The Pain Practitioner - Virtual Reality

Integrative Pain Management for Optimal Patient Care

The Pain Practitioner Winter 2018

Virtual Reality for + Stents Orofacial Pain

Academy 30th Anniversary

Academy of Integrative Pain Management

The Pain Practitioner

www.integrativepainmanagement.org

WINTER 2018

ACADEMY BOARD OF DIRECTORS President W. Clay Jackson, MD, DipTh Past President Joanna Katzman, MD, MSPH Vice President Paul Christo, MD Secretary George D. Comerci, Jr, MD, FACP Treasurer Kevin T. Galloway, BSN, MHA, Colonel, US Army (Retired) Directors-at-Large Lynette Cederquist, MD John Garzione, DPT Michael Kurisu, DO Joseph Matthews, DDS, MSc Roger Mignosa, DO Helen Turner, DNP Liaison to the Board Maggie Buckley

STAFF AND CONSULTANTS

30 PAGE 3

3 NOTES FROM THE FIELD Three Decades Promoting Integrative Pain Management

By Bob Twillman, PhD, FAPM, Executive Director 4 EDITORIAL When Managing One Crisis Is Not Enough

By W. Clay Jackson, MD, DipTh, Editor-in-Chief 6 EDUCATION Talking with Roger Mignosa

By Debra Nelson-Hogan 8 ADVOCACY Thank you!

9 Neurosensory Stents for the Treatment of Oral Neuropathies

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Executive Director Robert Twillman, PhD, FAPM Director of the State Pain Policy Advocacy Network (SPPAN) Amy Goldstein, MSW Assistant Director of Education Cathleen Coneghen Director of Legislative and Regulatory Affairs Katie Duensing, JD Member Services Manager Whitney O’Donnell Account Manager Rosemary LeMay Professional Development Project Manager MacKenzie Davis

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THE PAIN PRACTITIONER STAFF AND CONSULTANTS

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Editor-in-Chief W. Clay Jackson, MD, DipTh Editor Debra Nelson-Hogan Managing Editor Cathleen Coneghen Clinical Editor Christine Rhodes, MS Art Director Peter McKinley, Pak Creative Copy Editor Rosemary Hope

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By Joseph Matthews, DDS, MSc

11 Virtual Reality Therapy as an Adjunct to Pain Management

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The Pain Practitioner is published by the Academy of Integrative Pain Management solely for the purpose of education. All rights are reserved by the Academy to accept, reject, or modify any submission for publication.

The opinions stated in the enclosed printed materials are those of the authors and do not necessarily represent the opinions of the Academy or individual members. The Academy does not give guarantees or any other representation that the printed material contained herein is valid, reliable, or accurate. The Academy of Integrative Pain Management does not assume any responsibility for injury arising from any use or misuse of the printed material contained herein. The printed material contained herein is assumed to be from reliable sources, and there is no implication that they represent the only, or best, methodologies or procedures for the pain condition discussed. It is incumbent upon the reader to verify the accuracy of any diagnosis and drug dosage information contained herein, and to make modifications as new information arises.

All rights are reserved by the Academy to accept, reject, or modify any advertisement submitted for publication. It is the policy of the Academy to not endorse products. Any advertising herein may not be construed as an endorsement, either expressed or implied, of a product or service.

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NOTES FROM THE FIELD

Three Decades Promoting Integrative Pain Management

By Bob Twillman, PhD, FAPM, Executive Director IN 1988, THE AVERAGE PRICE OF A new home was around $90,000, and average annual income was $24,500. A gallon of gas cost 91 cents, and a new car running on that gas cost $10,000 on average. Movie tickets were $3.50, and a first-class postage stamp cost 24 cents.

Both Prozac and crack cocaine made their debuts on the world stage, and Surgeon General C. Everett Koop reported that nicotine’s addictive qualities were similar to those of heroin and cocaine.

The Jamaican bobsled team and Eddie “the Eagle” Edwards were media darlings of the Calgary Winter Olympics, while Florence “FloJo” Griffith Joyner starred in the Seoul Summer Olympics.

Kirk Gibson of the Los Angeles Dodgers crushed a dramatic World Series home run while overcoming pain from a pair of leg injuries, propelling the Dodgers to the championship, and “my” Kansas Jayhawks defeated conference rival Oklahoma in the NCAA basketball championship game, played at Kemper Arena in my hometown of Kansas City.

Vice President George H.W. Bush was tapped for a promotion, as he defeated Michael Dukakis in the presidential election.

And, on May 13 in Modesto, California, Richard Weiner signed the Articles of Incorporation for the American Academy of Pain Management, now the Academy of Integrative Pain Management.

It has been a wild ride for this organization over the last three decades, with times of ascendancy and times of struggle, as typifies professional associations. Executive directors have come and gone, the board of directors has turned over several times, our name has changed, and through it all, the mission of promoting integrative pain management has remained our guiding star.

Although the term “biopsychosocial” was used in the scientific literature as early as 1961, even by 1988 it was not a widely understood concept. It was, however, the basic idea underlying the formation of this organization. The idea that pain is a complex experience derived from biological, psychological, social, and spiritual factors was key. The

notion that what we now call “team pain care” was necessary to optimally relieve pain was perhaps a little radical at the time, and in some quarters, remains so today.

Through it all, AIPM has remained steadfast in promoting the necessity of a comprehensive, integrative, approach to caring for people with pain. We have always been inclusive, counting 32 clinical disciplines among our members, and we have always done our utmost to treat every discipline’s members as equals—even down to the absence of professional designations on name badges at our conferences.

As we enter our fourth decade, I believe we stand on the verge of a new revolution in pain care. Much of the past two decades has seen a shift away from multimodal, interdisciplinary pain care, in favor of medications (especially opioids) and procedural pain management.

Too late, we have realized relative ineffectiveness and the harms of such a narrow approach, and we now find ourselves searching for solutions that properly address the complexity of the condition we are treating. That search for new answers has, ironically, led us to “old answers,” namely, a model of pain care that was more common when Dr. Weiner founded this organization. It appears to me that a return to a truly interdisciplinary model that enables a team of experts to address all aspects of the pain experience in the service of returning a person with pain to wellness is the best prescription for what ails us. I’m proud to be part of teaching about, and advocating for, that kind of pain care, and it is my hope that, three decades from now, AIPM will still be on the vanguard of those efforts. n Bob Twillman, PhD, is the executive director for the Academy of Integrative Pain Management. Dr. Twillman is responsible for overseeing federal and state pain policy developments and advocating for those supporting an integrative approach to managing pain.

