Transcript Pain Medicine

Antonio Quidgley-Nevares, MD
Associate Professor
Eastern Virginia Medical School
Physical Medicine & Rehabilitation
Objectives
 Define pain
 Review pharmacologic management options for
chronic pain
 The opioid treatment agreement
 Documentation and monitoring
 How much opioids are consumed in the U.S.?
Opioid Statistics
 USA is 4.6% of world population
 USA consumes 80% of the world’s opioids
 USA consumes 99% of the world’s hydrocodone
 This statistic is very interesting
 Why? It’s complicated
Pain Epidemiology in The United
States
1. Pain is the most common reason a person seeks care
from a physician.
2. Ninety percent of all Americans regularly
experience acute or chronic pain.
3. One third of all Americans will experience chronic
pain during their lifetime.
Pain Epidemiology in The United
States
 The economic impact of pain on the healthcare
system and society is enormous.
 Chronic pain accounts for 90 million physician
visits annually, 14% of all prescriptions, and more
than 50 million lost workdays per year.
 Total annual healthcare costs are estimated in
excess of 100 billion dollars.
Pain Epidemiology - U.S. Estimates
CHRONIC PAIN
77.3 mil (US)
nociceptive
neuropathic
25.6 mil (US)
17.5 mil (US)
Diabetic neuropathy (DN)
post-herpetic neuralgia (PHN)
radiculopathy (RADIC)
Fibromyalgia
Osteoarthritis
rheumatoid arthritis
visceral
9.1 mil (US)
IBS
Pancreatitis
bladder pain
Non-cardiac chest pain
abdominal pain syndrome
MIXED
neuropathic and nociceptive
25.1 mil (US)
Cancer pain
Low Back pain
CRPS
Mixed agents will influence >
68.2 mil patients
 What is pain?
Pain Definitions
 Pain = An unpleasant sensory and emotional
experience associated with actual or potential tissue
damage, or described in terms of such damage.
International Association for the Study of Pain (IASP) – Committee on
Taxonomy 1979
Pain Definitions
In reality, pain is whatever the patient says it is.
It is always relative and highly subjective.
Pain Definitions
 Acute pain = Strictly speaking, pain lasting less than 3-
6 months.
Or : Pain occurring during a period of known injury.
Pain Definitions
 Chronic pain = Pain lasting more than 3-6 months.
Or : Pain lasting beyond the period of expected recovery
from an injury.
 Should we treat or manage every patient that reports
pain?
“…the ethical obligation to manage
pain and relieve the patient’s
suffering is at the core of the health
care professional’s commitment”
 Carr et al. US Dept of Health and Human Services
We ARE obligated to treat pain
But…
 Not obligated to treat on the first visit
 Not obligated to treat in the absence of adequate
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diagnostic workup (physical/psychological)
Not obligated to treat with opioids
Not obligated to treat as patient specifies
Not obligated to treat using only pharmacology
Not obligated to treat without requiring patient
involvement and responsibility
Pain Assessment
 Onset
 Psychological
 Location/Site
 Aggravating
 Temporal profile
 Alleviating
 Quality
 Impact on Function
 Unpleasantness
 Habits
 Distress
 Coping Skills
 Associated Symptoms
Pain Assessment
 In addition to a complete history, information
regarding all prior therapeutic measures attempted is
important.
 These may include: medication (by class), injections,
neurolytics, surgeries, physical/occupational therapy,
behavioral approaches, chiropractic care,
acupuncture, TENS, herbal remedies.
 If something has not worked previously, ask why.
Treatment failures occur for a number of reasons,
including: failure to stay on a drug due to tolerable
side-effects, improper dosing, improperly targeted
anatomy, change in the patient’s condition, co-morbid
conditions.
Pain Assessment
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Review prior work-up to assess for accuracy
and completeness.
 Does anything need to be repeated?
 Are prior diagnoses confirmed by the workup?
 Complete as needed:
1. Imaging
2. Electrodiagnostic Evaluation
3. Nuclear Medicine
4. Chemistries
5. Consultation – Psych, Surgical, Rheum.
6. Diagnostic blocks
Pain Assessment
 Complete prior:
medical/surgical/social/family/occupational
histories.
 Physical Exam should be complete, but
targeted to systems of complaint. Usually this
means functional musculoskeletal and
neurological exams are dominant.
