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10 Articles in Volume 9, Issue #4
Application of Spinal Segmental Physiology to Evaluating Chronic Pain
Dental Consequences of Pain Management
Facility Profile: Casa Palmera
Intellectual and Moral Tasks in Intersection—Part 2
Milnacipran: A New Treatment Option for Fibromyalgia
Neuroma Pain of the Foot Successfully Managed with Laser Therapy
Opioid Treatment Longevity Study: Interim Report
Pain Management in a Palliative Care Setting
Precursor Amino Acid Therapy
Prolotherapy for Sacroiliac Joint Laxity

Facility Profile: Casa Palmera

Casa Palmera has become a model center for the treatment of comorbid chronic pain, substance dependence, eating disorders, and emotional trauma by bringing together the best of Eastern and Western medicine with neuroscience.

Publisher’s note: Casa Palmera, an addiction treatment facility, has recently added a pain management program based on the “Share The Risk” program developed by Dr. Joseph Shurman. This program advocates the utilization of a number of specialists in treating chronic pain. Casa Palmera, for the first time, brings all of the necessary expertise together in a single facility. We are offering our readers the opportunity to learn about their program because they have a stated interest in informing physicians across the country. Without endorsement or recommendation, this publication offers the information that follows as a service to our readers.

Robert Foery, PhD, DABCC/TC

The contemporary Casa Palmera in Del Mar (a small coastal community of San Diego, California) opened its doors in June 2005. The ninety-five (95) bed residential treatment center was dedicated to the care of individuals with addictive, eating, and emotionally traumatic disorders. As time went on it became apparent that another population of patients, with many shared characteristics and often co-occurring with Casa’s patients, was vastly under- or mistreated in our community and the nation, namely those with chronic pain and comorbid medication/drug dependence. It was the commitment to state of the art treatment for this patient population that led to the creation of Casa Palmera’s newest clinical program.

“Share the Risk” Model

Dr. Joseph Shurman, MD, nationally recognized specialist in Pain Medicine, first developed the “Share the Risk” model’s basic principles in January of 2002 in San Diego, California. Interdisciplinary teams have been shown to improve patient care in a number of complex clinical situations and also deliver the best possible treatment to this challenging population. The “Share the Risk” fundamental premise is that no physician—no matter how well educated, confident, compassionate, committed or meticulous—can adequately meet all the needs of patients with chronic and intractable pain and chemical dependency. (Read an update to this article.)

Instead, the model calls for an interdisciplinary team approach to treat this special needs pain patient. Share the Risk was initiated when, in early 2000, physicians prescribing opioids for pain relief, particularly nonmalignant pain, were being sued for giving too little, giving too much, or even for “murder.”1,2 Several publications had made the statement that up to “seventeen percent (17%) of doctors who treat pain were investigated each year, and that a pain treating physician was arrested and charged criminally somewhere in the United States every day.”3,4 Although these statements are debated, depending on whom you speak to, the model was started in response to this problem. At the same time, the program—using multiple specialists—was extremely beneficial for the patient since it decreased the overall risks of treatment. The core of the model is elaborated through the five P’s as follows:

  • P1-Professional Pain Management Delivery System
  • P2-Patient Advocacy and Education Support
  • P3-Paperwork
  • P4-Precautions
  • P5-Physical Therapy and Integrated Techniques.

The “Share the Risk” model includes pain specialists, psychologists/psychiatrists, addiction specialists, pharmacists, and other agents and organizations. This professional pain management delivery system was one of the first in the country to:

  • involve an addictionologist early on with patients taking moderate to high doses of opioids for nonmalignant pain;
  • involve a psychologist or psychiatrist, because the risk of suicide can be up to three times higher in these patients5;
  • utilize patient advocacy and educational support;
  • work with the DEA;
  • focus on documentation and record keeping precautions; and
  • employ sleep disorder consultations and cognitive testing for driving safety in conjunction with the use of physical therapy and complementary techniques.6

“Share the Risk” was a major catalyst for the development of an educational program called “Emerging Solutions in Pain.” Emerging Solutions developed a comprehensive design to assist pain management physicians in overcoming the challenges they encounter by providing practical tools and resources. It has an advisory board of national leaders in pain management and addiction. The program includes a “tool kit” and a website (emergingsolutionsinpain.com), and is especially valuable for physicians who do not have access to other specialists.7

The ultimate goal of the “Share the Risk” model was to bring together various resources among clinicians and the community in order to provide the best overall care for the chronic pain patient. In applying the “Share the Risk” model, both the clinician and patient benefit. Thorough documentation, outside con-sultation, and urine screening all reduce risk in the clinical encounter. The “Share the Risk” model has continued to expand and to offer assistance to both physicians and patients in the treatment of chronic pain and chemical dependency.