He also serves as Chair of the Prescription Monitoring Program Advisory Committee for the Kansas Board of Pharmacy.

30 YEAR MEMBERS Eduardo Anguizola, MD (California) James Beech, DC (Tennessee) Solomon Behar, MD (Florida) Jack Berger, MD (California) Jon Botts, DO (Alabama) Aaron Calodney, MD (Texas) Joseph Carcione Jr., DO (New York) Michael Cronen, DO (Kentucky) Jo Ann Curcio-Cohen, PhD (Pennsylvania) Mark D’Andrea, MD (Texas) Richard Dicken, MA (Indiana) Dennis Dobritt, DO (Michigan) Alice Duigon, MSN, RN, APN, FAAPM C (New Jersey) Carl Eiben, MD (Michigan) Bryan Frank, MD (Oklahoma) Vincent Galan, MD (Georgia) Kunnathu Geevarghese, MD (Kentucky) Paul Giannandrea, MD (Maryland) Susan Gifford, PhD (Texas) Samuel Goldstein, PhD (Utah) Allen Gruber, MD (California) James Harrold Jr., MD (Louisiana) Debra Haworth, PT, GCS (Indiana) Frank Isele, PhD (New York) Mazhar Khan, EdD (Illinois) Riad Khoury, MD, PC (Michigan) Eileen Krimsky, PhD (Florida) E Franklin Livingstone, MD (Arizona) Jeremiah Loch, CRNA, DO (Can), PhD (Illinois) Dale Mann, PhD (North Carolina) Jack Martin, PhD, PC (Texas) Mehrdad Massumi, MD (Maryland) Robert McMahon, DDS (Indiana) Michael Miller, PhD, MFT (California) B Michael Nayeri, NMD (Arizona) Marilyn Neudeck, PhD (California) Aaron Noonberg, PhD (Maryland) James Nunley, DO (Tennessee) Douglas O’Dell, DDS (West Virginia) William O’Grady, DPT (Washington) Alan Ostrowe, MD (Louisiana) John Porter, MD (Arizona) Michael Prater, MD (Nevada) Mark Premselaar, MSW, LCSW (Nevada) Jonathan Quevedo, MD (New Jersey) K Dean Reeves, MD (Kansas) Nick Reina, MD (Michigan) Steven Rosenberg, PhD (Pennsylvania) Janet Mielke Schwartz, PhD (Ohio) David Selkowitz, PhD, PT, OCS (Massachuesetts) Hollis Seunarine, MD (Maryland) Ralph Steele, MA, MFT (New Mexico) James Steinhauer, MD (Alabama) Jose De Jesus Trevino, MD (Texas) Stephen Vitkun, MD, PhD (New York) Romanth Waghmarae, MD (New York) David Wall, MD (Florida) John Williams, MD (Pennsylvania) Anne Wolfe, PhD (Illinois) Kirk Yen, DDS (California)

THE PAIN PRACTITIONER

| VOLUME 28, NUMBER 4 |

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EDITORIAL

When Managing One Crisis Is Not Enough

By W. Clay Jackson, MD, DipTh, Editor-in-Chief

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Figure 1 8 8 7 7 6 6

Opioid sales kg/10,000 Opioid sales kg/10,000 Opioid deaths/100,000 Opioid deaths/100,000 Opioid treatment admissions/10,000 Opioid treatment admissions/10,000

5 5 RATE RATE

EVERY CLINICIAN IN THE PAIN SPACE has seen the graph—most people with a newspaper or a computer have seen the graph (Figure 1) (1). In pictorial simplicity, it offers the clarity of a powerful conclusion: increased opioid prescriptions in the US have tracked with increased opioid deaths and increased admissions for opioid treatment.

Purists quibbled that correlation observed does not causality make, but those of us in pain management, public health, and governmental policy felt the urgency of a foregone conclusion: the increased opioid prescribing of the early 2000s had caused unintended and frightening consequences—a rise in opioid addiction and overdose deaths. The corollary to that conclusion was a presumptive solution: if we lowered the amount of opioids prescribed, we would see a corresponding drop in opioid addiction and overdose deaths. Phrases like the “opioid epidemic” and the “opioid crisis” sealed the dilemma in the minds of clinicians and policy-makers alike: despite patients’ reports of pain, the key objective was to lower the overall amount of opioids being prescribed, to rein in deleterious outcomes.

We dutifully sounded the alarm: opioids were not benign medications, and prescribing should be judicious. State boards of health, national professional societies and regulatory bodies, and private and governmental payers all instituted initiatives aimed at reducing the rates of opioid prescriptions and the amount of opioids prescribed (measured by morphine equivalents). We then waited for the numbers to trend in an encouraging direction; after all, we had all seen the correlation. When opioid prescriptions fell, the negative outcomes were sure to follow.

But as a prominent Bostonian once said, facts are stubborn things (2). Take for an example the experience of my home state of Tennessee. In 2013, our Board of Health was ordered by the state legislature (3) to produce guidelines for the treatment of chronic pain, focusing on the proper use (and by extension, the avoidance of overuse) of opioids. In response to this initiative, total opioid prescription amounts were reduced by 19% over the three-year period from 2013 to 2016 (4). During the same time, however, opioid overdose deaths rose by

4 4 3 3 2 2 1 1 0 1999 2000 0 1999 2000

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YEAR YEAR Adapted from CDC. Vital Signs. 2011. cdc.gov/vitalsigns/PainkillerOverdoses/index.html

57% (5). We were beyond chagrined; we were flummoxed. The graph we had all seen had revealed a crisis. But having abated the opioid overprescription crisis, we still hadn’t affected public health in a salutary way.

Take a look at a second graph (Figure 2). It tells a different story (6). That story is this—battling one crisis (even successfully) is not enough. Even as prescriptions for opioids have fallen, opioid overdose deaths have risen—in large part because of the meteoric rise in deaths due to synthetic and illicit opioids such as fentanyl and heroin.

