In our previous article in the National Pain Strategy (NPS) series, we gave an overview of tools and approaches established at the Stanford Pain Management Center in order to improve pain management. The Chief of the Division of Pain Medicine at Stanford University, Sean Mackey, MD, PhD, presented NPS studies conducted at the Center, during the American Pain Society’s 35th Annual Meeting, which took place earlier this month in Austin, TX.
These tools allowed Mackey and his colleagues to collect a large amount of lower back pain data. While the mean number of patients for similar clinical trials is of 650, Mackey’s study, which he presented during the conference included 5300 patients. This larger sample size allowed him and his colleagues to gather very robust data through the use of higher-level statistical tools, going well beyond the traditional non-linear tools.
Using the open source learning healthcare platform, the ‘Collaborative Health Outcomes Information Registry’ (CHOIR)1, researchers confirmed findings from previous studies, establishing that catastrophizing was the most robust predictor of poor outcomes following surgery for lower back pain injury, and for individuals with chronic lower back pain.
Mackey presented an additional CHOIR-based study, currently under review and conducted by Beth Darnall, PhD, a Clinical Associate Professor in the Division of Pain Medicine at Stanford University, working at the Stanford Pain Management Center. Dr Darnall asked the 1800 study subjects the question: “Do opioids make a difference to patients with chronic pain?” The answer was “Yes”.
The likelihood for men being on opioids was however much greater than that of women – this was due to higher levels of pain intensity. In women, the main factor for using opioids was catastrophizing. What was most intriguing and interesting to Mackey in this study, was that the traditional finding showing that high levels of catastrophizing led to a higher likelihood of opioid use, was challenged here. This result was allowed thanks to the higher than usual number of study participants, which permitted the application of better statistical tools to define non-linear characteristics.
Results from this study showed that low-to-moderate levels of catastrophizing were critical in determining a patient’s likelihood of taking opioids, and of experiencing chronic pain. This prompted Dr Darnall to focus her treatment on catastrophizing, and to turn this study into a brief psycho-behavioral intervention. Treatments for catastrophizing typically consist in 8-9 weeks of cognitive behavioral therapy, and have poor patient adherence.
Dr Darnall therefore concentrated the treatment into a 3 hour class session as part of a pilot study on 57 patients. This shortened intervention resulted in dramatic and durable decreases in pain catastrophizing, which coincided with increases in psychological and physical functioning. Pilot data from this study allowed the Stanford group to obtain substantial NIH funding, and conduct broader studies in order to both refine and disseminate the treatment. “That’s the power of using data in your clinic, in real world patients” commented Mackey.
Other work conducted by a postdoctoral fellow in Mackey’s laboratory, Drew Sturgeon, PhD, dealt with social functioning. Sturgeon ran a mediation model on a large number of patients within the Stanford database, and found that, as expected, increases in pain led to increases in physical dysfunction, and consequently, to depression and anger.
But he also performed a mediation analysis to determine the importance of a patient’s satisfaction and social role in experiencing pain. Results showed that patients experiencing higher pain levels as well as reduced physical functioning, had decreased ability to engage with family and friends, and as a result, were not enjoying their social interactions as much. This combination of factors led to depression and anger. As Mackey pointed out, one should avoid inferring mechanisms, but in his opinion, this study highlighted a role for social satisfaction in modulating pain levels.
When investigators scanned survey results from about 4.4 million patients for all medical professions and medical practices across the country, they found patient satisfaction to be very low. Such results are not pleasing to hospital officials and administrators, and pain clinicians are often blamed. By performing a basic network analysis, Mackey’s team, however found that the individual role of a healthcare provider only plays about 20% of the overall patient experience. The key player, according to this analysis was coordination of patient care.
Investigators used data from CHOIR to assess whether patients were more or less likely to rate clinicians and facility high, before patients presented to the clinic. Such surveys could predict whether a certain patient would be “a lover or a hater”: individuals with high levels of pain, depression and catastrophizing were more likely to rate poorly on satisfaction.
In order to determine factors critical to patients’ satisfaction, Mackey and his colleagues established a ‘patient-family’ partnership model, consisting of a counsel in which the family was included, and in which the patient was involved in the decision-making.
They also established a number of group and individual therapy approaches for patients with lower back pain, as well as pain-coping skills groups in which pain psychologists and physical therapists work together. In addition, pain psychology groups, tai chi classes, self-management programs, and support groups were put in place. Data from these various endeavors is tracked using the CHOIR system, in an effort to determine which ones are most beneficial, the reasons for their efficacy, and the individuals they are benefiting the most.
The Stanford Pain Management Center has obtained several project grants from the National Center for Integrative and Complementary Health, designed to characterize mechanisms of treatment for several mind-body approaches, including Cognitive Behavioral Therapy, stress reduction, acupuncture, and the aforementioned single session to manage catastrophizing in lower back pain patients.
In addition, researchers there developed free pain management books and online courses, including one on opioid education2. Also, thanks to the Center grant around the theme of pain, an annual and free back pain education event3 is organized, broadcasted live stream, and watched around the world.
With these approaches, Mackey and his colleagues are able to leverage data and information to inform clinical decision-making, and determine “what works, for whom, and why”, but also to develop targeted and brief psychological and behavioral intervention therapies.
1.The Collaborative Health Outcomes Information Registry: https://choir.stanford.edu/
2.Patient Resources at the Stanford Pain Management Center:
3. Back Pain Education Day 2016: https://med.stanford.edu/pain/events.html