The Best of Eastern and Western Medicine Plus Neuroscience

Some of the significant problems pain specialists have to deal with are the noncompliant patient, the addicted individual, or the patient who desires to rotate off opioids. These issues have 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, other drugs and/or alcohol, utilizing the “Share the Risk” theme of an interdisciplinary and holistic approach. The team includes psychiatrists, psychologists, addictionologists, internists, pri-mary care physicians, anesthesiologists, nutritionists, acupuncturists, physical therapists, music/art and massage therapists, biofeedback, laser therapy, and more.

The “Share the Risk” group has had great difficulty in adequately serving the noncompliant patient, the drug dependent patient who wants to get off opioids and/or benzodiazepines, or the patient who turns up with an abnormal urine screen for illicit drugs. Where does one send such a patient? Pain specialists have had great difficulty with referrals to some of the major addiction centers because of the dilemma of helping these patients manage their inevitable post-detox pain. This was the major problem with all the in-house pain centers that evolved during the 1970’s, where people were hospitalized for many weeks and detoxified, but still left with inadequately or under-treated pain. Over time, most of these centers closed. This unacceptable situation further motivated the development of the Casa Palmera concept, that of the “integrated” treatment of chronic pain and co-occurring drug dependence. Casa hopes to take this model and expand it throughout the United States in order to help educate physicians, health care professionals, and patients.

Casa Palmera Team Approach

On a continuum of team models (see Figure 1), Casa Palmera utilizes an integrated interdisciplinary treatment team approach. The following descriptions of some notable team models are presented for comparison.

Multidisciplinary Team Model

  • Patient care is planned and managed by a team leader.
  • Leadership is often hierarchical.
  • One or two individuals direct the services of a range of team members.
  • Team members have individual goals and make independent decisions.

Interdisciplinary Team Model

  • Team members work together toward a common goal.
  • Make collective therapeutic decisions.
  • Communicate and consult with other team members, in face to face meetings.
  • Teams possess a combination of skills that no single individual demonstrates.
  • Team is able to achieve more than the sum of the individuals involved.

Integrative Model

  • When one clinician or a team of clinicians coordinates care across multiple disciplines, delivery systems, and/or treatment programs.
  • Service integration can improve the efficiency of heath care delivery systems and produces better results, particularly for individuals with comorbid mental and substance use disorders or comorbid pain and addictive disorders.

Figure 1. Continuum of Team Models8

Key Staff

The following physician leaders at Casa Palmera helped guide the creation of these innovative treatment programs:

  • Joseph Shurman, MD, is Chairman of Pain Management at Scripps Hospital and now Chairman of the Pain Management Services Depart-ment at Casa Palmera and the founder of the “Share the Risk” model. He is also a board member of the Whittier Institute for Diabetes, with a strong interest in pain associated with diabetic neuropathy. He is a graduate of Temple University Medical School and did his anesthesiology residency at Harvard Medical School. He is one of the top pain specialists in his field and was voted by his peers as the “top pain doctor” (San Diego Medical Society).
  • Dr. David Bergman, MD, DLFAPA, is Casa Palmera’s Medical Director, a psychiatrist, and addiction medicine specialist. He is a Harvard Medical School graduate who has been involved in psychiatry and chemical dependency treatment for more than 40 years, and is an Associate Clinical Professor of Psychiatry at the University of California, San Diego. Dr. Bergman has stated that “nothing in medicine has been as satisfying to him than to have helped a person devastated by addictive illness achieve a successful and lasting recovery.” He is the author of “Kids on the Brink.”
  • Michael Lardon, MD, is the Chairman of the Eating Disorder Services and a sports medicine consultant. Dr. Lardon has a degree in psychology with honors from Stanford University and a medical degree from the University of Texas. He completed an internship in internal medicine at UCLA and a psychiatric residency and subsequent fellowship in psychopharmacology and psychobiology at UCSD. Dr. Lardon won the Judd Research Award at UCSD for brain research and athletic peak performance. He is also an Associate Clinical Professor at UCSD and consulting psychiatrist for the United States Olympic Teams. He has extensive experience in the treatment of eating disorders and is a nationally recognized speaker on various topics including eating disorders, sports psychiatry, depression and anxiety disorders. He is the author of “Finding Your Zone.”