The truth is, we have multiple crises in our country.

We have a crisis of untreated opioid addiction, with a shortage of capacity for medical-assisted therapy (relative to the need) in 96% of states and the District of Columbia (7). We already know a large percentage of those who die from prescription opioid overdoses don’t have a prescription for the medication (8); thus, addressing abuse is a critical factor in reducing fatal outcomes. Without adequate access to medication-assisted treatment (MAT), patients with substance use disorder remain at high risk of relapse and overdose.

We have a crisis of lack of treatment of mental illness. When patients have

mental illness, they are twice as likely to develop chronic pain. When patients have chronic pain, they are twice as likely to develop mental illness (9). When we insist on approaching chronic pain as a purely biomedical phenomenon and ignore its psychosocial and spiritual components, we doom the patient to suboptimal treatment.

To make matters worse, when mental health disorders aren’t addressed (including substance use disorders), they don’t go away; they hurt patients. Of deaths attributed to opioid overdose in 2015, 23% of the decedents also had positive serum levels of a benzodiazepine (10).

We have a crisis of quality psychosocial services designed to reduce the incidence of adverse childhood experiences (ACEs), which are known risk factors for the development of chronic pain (11), substance use disorders (12), and mental health disorders (13).

When our children are set up for failure before they enter kindergarten, there is no amount of illicit drug interdiction or punitive intervention that will solve the public health problem of addiction. Human brains work better when they are allowed to develop in safe and nurturing environments.

We have a crisis of undertreatment of chronic pain, with many patients

EDITORIAL

to integrative pain management—will only prolong patient’s suffering, and perpetuate negative outcomes. n

facing difficulty in accessing proven nonpharmacologic and non-opioid therapies, owing to pejorative payment policies of traditional insurance plans and formulary exclusion by private and public payers (14). Until clinicians are able to offer true integrative pain management, their patients will continue to suffer, and the possibility that opioids will continue to be overutilized will remain (15).

We have a crisis of misconceptions.

Pain is not a “sign;” it is a symptom, and adding a metric to its assessment does not objectify what is essentially a subjective experience. Chronic pain is not merely an extension of acute pain through time; it is a distinct clinical syndrome with individuated, complex biopsychosociospiritual dynamics. The vast majority of patients who take opioids (think 99%) (16) don’t take them long-term, and they don’t become addicted; however, few of them become pain-free, either. The truth is, living with chronic pain is challenging, and so is treating it successfully—but it can be incredibly rewarding.

The take-home message is this: the opioid crisis must continue to be addressed. But complex problems rarely admit to simple solutions. Ignoring the “other” attendant crises—early life adversity, mental illness, lack of appropriate treatment for substance use disorder, and the lack of access

@mydocjackson W. Clay Jackson, AIPM board president, is clinical assistant professor of family medicine and psychiatry at the University of Tennessee College of Medicine in Memphis, Tennessee, where he maintains a private practice in family and palliative medicine. Dr. Jackson is the associate fellowship director of palliative medicine at the University of Tennessee College of Medicine.

REFERENCES 1. Kolodny A, Courtwright DT, Hwang CS, et al. The prescription opioid and heroin crisis: a public health approach to an epidemic of addiction. Annu Rev Public Health 2015;36:559-574.

2. Adams J. Argument in Defense of the Soldiers in the Boston Massacre Trials.

December 1770.

3. The relevant law was TN Public Chapter 430. Full disclosure: I have served on the Board of Health commission responsible for guidelines development since its founding. https://www.tn.gov/content/ dam/tn/health/healthprofboards/ ChronicPainGuidelines.pdf

Figure 2 8

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Opioid sales kg/10,000 Opioid deaths/100,000 Opioid treatment admissions/10,000 Prescription Opioid Volume

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Adapted from Sullum J. As opioid prescriptions fall, opioid deaths rise. Reason. 2018. reason.com/blog/2018/04/19/as-opioid-prescriptions-fall-opioid-deat/print.

0 1999 2000

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4. Comprehensive Report of the Controlled Substances Monitoring Database Committee to the Tennessee State Legislature, 2017; 24.

5. https://www.tn.gov/health/healthprogramareas/pdo/pdo/data-dashboard.html (accessed 29 October 2018).

6. https://www.cdc.gov/nchs/products/ databriefs/db294.htm (accessed 29 October 2018).

7. Jones CM, Campopiano M, Baldwin G, McCance-Katz, et al. National and state treatment need and capacity for opioid agonist medication-assisted treatment.

Am J Public Health. 2015;105(8):e55-63.

8. In Tennessee, the percentage of those who suffer opioid overdose deaths without a prescription in the preceding 60 days is 46%. Comprehensive Report of the Controlled Substances Monitoring Database Committee to the Tennessee State Legislature, 2017; 4.

9. Bondesson E, Pardo FL, Stigmar K, et al. Comorbidity between pain and mental illness-evidence of a bidirectional relationship. Eur J Pain.

2018; doi:10.1002/ejp.1218.

10. https://www.drugabuse.gov/drugsabuse/opioids/benzodiazepinesopioids (accessed 29 October 2018).

11. Edwards RR, Dworkin RH, Sullivan MD, Turk DC, Wasan AD. The role of psychosocial processes in the development and maintenance of chronic pain. J Pain. 2016; 17(9 Suppl): T70–T92.

12. Wolitzky-Taylor K, Sewart A, Vrshek-Schallhorn S. The effects of childhood and adolescent adversity on substance use disorders and poor health in early adulthood. J Youth Adolesc. 2017; 46(1): 15–27.

13. Danese A, Moffitt TE, Harrington H, et al. Adverse childhood experiences and adult risk factors for age-related disease. Arch Pediatr Adolesc Med. 2009; 163(12): 1135–1143.

14. Twillman B. The three-headed monster: the crises of mental health, chronic pain, and prescription opioid abuse. Pain Practit. 2018; 28(1): 9.

15. National Pain Strategy. 2016; 6.

16. Kroenke K, Cheville A. Management of chronic pain in the aftermath of the opioid backlash. JAMA. 2017;317(23):2365-2366.

YEAR THE PAIN PRACTITIONER

| VOLUME 28, NUMBER 4 |

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EDUCATION

Talking with Roger Mignosa

By Debra Nelson-Hogan

Dr. Mignosa, a physical medicine and rehabilitation physician, clinical professor, and an exercise physiologist, has served on the AIPM Board of Directors for two years.

THE PAIN PRACTITIONER: WHY DID YOU BECOME A DOCTOR OF OSTEOPATHY? I became a physician because I wanted to learn how to heal myself. In high school I suffered for over two years with pain and injury and I was unable to compete in sports. It was at my lowest point that I saw Andrew Weil, MD, on “Oprah” talking about his book, Spontaneous Healing: How to Discover and Enhance Your Body’s Natural Ability to Maintain and Heal Itself.

I went to the library and checked out the book. His book was mostly about the incredible capacity of the body to heal itself and it was my first exposure to osteopathic medicine.

The next step of my journey led me to Tim Brown, DC, who just happened to practice only a few miles away from me and was medical director for the World Surf League. Dr. Brown was so thoughtful and interested in my story. He conducted a more thorough physical exam than I had received by any physician. He opened my eyes to understanding how the body is one solid unit instead of a bunch of parts. With his help I was able to return to running in my senior year of high school and also set a career in motion.

In college I majored in chemistry/ biochemistry with my passion for nutrition and I earned status as an AllAmerican triathlete. Upon graduation I was awarded a Rotary Ambassadorial Scholarship to study clinical exercise science at the University of Queensland, Australia. My experience with injury was a gift. My struggle gave me a new lens with which I could see the world of medicine. The work of Dr. Weil, the care of Dr. Brown, and my education at the University of Queensland led me on the path to osteopathic medicine.

The philosophy of osteopathic medicine is to enhance the innate healing capacity by treating the body

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as one unit. In my case I felt the stark contrast between the integrative and allopathic models. I simply want to be the doctor that I wish I had met along my journey in health. I hope to help people understand how to tap into the most powerful medicine that will ever exist, the medicine of self-discovery and consciousness.

TPP: WHERE IS YOUR PASSION AROUND MEDICINE? My profession is physical medicine and rehabilitation, and my passion is to enhance dignity within life. Medicine values diagnostics and treatment, but searching for the cure doesn’t make sense if you don’t address the cause.

Dysfunctions in disposition, lack of education, inadequate self-care, and compromised environmental health contribute to the bulk of chronic pain and suffering.

The United States is often criticized for inefficient spending in health care.

It is correct that the US spends a lot on reactive care, but that kind of care is not the entire story. Instead of utilizing a reactive method to treat disease, many of the countries with the most efficient cost of health care devote national resources to addressing the determinates of health. These countries spend less on health care, but more on social services that prevent disease through education, environmental health, and community building.

My mission is to help people prevent disability and optimize community building through education and skill building. Disability and isolation, not pain and addiction, are the enemy. If people have the basic education, skills, disposition, and resources they are able to maintain a sense of connectedness and dignity. I believe the simple truth is that mental and emotional well-being are key components to health. We know

that mental health is immediately lifethreatening to the person who is suffering and in many tragic cases it is threatening to their community as well (as seen in mass shootings around the US).

TPP: CAN YOU DESCRIBE YOUR EXPERIENCE WITH INTEGRATIVE MEDICINE, PARTICULARLY AROUND PAIN MANAGEMENT? My experience with traditional medicine is that of order, logic, and linear thinking.

When I read a traditional patient note it names a diagnostic code with a treatment to match. The treatment is for controlled substances and physical therapy for pain, or statins and diet for high cholesterol. It is easy to defend and easy to prescribe.

Integrative medicine values the patient’s story, beliefs, and exam over films and labs. This branch of medicine also values training with patient-centered treatment to optimize the determinants of health. The lack of results in the fields of pain and rehabilitation in traditional medicine has fostered the growth of integrative medicine.

Pain medicine was an early adopter of integrative medicine because traditional pain medicine was failing. Pain is defined as a physical and emotional response to tissue damage or potential tissue damage. I think traditional medicine trains physicians to be technicians who treat one aspect of pain with an attitude that the full scope of pain is outside of their scope. As a result, interventional physicians who have a background in anesthesiology with poor training in physical medicine, psychology, nutrition, and chronic inflammation set up a pain practice. They should be called an injection practice, because that is what they do. This nail-and-hammer approach to medicine negates the broad training and deep knowledge that is available within medical training.

(Continued on page 15)

ADVERTORIAL

Misdiagnosed Trauma is at Root Cause of Opioid Crisis

By Bennet Davis, M.D., Pain Program Director, Sierra Tucson

Changing our Approach: Trauma-Informed Pain Care Can Effectively Address Causes of Prescription Opioid Dependence Hiding deep within the shadows of the most talked about health emergency in America — the opioid crisis — is actually another tragedy. It is at the heart of an epidemic that is daily making headlines.

It is, in fact, at the crux of what is feeding the over-prescribing of opioid and benzo medications and why many patients diagnosed with chronic pain end up in a hopeless cycle of medication prescribing that may progress to addiction and, too often, overdose. This underlying crisis?

The rampancy of psychological trauma.

According to CDC statistics, about 40 million Americans have experienced significant psychological trauma.1

HOW IS THE TRAUMA EPIDEMIC RELEVANT TO SOLVING THE OPIOID CRISIS? Trauma changes nervous system function in a way that leads to symptoms, like pain, insomnia, fatigue, and anxiety that respond, in the short run, to opioids. Since the brain’s pain circuitry is active, these symptoms are real, but they are often misdiagnosed and labeled as pain from tissue injury, which is why patients are started on opioids long-term. This is how millions of Americans have found themselves on high-risk opioid + benzo medication regimens that do not work in the long run; opioid is not the right long-term choice for pain from psychological trauma.

CHALLENGING THE WAY WE TREAT THE OPIOID CRISIS One hidden consequence of the trauma crisis is a false assumption that the recent increase in overdose deaths is strictly the consequence of an epidemic

of addiction. Reducing opioids and introducing addiction resources hasn’t been enough. Center for Disease Control statistics show that the crisis has only deepened, as we restrict access to prescription opioids.

There are three fundamental questions about pain that traditional medical and behavioral health care haven’t answered successfully: 1. To what degree do psychological factors drive the somatic complaints of pain?

2. What are the psychological factors?

3. What, if anything, can be done to remediate them?

TRAUMA CAN BE EASILY SCREENED AND EFFECTIVELY TREATED AT LOW COST RELATIVE TO THE COST OF TREATING THE MYRIAD CONSEQUENCES OF UNTREATED TRAUMA It is common for individuals labeled with chronic pain to be brought in to a biomedical model of pain. At Sierra Tucson, we employ a biopsychosocial approach that embraces all possible causes of pain and distress because medical complaints are often driven by a combination of past psychological trauma, plus physical pathology.

The details of the typical care plan depend on the individual patient context.

Which is the most important aspect of the patient’s situation to address first: addiction, trauma, mood, or medical pain issues? This question guides each patient’s care at Sierra Tucson.

OPIOIDS AND PAIN PATIENTS:

The Facts

• 51% of the opioid pain killer prescriptions written in the United States go to the 16% of the American population with mental health diagnoses of anxiety or depression.2 • An American with Depression or Anxiety is four times more likely to be prescribed an opioid pain killer than an American without these diagnoses.2 • Sierra Tucson is taking another approach to addressing the opioid crisis. The Pain Recovery Program at Sierra Tucson is comprised of a multidisciplinary treatment team using a holistic approach that encompasses behavioral health and traditional medicine.

For more information go to www.sierratucson.com/programs/pain-management-recovery/ 1) “Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults,” published in the American Journal of Preventive Medicine in 1998, Volume 14, pages 245–258.

2) Davis M et al. Prescription Opioid Use Among Adults with Mental health Disorders in the United States. J Am Board Family Med 2017; 30:338-401 http://jabfm.org/content/30/4/407

ADVOCACY

Thank you!

AIPM would like to sincerely thank the following organizations and agencies for participating in the Integrative Pain Care Policy Congress!

To continue the work started at 2017’s inaugural meeting, the second Integrative Pain Care Policy Congress was held in Boston on November 10, 2018, and brought together leaders from more than 65 organizations and agencies committed to advancing comprehensive integrative pain management for people with pain.

Executive Branch Agency for Healthcare Research and Quality (AHRQ) Centers for Disease Control and Prevention (CDC) Centers for Medicare & Medicaid Services (CMS) Defense & Veterans Center for Integrative Pain Management (DVCIPM) Health Resources & Services Administration (HRSA) Indian Health Service (IHS) National Center for Complementary and Integrative Health (NCCIH) Substance Abuse and Mental Health Services Administration (SAMHSA) U.S. Food & Drug Administration (FDA) Veterans Health Administration (VHA) Payers America’s Health Insurance Plans Beacon Health Options The Hartford UnitedHealth Group Patients American Cancer Society Cancer Action Network Ehlers Danlos Society International Pain Foundation National Fibromyalgia & Chronic Pain Association National Patient Advocate Foundation The Pain Community US Pain Foundation Research Chronic Pain Research Alliance PCORI Full Scope of Providers Academic Collaborative for Integrative Health Academic Consortium for Integrative Medicine and Health

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Academy for Integrative Health & Medicine Academy of Integrative Pain Management Alliance for Balanced Pain Management American Academy of Hospice & Palliative Medicine American Academy of Medical Acupuncture American Academy of Orofacial Pain American Academy of Pain Medicine American Academy of PAs American Association of Naturopathic Physicians American Association of Nurse Anesthesists American Association of Nurse Practitioners American College of Emergency Physicians American College of Physicians American Holistic Nurses Association American Institute of Homeopathy American Massage Therapy Association American Medical Association American Occupational Therapy Association American Osteopathic Association American Pain Society American Pharmacists Association American Physical Therapy Association American Society for Pain Management Nursing American Society of Acupuncturists Foundation for Chiropractic Progress Integrative Health Policy Consortium International Association for Yoga Therapists Massachusetts Medical Society National Association of Social Workers National Certification for Acupuncture and Oriental Medicine New York State Pain Society Pennsylvania Pain Society Society of Palliative Care Pharmacists Society for Health Psychology, American Psychological Association UCLA Pediatric and Palliative Care Program Other Organizations A Healing Place – The Estates American Specialty Health Atlas Project Center on Health Insurance Reforms, Georgetown University Concerted Care Group Emergency Medicine Foundation Fulcrum Health, Inc. Integrative Medicine for the Underserved Midwest Business Group on Health National Academies of Science, Engineering, and Medicine National Governors Association PAINS Project Partnership for Drug Free Kids Thought Leadership Innovation Foundation

THE INTEGRATIVE PAIN CARE POLICY CONGRESS IS HOSTED BY:

IN PARTNERSHIP WITH:

IN COLLABORATION WITH OUR VALUED SPONSORS: Paradigm Shifter Level

Leader Level

Expert Level

Collaborator Level International Association of Yoga Therapists Contributor Level American Physical Therapy Association American Society of Acupuncturists National Association of Social Workers Society of Palliative Care Pharmasists

NEUROSENSORY STENTS FOR THE TREATMENT OF ORAL NEUROPATHIES

Neurosensory Stents for the Treatment of Oral Neuropathies

By Joseph Matthews, DDS, MSc

TRIGEMINAL NEUROPATHIC PAIN MAY DEVELOP AS A RESULT of injury or a pathological condition, and its classification is based on whether it arises in the peripheral or central nervous system. Neuropathic pain is also classified as either continuous or episodic (1). Successful management of these disorders is more predictable with an accurate diagnosis. Patients may present with a preliminary diagnosis of trigeminal neuralgia (TN), but this should be confirmed with a thorough assessment of symptoms and supporting imaging studies, if needed.

The International Classification of Headache Disorders ICHD 13.1.1 code for TN is frequently applied too broadly to painful neuropathies. This designation is now appropriate for pain secondary to vascular compression of the trigeminal dorsal root entry zone as well as for idiopathic pain. A more appropriate diagnosis for non-neurovascular etiologies may be painful trigeminal neuropathy, ICHD 13.1.2 (2). This term includes conditions that mimic TN as well as those whose cause is obscure. The diagnosis is complicated when symptoms include paroxysmal episodes that are typical of TN along with

continuous pain that is more characteristic of other trigeminal nerve disorders (3).

Distinguishing between pain that originates from peripheral nerves versus pain from the central nervous system can be challenging.

One helpful technique for diagnosis is anesthetic testing (4). Intraoral anesthesia is useful for evaluating the trigeminal nerve branches V2 (maxillary) and V3 (mandibular), the most commonly involved branches. The extent of peripheral and central involvement can be ascertained by starting with an application of 20% topical anesthetic to the painful area. Lidocaine distal blocks are then achieved before moving progressively more proximally. After each anesthetic block, it is crucial to wait three to five minutes before applying the next block so that the involved nerve can be located. If the pain is unchanged after the series of anesthetic blocks, a central etiology is likely. Some painful neuropathies have both peripheral and central elements, which becomes evident with a partial response to anesthetic testing.

A topical treatment may be effective when the epicenter of the pain is located in the peripheral oral tissues. This may also be helpful to block a peripheral trigger in TN. Topical medications

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NEUROSENSORY STENTS FOR THE TREATMENT OF ORAL NEUROPATHIES

are preferred because they avoid first pass metabolism, achieve REFERENCES 1. Dworkin RH, Backonja M, Rowbotham MC, et al. Advances in lower blood levels of the medications with reduced adverse neuropathic pain: diagnosis, mechanisms, and treatment receffects and drug interactions, and result in higher concentrations ommendations. Arch Neurol. 2003;60(11):1524–1534. of the medications in the target area. They are also absorbed 2. Headache Classification Committee of the International more rapidly through mucosal and gingival tissues (5).

Headache Society (IHS). The International Classification Medication quantity is minimized and can be kept in close of Headache Disorders, 3rd edition (beta version). contact with the soft tissues using an oral neurosensory stent Cephalalgia. 2013;33(9):629-808. that covers the affected area (6). A stent can also protect 3. Benoliel R, Zini A, Khan J, Almoznino G, Sharav Y, Haviv Y. the tissues from additional stimulation and irritation. An oral Trigeminal neuralgia (part II): Factors affecting early pharmaconeurosensory stent can be fabricated from acrylic to achieve therapeutic outcome. Cephalalgia. 2016;36(8):747-759. optimal fit and comfort with minimal impact on speech and 4. Brown RS, Hinderstein B, Reynolds DC, Corio RL. Using function (7). The stent is worn continuously except while eating, anesthetic localization to diagnose oral and dental pain. and the medication paste should be added four to five times J Am Dent Assoc. 1995;126(5):633-634, 637-641. daily, including after meals and at bedtime.

5. Stanos SP, Galluzzi KE. Topical therapies in the management Treatment may be initiated with a 20% benzocaine paste of chronic pain. Postgrad Med. 2013;125(suppl 1):25-33. without prescription. However, the clinician will want to select 6. Romero-Reyes M, Uyanik JM. Orofacial pain management: an appropriate formulation based on the nerve receptors that current perspectives. J Pain Res. 2014;7:99-115. are involved as well as the patient’s medical profile. The paste can 7. Matthews J, Merrill RL. Sodium hypochlorite-related injury with be ordered from a compounding pharmacy and should be finely chronic pain sequelae. J Am Dent Assoc. 2014;145(6):553-555. milled to achieve predictable absorption. Simple compounds with 8. Heir G, Karolchek S, Kalladka M, et al. Use of topical lower concentrations are preferred when possible. Concentrations medication in orofacial neuropathic pain: a retrospective for all topical oral medications are much lower than those typically study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. used for the skin, and the optimal concentration may require time 2008;105(4):466-469. to achieve as each patient has different requirements. Medications used may include capsaicin, gabapentin, carbamazepine, lidocaine, ketoprofen, ketamine, or clonidine (when there is sympathetically maintained pain).

The neurosensory stent and medication For 34 years, Sierra Tucson has pioneered the integration of behavioral health care may be needed variably for weeks or with traditional medical evaluation, providing evidence-based treatment therapies years. Topical medications may be that address the underlying causes of pain. used in conjunction with systemic medications when both central and Our residential Pain Recovery Progam includes treatment for: peripheral mechanisms are suspected • Post-Surgical Pain • Neck and Back Disorders (8). Patients accept the treatment readily • Central Nervous System Sensitivity, • Opioid-Induced Hyperalgesia and some insurance plans cover the including pain due to nervous system • Complex Regional Pain Syndrome treatment, although explanatory letters trauma such as Fibromyalgia • Musculoskeletal and Rheumatic may be requested. Large-scale clinical • And more Conditions trials are lacking, but the effectiveness of neurosensory stents with topical compounds cannot be overestimated for the relief of intraoral peripheral neuropathic pain. n Joseph Matthews, DDS, MSc, practices orofacial pain management with Southwest Orofacial Group in Phoenix.

In addition, he lectures on orofacial pain at the University of New Mexico School of Medicine and critical appraisal of medical literature at the UCLA School of Dentistry.

He is a diplomate of the American Board of Orofacial Pain and a fellow of the American Academy of Orofacial Pain and a member of the American Headache Society.

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Where Change Begins®

VIRTUAL REALITY THERAPY AS AN ADJUNCT TO PAIN MANAGEMENT

Virtual Reality Therapy as an Adjunct to Pain Management

By Brenda K. Wiederhold, PhD, Vrajeshri Patel PhD, and Mark D. Wiederhold, MD, PhD

Left: Enchanted Forest VR environment Inset: VR for pain distraction and anxiety reduction during dental procedures

BECAUSE MANY CHRONIC PAIN PATIENTS STILL EXPERIENCE pain on narcotics, it is evident that pharmacologic therapy is only part of the solution to pain management. The continued and growing recognition of psychological and social factors in pain management requires consideration of additional approaches to this complex, multimodal problem. A very effective approach, cognitive behavioral therapy, works to shift negative thoughts on pain to positive and empowering ones. Distraction techniques, such as meditation, hypnosis, and guided imagery, aim to divert attention away from pain altogether. Virtual reality (VR) is an especially effective medium for distraction (1), where the borders of reality can be modified in ways that enhance the therapeutic process. VR systems are also compatible with biosensors and brain imaging devices, making a comprehensive assessment of the global effects of pain and chronic pain syndromes possible.

