Antonio Quidgley-Nevares, MD Associate Professor Eastern
Virginia Medical School Physical Medicine & Rehabilitation
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Objectives Define pain Review pharmacologic management options
for chronic pain The opioid treatment agreement Documentation and
monitoring
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How much opioids are consumed in the U.S.?
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Opioid Statistics USA is 4.6% of world population USA consumes
80% of the worlds opioids USA consumes 99% of the worlds
hydrocodone This statistic is very interesting Why? Its
complicated
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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.
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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.
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Pain Epidemiology - U.S. Estimates CHRONIC PAIN MIXED
neuropathic and nociceptive Cancer pain Low Back pain CRPS
neuropathic Diabetic neuropathy (DN) post-herpetic neuralgia (PHN)
radiculopathy (RADIC) Fibromyalgia nociceptive Osteoarthritis
rheumatoid arthritis IBS Pancreatitis bladder pain Non-cardiac
chest pain abdominal pain syndrome visceral 25.1 mil (US) 25.6 mil
(US)9.1 mil (US) 17.5 mil (US) 77.3 mil (US) Mixed agents will
influence > 68.2 mil patients
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What is pain?
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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
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Pain Definitions In reality, pain is whatever the patient says
it is. It is always relative and highly subjective.
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Pain Definitions Acute pain = Strictly speaking, pain lasting
less than 3- 6 months. Or : Pain occurring during a period of known
injury.
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Pain Definitions Chronic pain = Pain lasting more than 3-6
months. Or : Pain lasting beyond the period of expected recovery
from an injury.
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Should we treat or manage every patient that reports pain?
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the ethical obligation to manage pain and relieve the patients
suffering is at the core of the health care professionals
commitment Carr et al. US Dept of Health and Human Services
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We ARE obligated to treat pain But Not obligated to treat on
the first visit Not obligated to treat in the absence of adequate
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
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Pain Assessment Onset Location/Site Temporal profile Quality
Unpleasantness Distress Associated Symptoms Psychological
Aggravating Alleviating Impact on Function Habits Coping
Skills
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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 patients condition, co-morbid
conditions.
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Pain Assessment Review prior work-up to assess for accuracy and
completeness. Does anything need to be repeated? Are prior
diagnoses confirmed by the work- up? Complete as needed: 1. Imaging
2. Electrodiagnostic Evaluation 3. Nuclear Medicine 4. Chemistries
5. Consultation Psych, Surgical, Rheum. 6. Diagnostic blocks
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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
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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 childs perspective Do not compare one patients VAS with
another patient
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VAS
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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.
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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.
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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.
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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.
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Assess for addiction risk
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Tools of the Pain Trade Non invasive Exercise Cognitive
Behavioral 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
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
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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: Diphenylheptanes Representing drug: Methadone Similar
drugs: Propoxyphene (Darvon)
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Tramadol Partial mu agonist, serotonin and norepinephrine
reuptake inhibitor Risk for seizures May be helpful for neuropathic
pain due to multiple areas of action.
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Tapentadol Partial mu agonist, norepinephrine reuptake
inhibitor Schedule II opioid May be helpful for neuropathic pain
due to multiple areas of action.
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Opioid side effects Constipation* Respiratory depression
Drowsiness Itching Confusion *most common, mu binding in GI track,
no tolerance
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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
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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
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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
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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
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PNS Na + TTXr TTXs Spinalcord Brain Descending inhibition Ca ++
: NMDA : PGE: Subs P Mechanistic Approach to Pain Treatment Central
sensitization Peripheral sensitization NE/5HT GABA Opioid receptors
PGEr Na+ TTXr NK-1 VR-1 NGF Opioid r NEr Terminal
Treatment of Pain 2. Physical/Occupational Therapy
(Outpatient/Inpatient/Home Health) Bracing, orthoses Modalities
TENS Stabilization active and passive Strengthening Biomechanical
re-education Aquatics Home exercises
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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
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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
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Treatment of Pain 5. Pain Psychology Pain is not equivalent to
just nociception
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Treatment of Pain
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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
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Treatment of Pain 6. Homeopathic/Adjunctive Acupuncture
Chiropractic/Osteopathic manip. 7. Weight Control and Activity 8.
Education
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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
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Documentation Proper diagnosis Goals of treatment Increase
function Palliative care Increase social interactions Proper use of
medications 4 As Activity Analgesia Adverse reactions Falls?
Problems driving? Aberrant behavior
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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
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Monitoring Random pill counts Prescription monitoring programs
Urine drug screens I know my patients has been disproven as a way
of monitoring
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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
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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 Cancer pain Hospice/Palliative
care
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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.
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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.
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Brief points and examples Strictly for my own use. