Share the Risk Pain Management in a Dedicated Facility
An article in the May issue of Practical Pain Management1 described the Casa Palmera facility and its incorporation of the “Share the Risk Program.” The Del Mar Casa Palmera facility opened in 2005 to treat individuals with addictive, eating and emotional disorders. The multidisciplinary in-patient treatment proved very successful and raised the question as to whether or not the concept of intensive, in-patient care by a team of specialists could be applied to the management of chronic and persistent pain.
Fortuitously, Dr. Joseph Shurman of nearby San Diego had, in 2002, introduced the Share The Risk Model2 that professed that no one specialty could adequately treat complex pain cases and it outlined the composition of a team that could cover all contingencies. Dr. Shurman has lectured extensively on this approach and it became the inspiration and catalyst for the national, Cephalon-sponsored Emerging Solutions in Pain program.3
The objective of this series of articles is to let Practical Pain Management readers understand the efficacy of the approach and to suggest that they consider utilizing Casa Palmera for their most difficult cases and/or when they are not suitable for outpatient therapy. In addition, Casa Palmera also has an intensive outpatient program. Both the residential in-patient and the intensive outpatient program at Casa Palmera are suitable for the noncompliant pain patient, the drug dependent or “addicted” pain patient who wants to get off opioids and/or benzodiazepines, or the pain patient who turns up with an abnormal urine screen for illicit drugs.
Bringing Together the Best of Eastern and Western Medicine with Neuroscience
One of the significant problems pain specialists had—how to deal with the noncompliant patient, the addicted individual, or the patient who desired to rotate off opioids—was what more specifically led to the development of the Chronic Pain Management Program at the Casa Palmera Care Center. The goal was to bring together skilled, experienced professionals, together with state of the art “holistic” resources, for the comprehensive and simultaneously integrated treatment of chronic pain associated with problems of dependence upon pain medication or other drugs and/or alcohol. Utilizing the “Share the Risk” theme of an interdisciplinary team and holistic approach, Casa Palmera staff includes psychiatrists, psychologists, addictionologists, internists, primary care physicians, anesthesiologists, nutritionists, acupuncturists, physical therapists, music/art and massage therapists, biofeedback, laser therapy and more (see Table 1). All of these specialties are in residence at Casa Palmera—embracing a philosophy of efficient, integrated treatment for the severe and complex pain patient.
Pain management, under the direction of Dr. Shurman, was added in June 2008 as a logical expansion of the existing treatment services for eating disorders, emotional disorders, and comorbid disorders. The result is that severe and complex pain patients are being successfully treated at Casa Palmera.
The treatment center combines approaches from both Eastern and Western medicine, complemented by many alternative modalities from acupuncture to massage therapy (see Table 2). It also offers access to Scripps Hospital, where Dr. Joseph Shurman is Chairman of Pain Management and Dr. Tom Foster, a primary care physician at Casa Palmera, is Chairman of Family Practice; as well as access to UCSD, where Dr. Bergman, Casa’s Medical Director, and Dr. Lardon, Casa’s Chair of Eating Disorder Services, are clinical faculty members.
Because Casa represents the “state of the art,” there have been very few outcomes studies evaluating this approach. Hence our plan is to do such studies with the help of Dr. George Koob, PhD, Casa’s Director of Neuroscience. Dr. Koob will be establishing objective outcome measures resulting from treatment at Casa Palmera utilizing novel and validated approaches for follow up of former patients. Dr. Koob, one of the foremost neuroscientists in the world of chemical dependency, stress and pain—and editor in chief of the Journal of Addiction Medicine—is a major consultant at Casa, educating staff and lecturing to patients to help make the science relevant and understandable.
Since the inception of Casa’s Pain Management Program, we have been pleased and satisfied with our clinical results. Seventy five to eighty percent (75-80%) of patients have reported a significant reduction in perceived pain and a substantial improvement in pain management, motor function, as well as general function and well-being. On average, the stay has been 30-45 days.
Since the availability of all the specialties required for Share the Risk is sometimes geographically impossible for many pain clinics, Casa Palmera offers an alternative, comprehensive in-patient option for the complex, chronic pain patient.
The patient selected for this case report represents a very challenging case. Dr. Shurman, who has been in practice for 30 plus years, describes this case as one of the most challenging young chronic pain patients he has encountered. The pertinent data presented includes the pain symptoms and the general plan of treatment.
A 19-year-old Caucasian female presented with migraine headaches from age of nine. During early teens, this high school honor student was given various and multiple medications for pain relief, including Imitrex, Maxalt and Vicodin, with limited efficacy. Approximately three years prior to admission—associated temporally with the loss of two grandparents—the patient experienced an increase in intensity and frequency of headaches associated with, and compounded by, generalized anxiety. Opioids were again prescribed, rotated and combined. With negative MRI’s and CAT scans, pain and related opioid dosing escalated under the care of neurologist and consultative pain specialists. The patient’s emotional state and general level of functioning declined and her high school education was interrupted.
At the time of admission to Casa Palmera in July 2009, the patient had just graduated from high school (one and a half years late), was spending 90% of her time at home and was taking 100-150 mg of Demerol IM, 6-8 times daily—with resultant gluteal abscesses, and 35-45 800 mcg Fentora tabs daily, along with Cymbalta and Topamax. She was still complaining of moderate-to-severe pain. At that time, her neurologist and pain specialist referred her to Casa Palmera.
At Casa Palmera, the patient’s Demerol was discontinued and Fentora tapered on a prn basis with successful rotation to Suboxone during the first week. She was placed in a comprehensive therapeutic milieu with alternative and complementary treatment elements—combined with eastern and traditional western medicine—directed at pain, drug dependence management and control of anxiety. She utilized and responded well to all treatment modalities: including group therapy, chemical dependence counseling, massage, physical therapy, reiki, yoga, bio/neuro feedback and pharmacotherapy (see Table 2).