 Localization of pain by region and down to
point of maximal tenderness.
 The exam starts when you first see the patient.
All observational information is important.
 Watch for inconsistencies
Assessment of Pain
 Visual Analog Scale
 Vertical or horizontal line with verbal, facial or
numerical continuum
 5 years or older
 Reliable and valid
 Intervals on numerical scales may not be equal from a
child’s perspective
 Do not compare one patient’s VAS with another patient
VAS
Treatment of Pain
 Many patients come to pain center/clinics with
misconceptions and unrealistic expectations. These
should be addressed fairly early on, without alienating
the patient.
 The primary goal of treatment must be based on
improving function, not on reducing pain.
 Most people will increase their activity level until
they are essentially in the same level of pain.
Treatment of Pain
 Pain Management centers and clinics are not able to
“cure” pain – Patients often do not understand this.
 Approach pain reduction by setting realistic goals.
 50% reduction of daily pain reduction represents a
major improvement.
Treatment of Pain
 Use of a multidisciplinary approach is resource
intensive, therefore it must be planned and make
sense for a given patient. The plan should evolve as
the patient makes gains.
 Having said this, patients should not be able to pick
and choose their most desired portions of the
program. For many this results in only passive
participation, which may be why prior attempts to
treat them have failed.
 Patients must recognize the importance of being
invested in their own recovery.
Treatment of Pain
 Failure to treat co-morbid medical and psychiatric
conditions makes the task of the pain center/clinic
difficult, if not impossible.
 A history of addiction or drug seeking behavior should be
investigated and addressed. This type of patient may be
more appropriate for a different clinic.
 Compliance with the clinic policies is very important.
Assess for addiction risk
Tools of the Pain Trade
 Non invasive
 Exercise
 Cognitive Behavioral
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Therapy
Physical and
Occupational Therapy
Chiropractic
Nutritional Therapy
Massage Therapy
Psychotherapy
Alternative/complementa
ry therapies
 Invasive
 Pharmacologic pain
meds
 Anesthetic blocking
agents
 Neuromodulatory
techniques
 Surgery
 Neuroablation
Treatment of Pain
1. Pharmacology – Drug Classes
A.Opiates
1. Methadone
2. Morphine, Fentanyl, Demerol, Oxycodone, Hydromorphone
3. Darvon, Ultram
B.Non-Opiates
1. Tricyclics and atypical antidepressants
2. NSAIDS – COX1, COX2
3. Steroids
4. Antiepileptics
5. Muscle relaxants
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Alpha agonists
Benzodiazepines
Opioid Analgesics
 Bind to mu, kappa, delta opioid receptors
 Inhibit transmission of nociceptive input periphery to
spinal cord, activate descending inhibitory pathways,
alters limbic system
Opioid Analgesics
 Most effective are full mu agonist - do not exhibit
ceiling effect
 Avoid partial and mixed due to possible ceiling
 Often cross sensitivity within a subclass but patient
may respond differently to another subclass
Opioids: Phenanthrenes
 Representative drug:
 Nalbuphine (Nubaine,m)
Morphine
 Similar drugs:
 Butorphanol (Stadol,m)
 Buprenorphine (Bupronex,p)
 Codeine
 Hydrocodone
 Oxycodone
 Hydromorphone
 Levorphanol
 Oxymorphone
 Heroin
 Naloxone
 p=partial agonist
 m=mixed
Opioids: Benzomorphans
 Representative drug: Pentazocine (Talwin, m)
 Similar drugs:
 Diphenoxylate (lomotil)
 Loperamide
Opioids: Phenylpiperidines
 Representative drug: Meperidine (Demerol)
 Similar drugs:
 Fentanyl
 Sufentanyl
 Alfentanyl
 Remifentanyl
Opioids: Diphenylheptanes
 Representing drug: Methadone
 Similar drugs:
 Propoxyphene (Darvon)
Tramadol
 Partial mu agonist, serotonin and norepinephrine
reuptake inhibitor
 Risk for seizures
 May be helpful for neuropathic pain due to multiple
areas of action.
Tapentadol
 Partial mu agonist, norepinephrine reuptake inhibitor
 Schedule II opioid
 May be helpful for neuropathic pain due to multiple
areas of action.