Furthermore, witnessing how their own brains react to pain, medication, and pain-reducing stimuli can help sufferers learn to control how they perceive pain (2).

A UNIQUE METHOD FOR PAIN MANAGEMENT VR, an immersive 360-degree interactive 3-D computer display technology, combined with 3-D audio, surrounds the patient with a virtual world that serves as a distraction from the current unpleasant experience or sensation. VR has been created to induce a strong feeling of “presence,” or “immersion”—the experience of actually being in the simulation. Recent advances in computer simulation make the experience almost impossible to distinguish from “real” life.

VR environments allow some adjustment by the therapist to synchronize the experience with the individual patient’s requirements; for example, the intensity of accompanying sounds can be regulated. Cues or important aspects of the world can also be activated or diminished as needed.

VR is a heightened experience of human-computer interaction, allowing the patient to become an active participant and results in staying “on task” versus drifting off or becoming bored. As a metamedium, VR can interface with film, video, photography, and other

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media forms to create a rich 360 experience. Users of VR become an active part of the story. The story doesn’t proceed without their personal involvement. Users therefore are more directly engaged in the process of the distraction technique than they are when passively receiving traditional distraction methods, resulting in a lower level of pain perception.

Icy Cool World is a VR experience developed for burn patients.

Non-invasive physiological sensors can continuously monitor patients’ responses. This serves several purposes: a) variations in the patients’ responses within and between sessions can be quantified without self-report biases; and b) acknowledging physiological responses of patients helps keep the therapist “in touch” with patients’ concerns. It lets the patient know that the clinician is objectively monitoring them, and it also allows the patient to view and internalize the level of their physiological arousal.

VR can be added to any clinical protocol. We have seen patients reduce their dose of narcotics while using VR therapy, and we have combined VR therapy with pulsed electromagnetic frequency (PEMF) devices for chronic musculoskeletal pain.

VR DISTRACTION STUDIES WITH BURN PATIENTS We have conducted several VR distraction studies in patients with second- and third-degree burns. In these studies, burn patients were placed inside “Icy Cool World,” a virtual world developed

by Virtual Reality Medical Center (VRMC) specifically for burn patients, and navigated through the virtual environment using a head-mounted display. All patients reported less pain when distracted with VR as compared to baseline. The magnitude of pain reduction by VR was statistically significant, and patients had further reductions in pain as their ability to navigate the environment improved. In addition, time spent thinking about pain during physical therapy decreased significantly.

We have investigated how the content might affect the patient’s perception of pain by investigating how influential hot and cold environments are in reducing pain originating from cold and hot stimuli, respectively (4). Results indicate that although VR distraction equally reduced pain intensity and unpleasantness when perceiving pain in both warm and cold environments, the content of the environment had no interaction with the type of pain stimulus. In another study, VR distraction reduced thermal pain, with users of a head-mounted display (HMD) reporting lower pain scores than those viewing a flat panel display. This suggests a higher level of immersion using the headset, which may be correlated with an increased level of relaxation and engagement.

DENTAL PAIN

Figure 1: Subjective and objective ratings during Pain Focus and VR conditions—indicating reduction in both self-reported pain and decrease in physiological arousal.

VR DISTRACTION FOR CHRONIC PAIN We have studied the effectiveness of VR distraction in relieving chronic pain. In one study patients using VR had significantly lower pain scores (P = .028) and significantly higher skin temperatures (P = .027) than when in the pain focus condition, indicating greater relaxation during VR (Figure 1). These results suggest that VR can be an effective addition to standard pain management techniques (3).

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Despite the advances in dental technologies and treatment, many individuals still avoid or delay dental care because of fear and anxiety, with up to 15% of all Americans avoiding regular dental care. Previous studies show that visual techniques are more effective distraction techniques than audio programs.

We performed a VR distraction study with 20 dental patients who were receiving a variety of dental services, such as crown replacements, fillings, root canals, and cosmetic dental work.

Patients wore an HMD and explored “Enchanted Forest” or “Icy Cool World,” virtual worlds developed by VRMC. Psychological measurements, such as anxiety assessments and questionnaires, were implemented along with physiological measurements, such as electrocardiograms (ECG), skin temperature, skin conductance, and respiratory rate. Patients reported lower levels of discomfort and pain while immersed in VR. Heart and respiration rates showed greater stability with VR exposure (see Figure). Moreover, perceptions of time were altered while in VR, indicating immersion. Fourteen out of 20 patients estimated their time in VR to be significantly less than actual time spent during procedure. These results suggest that immersive VR merits more attention as a potentially viable, non-pharmacologic addition for procedural dental/periodontal pain (5).

VIRTUAL REALITY THERAPY AS AN ADJUNCT TO PAIN MANAGEMENT

VIRTUAL REALITY DURING SURGICAL PROCEDURES We have used VR as an adjunct to anesthesia during surgical procedures in more than 1,000 patients. Although general anesthesia is very safe, some patients wish to avoid intubation and anesthetic induction. Using immersive VR environments, we have been able to conduct laparoscopic procedures, endoscopy, and colposcopy in VR without general anesthesia, instead using either local, or in some cases, regional anesthesia. Avoiding general anesthesia can reduce length of stay, avoid or reduce potential post-operative complications, and reduce costs.

Patients have also used VR pre-operatively for stress reduction and relaxation. They were first taught paced breathing and muscle relaxation. During the procedure they wore an immersive VR head-mounted display and were able to communicate with the surgeon and nursing team. VR was then used postoperatively in the recovery room where pain levels were carefully monitored along with vital signs. Post-operatively, patients reported less anxiety and fear about the procedure. During the procedure, they reported less pain and discomfort, and had more stable vital signs. Post operatively, they had less recovery time and lower levels of complications. Ambulation was encouraged and helped to reduce perceived levels of pain. Some patients could be managed without the use of narcotics (6-8).

Many women are interested in natural delivery during uncomplicated birth. We were able to use VR as an adjunct to normal vaginal delivery without the use of narcotics. In some cases, spinal block was avoided (7).