Casa Palmera also employs a major consultant, Dr. George Koob, in the new area of psychoneuropharmacology. Dr. Koob is Professor and Chair of the Committee on the Neurobiology of Addictive Disorders at The Scripps Research Institute, co-Director of the Pearson Center for Alcoholism and Addiction Research and Adjunct Professor of Psychology, Psychiatry and Pharmacy at the University of California San Diego. Dr. Koob has published over six hundred and seventy scientific papers and has received continuous funding for his research from the National Institutes of Health, including the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute on Drug Abuse (NIDA). He has trained ten predoctoral and sixty-four postdoctoral fellows. Dr. Koob has won several excellence in research awards. He published a landmark book in 2006 with his colleague Dr. Michel Le Moal entitled: “Neurobiology of Addiction” (Academic Press-Elsevier, Amsterdam).

Sixth P Added for “Place”

The “Share the Risk” model had five P’s for healing and, at Casa Palmera, we’ve added a sixth P, “Place.” In other words: Casa Palmera’s therapeutic environment. In keeping with eco-therapy and a healing environment, Casa Palmera is a serene and soothing setting, where a team of caring and knowledgeable professionals is dedicated to helping one achieve a healthy, happy, and productive life free from disabling physical, emotional, and/or spiritual pain. The treatment center combines approaches from both Eastern and Western medicine, complemented by many alternative modalities —from acupuncture to massage therapy. It also offers access to Scripps Hospital, where Dr. Joseph Shurman is Chairman of Pain Management and where Dr. Tom Foster, a primary care physician at Casa Palmera, is Chairman of Family Practice, as well as to UCSD, where Drs. Bergman and Lardon are Clinical Faculty members.

Seventh P Added for “Psycho-neuropharmacology” Science

Casa Palmera recently added yet a seventh P, “Psychoneuropharmacology” Science. In that regard, Dr. George Koob—one of the foremost neuroscientists in the world of chemical dependency, stress, pain, as well as Editor in Chief of the Journal of Addiction Medicine—educates staff and lectures to patients. Dr. Koob helps make the science relevant and understandable. Dr Koob provides information to patients on the latest advances in our understanding of the changes in the brain associated with the development of addiction, how the therapeutic process returns the brain to normalcy, and how recognition of the nature of compromised brain function at different stages of the addiction cycle can aid the therapeutic process.

Individualized Treatment

All treatment is uniquely individualized to the particular patient and is tailored to use a minimal amount of medications to achieve pain control while utilizing alternative techniques wherever possible. Casa’s clinical treatment philosophy approaches the treatment of pain patients with a comprehensive understanding of the variable effects and manifestations that substances may have on a pain patient. Care must be taken with pain patients to properly assess for and differentiate when possible between:

  • Abuse
  • Dependence
  • Pseudoaddiction (“Aberrant Drug Behaviors”)
  • Addiction
  • Tolerance
  • Withdrawal

Dependence does not necessarily equal addiction. Tolerance and with-drawal are universal with prolonged opioid treatment, therefore the presence of repetitive self-endangering and/or destructive behaviors are needed to diagnose addiction.

Addiction versus pseudoaddiction. “The key with pseudoaddiction is that with proper pain management, retrospectively, the patient’s behavior normalizes. However, with the disease of addiction, in the genetically sensitive individual, behavior deteriorates with pain management.”9

Addiction, psychopathology and pain are related, co-occurring, interdependent and compounding brain diseases (see Figure 2). In addition, all areas of illness, including any medical co-morbidity must simultaneously be managed in the pain patient. Successful management of one without the others will result in failure in all.10 In addition it is important to avoid treatment of one illness that is likely to exacerbate another.

Figure 2. Interaction of Addiction, Pain, Psychiatric, and Medical Comorbidities.

Integrated, Comprehensive and Holistic Treatment

Casa’s approach leads to successful recovery from pain by incorporating health and healing in all areas of an individual’s life (see Table 1).

Table 1. Health and Healing from an Integrated, Comprehensive, Holistic Approach
Physical Address underlying medical illnesses/ medication issues Improve nutrition, strength, health Decrease physical pain
Neurological/ Behavioral Improve brain function Improve cognitive function, memory Decrease perceived pain
Emotional Decrease anxiety, depression Improved self esteem Decrease emotional pain
Social/ Psychological Improve relationships with family and friends Lifestyle redesign and direction Sense of well-being
Spiritual Importance of other than self Possibility of “higher power(s)” Increased spiritual sense

Because Casa represents the “state of the art,” there have been very few outcomes studies in such treatment centers. Hence our plan is to do such studies with the help of Dr. Koob, our Director of Neuroscience. Dr. Koob will be establishing objective outcome measures resulting from treatment at Casa Palmera utilizing novel and validated approaches in follow up of former patients.

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, general function, and well-being. We have instituted an American Society of Anesthesiology Outcome questionnaire with our patients (see Figure 3).

Figure 3. American Society of Anesthesiology Outcome Measures

Last updated on: March 4, 2018
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