Opioid side effects
 Constipation*
 Respiratory depression
 Drowsiness
 Itching
 Confusion
 *most common, mu binding in GI track, no
tolerance
Non-opioids: Acetaminophen
 No platelet activity, no gastric mucosa, no anti-
inflammatory effects
 Similar analgesic and anti-pyretic to NSAIDs
 Dose limited to 4000 mg/day – often not noticed in
combo meds
 Careful with Liver and warfarin
NSAIDs
 Inhibition of cycloxygenase inhibiting formation
of prostaglandin / leukotrienes -> sensitize
peripheral nerves and central sensory neurons
 Have ceiling dose (increase in side effects without
additional analgesia)
 Antipyretic
 No physical or psychological dependence
Adjuvants
 TCA, SSRI and SNRI– neuropathic pain and
concomitant depression
 Block reuptake of monoaminergic neurotransmitters
(i.e. serotonin...) in CNS.
 Descending pain modulatory pathways use these
neurotransmitters.
 Anticonvulsants – decrease ectopic spontaneous firing
of sensory neurons associated with neuropathic pain
Adjuvants
 Muscle relaxants – for relief of acute muscle injury
 Soma – high potential of addiction
 BNZ – acute anxiety or spasms, not analgesics
 Lidoderm – neuropathic pain
 Calcitonin – pain of osteosporotic fracture
 Baclofen – spasm / spasticity
 Capsaicin – Depletes Substance P
Mechanistic Approach to Pain Treatment
Descending inhibition
Brain
NE/5HT GABA
Opioid receptors
Peripheral sensitization
Terminal
PGEr
Na+ TTXr
NK-1
VR-1
NGF
Opioid r
NEr
PNS
Na+ TTXr
TTXs
Spinal
cord
Central sensitization
Ca++ :
NMDA:
PGE:
Subs P
Mechanistic Approach to Pain Treatment
Descending inhibition
Brain
NE/5HT GABA
Opioid receptors
TCAs
SNRIs
Opioids
Tramadol
Clonidine
Baclofen
Clonazepam
Peripheral sensitization
Terminal
PGEr
Na+ TTXr
NK-1
VR-1
NGF
Opioid r
NEr
PNS
Na+ TTXr
Spinal
cord
TTXs
NSAIDs
COX-2i
Opioids
Capsaicin
Clonidine
TCA
CBZ OXC
TPM LTG
Mexiletine
Lidocaine
Central sensitization
Ca++ : GBP; OXC Conotoxin
NMDA: Ketamine, TPM
PGE:
Dextromethorphan
Methadone
NSAIDs / COX-2
Mechanistic Approach to Pain Treatment
Descending inhibition
Disease
Modifiers
Brain
NE/5HT GABA
Opioid receptors
TCAs
SNRIs
Opioids
Tramadol
Clonidine
Baclofen
Clonazepam
Peripheral sensitization
Terminal
PGEr
Na+ TTXr
NK-1
VR-1
NGF
Opioid r
NEr
PNS
Na+ TTXr
Spinal
cord
TTXs
NSAIDs
COX-2i
Opioids
Capsaicin
Clonidine
TCA CBZ
OXC TPM
LTG
Mexiletine
Lidocaine
Central sensitization
Ca++ : GBP; OXC Conotoxin
NMDA: Ketamine, TPM
PGE:
Dextromethorphan
Methadone
NSAIDs / COX-2
Treatment of Pain
2. Physical/Occupational Therapy
(Outpatient/Inpatient/Home Health)
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Bracing, orthoses
Modalities
TENS
Stabilization – active and passive
Strengthening
Biomechanical re-education
Aquatics
Home exercises
Treatment of Pain
3. Interventions
1. Epidural Steroid Injection
2. Neurolytic Procedures
3. Radio frequency vs Chemical
4. Peripheral Nerve Blocks
5. Therapeutic vs Diagnostic
6. Autonomic vs. somatic
Treatment of Pain
4. Implanted Therapeutics
a. Spinal Cord Stimulators
Indicated for chronic pain of the limb or trunk
Electrical stimulation of the dorsal columns
b. Intrathecal Pumps
Intrathecal delivery of medications
Indicated for chronic pain and spasticity not
controlled with PO meds
IT opioids are 1/300 of the PO dose
Treatment of Pain
5. Pain Psychology
Pain is not equivalent to just nociception
Treatment of Pain
Mood and Pain
 Develop a trusting treatment relationship
 Educate the patient and family
 Monitor for treatment adherence
 Multiple meds can be used
 Cognitive Behavioral Therapy
Treatment of Pain
6. Homeopathic/Adjunctive
Acupuncture
Chiropractic/Osteopathic manip.