In other cases, surgical excisions of lipomas or other lesions were carried out under local anesthesia. Recovery was shorter and fewer complications were seen. We have begun to deconstruct which aspects of the VR experience are most important to the management of both anxiety and pain. In a smaller series of cases we were able to achieve pain reduction during local excisions using a Google Cardboard HMD (9).

FEAR OF NEEDLES, INJECTIONS, AND MRI CLAUSTROPHOBIA Our relaxation worlds have also been tested in patients with severe fear of needles, blood, or injections. Some patients either never go to a physician’s office, avoid important tests or vaccinations, or, in some cases, faint whenever they need to have blood drawn.

In extreme cases of claustrophobia and fear of MRI procedures, patients have required complete induction of anesthesia. We created a virtual hospital with a virtual blood drawing facility.

Cognitive behavioral therapy (CBT) plus VR exposure has successfully treated patients with these significant fears and phobias. CBT-based approaches can often help patients overcome those fears, and, in some cases, patients only required small doses of short acting benzodiazepines (10).

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Recent improvements in the graphics capabilities of cell phones and handheld devices, along with the creation of platform-independent game engines, have allowed graphicrich environments to be transitioned to these portable platforms. We have conducted several studies using VR content on iPhones and iPads to relieve both procedural and chronic pain. Patients exhibited a significant reduction in pain levels when compared to pain focus or when compared to baseline levels. These results suggest that augmenting clinic-based pain interventions with portable platforms that transition to the home environment for prolonged use of the VR intervention can help prolong pain-free intervals (11,12).

CONCLUSION The increasing prevalence of pain syndromes requires a thoughtful THE PAIN PRACTITIONER

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and multidimensional treatment approach to pain management.

Transitional approaches that bridge the clinic/hospital model to the home environment are especially important. Increased funding, attention, and support will result in the implementation of diverse, non-traditional treatment methods resulting in lower rates of opioid misuse and addiction. On a larger scale, improved management of pain syndromes could reduce the health care costs of managing chronic pain. Together, we can better address and manage pain syndromes and secure an improved quality of life for our patients. n Brenda K. Wiederhold, PhD, MBA, BCB, BCN, is President of the Virtual Reality Medical Center, a licensed clinical psychologist, board certified in biofeedback and neurofeedback, CEO of the Interactive Media Institute, on medical staff at Scripps Memorial Hospital, co-chair of the pain and palliative care committee and Editor-in-chief of the CyberPsychology, Behavior, and Social Networking journal.

Mark D. Wiederhold, MD, PhD, FACP, CPE, FACPE, is an internal medicine and critical care specialist. He is the CEO of Virtual Reality Medical Center. He has created a number of non-invasive medical imaging technologies and has expertise in AI and machine learning.

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Vrajeshri Patel, PhD, is a biomedical engineer at Virtual Reality Medical Center, where she develops integrative VR programs for clinical use.

REFERENCES 1. Wiederhold MD, Wiederhold BK. Virtual reality and interactive simulation for pain distraction.

Pain Med. 2007;8(Suppl 3):S182-S188.

2. Wiederhold MD, Wiederhold BK. Virtual reality and interactive simulation for Pain Distraction. CyberTher Rehabil.

2010;3(1):14-19.

3. Wiederhold BK. Gao K, Sulea C, Wiederhold MD. Virtual reality as a distraction technique in chronic pain patients.

CyberPsychol Behav Soc Netw. 2014;17(6):346-352.

4. Mühlberger A, Wieser M.J, Kenntner-Mabiala R, Pauli P, Wiederhold BK. Pain modulation during drives through cold and hot virtual environments. CyberPsychol Behav.

2007;10(4):516-522.

5. Wiederhold MD, Gao K, Wiederhold BK. Clinical use of virtual reality distraction system to reduce anxiety and pain in dental procedures. CyberPsychol Behav Soc Netw., 2014;17(6):359-365.

6. Vázquez JL M, Wiederhold BK, Miller I, Wiederhold MD. Virtual reality assisted anesthesia during upper gastrointestinal endoscopy: report of 115 cases. EMJ Innov. 2017;1(1):75-82.

7. Vasquez J M, Vaca V L, Wiederhold BK, Miller I, Wiederhold MD. Virtual reality pain distraction during gynecological surgery: a report of 44 cases. Surg Res Updates. 2017;5.12-16.

8. Mosso-Vázquez JL, Gao K, Wiederhold BK, Wiederhold MD Virtual reality for pain management in cardiac surgery.

CyberPsychol Behav Soc Netw.

2014:17(6):371-378.

9. Mosso Vázquez JL, Wiederhold BK, Mosso LD, Mosso JL, Miller I, Wiederhold MD.). Pain distraction during ambulatory surgery: virtual reality and mobile devices. Cyberpsychol Behav Soc Netw. 2018 Sep 25. doi: 10.1089/cyber.2017.0714. [Epub ahead of print] 10. Wiederhold B., Mendoza M, Nakatani T, Bullinger AH, Wiederhold MD. VR for blood-injection-injury phobia.

Ann Rev CyberTher Telemed.

2005;3:109-116.

11. Wiederhold BK, Gao K, Kong L, Wiederhold MD. Mobile devices as adjunctive pain management tools.

CyberPsychol Behav Soc Netw.

2014;17(6):385-389.

12. Wiederhold BK Lessons learned as we begin the third decade of virtual reality. Cyberpsychol Behav Soc Netw. 2016;19(10):577-578.

(Continued from page 6) The biggest challenge in integrative medicine is that health care organizations are attempting to incorporate “integrative medicine modalities” within the traditional model of care. Now institutions offer treatments, such as acupuncture and osteopathy, within their organizations but they are tools instead of philosophies.

Researchers ask the question, “Does acupuncture work for back pain?” or “Does osteopathy work for neck pain?”

The question is not, “Does osteopathy work?” The question is why does the person have back pain? The answer is not an imaging result. The answer is a story that explains the complex mess of life and that includes how mental, emotional, and physical stress, along with numerous factors that are outside of our control, feed pain.

If medicine as a whole is to advance, then health care professionals and researchers must change their questions to match the complexity of health.

We can start by asking one simple question to every patient: “What is the greatest area of suffering in your life?”

I guarantee that that given 100 patients with the same diagnosis you will get 100 different answers. n

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