, summer shorts and Hawaiian shirt to brighten the day of the children hospitalized on the Pediatric unit.  She has also worked for several years with the medical center’s Foundation and Marketing department to receive generous donations of money from the Spirit of Children program, allowing her to furnish the teen side of the Pediatric playroom with an 8-foot high ‘basketball shoot to win game’, a Mustang car pinball machine, a Boom-A-Rang table air hockey game and a Rock-Ola Juke Box.  The most recent project involves the trial of Virtual Reality headsets from AppliedVR to help with pain management, distraction and relaxation during procedures and treatments for pediatric patients and adults receiving cancer treatments.    

To celebrate the 20th anniversary of the Healing Arts Network the clinicians are educating staff and visitors through internal flyers, and public display cases showcasing patient feedback and the services and benefits of the healing arts network.  In addition, there will be open yoga, tai chi/qi gong and music therapy drumming sessions held in the cafeteria courtyard and outside in front of the medical center allowing visitors and staff to participate in some of the services offered through the Healing Arts Network at New Hanover Regional Medical Center.  Certainly 20 years of patients having more fully integrative care as the result of an innovative vision that has been nurtured and has flourished is much to celebrate!

  Reference:

  1. Fleischauer, A. T. (2017). Hospitalizations for Endocarditis and Associated Health Care Costs Among Persons with Diagnosed Drug Dependence—North Carolina, 2010–2015. MMWR. Morbidity and Mortality Weekly Report, 66.
  2. Rudd, R. A., Aleshire, N., Zibbell, J. E., & Matthew Gladden, R. (2016). Increases in drug and opioid overdose deaths—United States, 2000–2014. American Journal of Transplantation, 16(4), 1323-1327.
  3. Chou, R., Gordon, D. B., de Leon-Casasola, O. A., Rosenberg, J. M., Bickler, S., Brennan, T., … & Griffith, S. (2016). Management of Postoperative Pain: a clinical practice guideline from the American pain society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ committee on regional anesthesia, executive committee, and administrative council. The Journal of Pain, 17(2), 131-157.

Innovation: Opioid Substance Use Disorder

by Ann Quinlan-Colwell, PhD, RN-BC, DAAPM

During 2014, patients were admitted more frequently with diagnoses of soft tissue abscesses, epidural abscesses, and endocarditis. Two common denominators, among many of these patients, were a history of self-administering opioids intravenously and now needing intravenous (IV) antibiotics for prolonged periods of time. This combination posed a challenge for health care providers who believed that it was not prudent or safe to discharge patients with a port or peripherally inserted catheter (PICC) line for IV access when the patient was known to abuse opioids intravenously.  Thus, the patients with these dual diagnoses -serious infections requiring IV antibiotics and substance use disorder- were admitted to the hospital for administration of IV antibiotics for six to twelve weeks. 

Two additional concerns arose. Many providers believed that it was important to control pain and to work with these patients, encouraging them to work toward sobriety.  In many instances this was reasonable and opportune since some of the very ill and scared patients demonstrated greater motivation to seriously consider abstinence and sobriety.  The providers consulted the Pain Management Clinical Nurse Specialists (CNS) to help control the patients’ pain while minimizing opioids and then wean the opioids to discontinuation whenever possible.      

Two cardiovascular surgeons who saw the patients with endocarditis invited a team to meet to address how to best work with the patients with endocarditis resulting from IV substance use (IVSU).  The initial group included the cardiovascular surgeons, infectious disease (ID) physician, cardiology administrator, cardiology nurse administrator, behavioral health administrator, substance abuse counselor, pharmacist, social worker, case manager and pain management CNS.  An addictionologist and community provider of buprenorphine were consulted.

Since patients were also being admitted for non-cardiac infections resulting from IVSU, the team expanded to coordinate with the medical center Code Outreach physicians.  Code Outreach is the established process through which the medical center coordinated interdisciplinary care of patients who were frequently evaluated in the emergency department (ED) and/or admitted.  Eventually, the Code Outreach team assumed primary oversight for interventions, patient care, and group activities. 

The intervention and group is now known as the Code Outreach Special Team or “COST”.  It consists of the two Code Outreach physicians, a pharmacist, the substance abuse counsellors, pain management CNSs, case management, cardiac nurse coordinator and one social worker (MSW). This MSW follows all the patients who are admitted to receive long term IV antibiotics to treat infections resulting from IVSU. Each patient in this category is reviewed weekly by the COST.  At the weekly meetings, the patients’ condition, challenges, pain management, progress toward goals, discharge needs/plans as well as the barriers to achieving these are discussed.  The plan of care is amended as needed. A template was developed for an individualized COST note to be created during the meeting and entered into the electronic medical record for the patient. This COST note is available to all professionals providing care and working with the patient. 

Each of the patients is also individually followed at least weekly by the pain management CNS, substance abuse counsellors and MSW.  The team, especially the MSW, works closely with methadone maintenance programs and providers of buprenorphine in the community to identify resources to connect with the patient prior to discharge.  While hospitalized, the substance abuse counsellors, MSW and pain management CNS work with the patients to encourage and support sobriety.  Recently, the team has located an Alcoholic Anonymous/Narcotics Anonymous group to conduct meetings for this group of patients while hospitalized. 

The pain management CNS works with the patients to control their acute pain which generally requires some opioids as part of a multi-modal analgesic plan of care (MMA-APOC).  As resolution of the acute infection resolves, the focus changes to weaning opioids and progressing to a non-opioid MMA-APOC.  Patients are encouraged to learn non-pharmacologic ways to control pain including square breathing, relaxation, distraction, and exercise.  The medical center Healing Arts Network are consulted for patients to learn tai chi and/or yoga and receive massage. 

Future plans include:

  • the MSW being dedicated full time to working with these patients
  • securing a room for the AA/NA meetings
  • identifying a physician to initiate prescription of buprenorphine for interested patients
  • developing a care plan or care trajectory that provides for consistency with room for individual care
  • educating all medical center staff about the COST, clinical note and care plan
  • increase funding for Healing Arts Network to increase support of non-pharmacologic interventions and education
  • increase interactions with community treatment and behavioral health providers and facilities
  • increase interaction and expand work with families of patients followed by the COST
  • collect and analyze data to determine effectiveness of COST activities
  • obtain grant funding to improve and formalize the COST and increase resources

The dedication and work of the member of the Code Outreach Special Team is acknowledged.

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