7. Weight Control and Activity
8. Education
Educate the Patient
 Educate the patient and the family on the nature
and prognosis of their condition.
 On the treatment
 On the importance of function
 On the possibility of acute exacerbations and how
to address them
 Not just by popping a pill
 On the importance of their active participation in
their recovery
Documentation
 Proper diagnosis
 Goals of treatment
 Increase function
 Palliative care
 Increase social interactions
 Proper use of medications
 4 As
 Activity
 Analgesia
 Adverse reactions
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Falls? Problems driving?
 Aberrant behavior
Documentation
 Monitoring
 Compliance of diagnostic and treatment plans
 Opioid treatment agreement and consent
 Outside records
 Preferably from the source and not the patient
 Make a copy of valid state issued ID with current
address
Monitoring
 Random pill counts
 Prescription monitoring programs
 Urine drug screens
 “I know my patients” has been disproven as a way of
monitoring
Pain Management Protocol
 Familiarize with the management options
 Decide what you are comfortable with
 Write down the protocol
 Do not deviate from the protocol
 Do not wait until you are uncomfortable or reached
the limits of the protocol before referring out
Special populations
 There are special populations you may feel the need to
deviate from the protocol
 You must document why you are making a therapeutic
exception
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Cancer pain
Hospice/Palliative care
Opioid treatment agreement and
consent form
 Some patients feel they are being treated like criminals
due to the opioid treatment agreement
 “The purpose of this agreement is to give you
information about the medications you will be taking
for pain management and to assure that you and your
physician/health care provider comply with all state and
federal regulations concerning the prescribing of
controlled substances.”
Brief points and examples
 I am responsible for my pain medications.
 I will not request or accept controlled substance
medication from any other physician or individual
 There are side effects with opioid therapy
 It is my responsibility to notify my physician for any side
effects that continue or are severe (i.e., sedation,
confusion).
 I am also responsible for notifying my pain physician
immediately if I need to visit another physician or need to
visit an emergency room due to pain, or if I become
pregnant.
Brief points and examples
 Strictly for my own use. Never be given or sold to others
because it may endanger that person’s health and is
against the law.
 I should inform my physician of all medications I am
taking, including herbal remedies.
 I understand that opioid prescriptions will not be mailed
 Any evidence of drug hoarding, acquisition of any opioid
medication or adjunctive analgesia from other physicians
(which includes emergency rooms), uncontrolled dose
escalation or reduction, loss of prescriptions, or failure to
follow the agreement may result in termination of the
doctor/patient relationship.
Brief points and examples
 Not use any illicit substances, such as cocaine,
marijuana
 Not use alcohol
 While physical dependence is to be expected after
long-term use of opioids, signs of addiction, abuse,
or misuse shall prompt the need for substance
dependence treatment as well as weaning and
detoxification from the opioids.
 there is no improvement in my daily function or
quality of life from the controlled substance, my
opioids may be discontinued.
Brief points and examples
 perform random or unannounced urine drug testing.
 I agree to allow my physician to contact any health care
professional, family member, pharmacy, legal
authority, or regulatory agency to obtain or provide
information about your care or actions if the physician
feels it is necessary.
Brief points and examples
 responsible for keeping my pain medications in a safe
and secure place
 Refills will not be made as an “emergency”, such as on
Friday afternoon because I suddenly realize I will “run
out tomorrow”
Brief points and examples
 I understand that non-compliance with the above
conditions may result in a re-evaluation of my
treatment plan and discontinuation of opioid therapy.
I may be gradually taken off these medications, or even
discharged from the clinic.
 There are several good examples of opioid treatment
agreements to be found on the internet.
Thank You !
Rich the treasure, Sweet the pleasure
Sweet is pleasure after pain
For all the happiness man can gain
Is not in pleasure, but in rest from pain.
John Dryden (1631-1700)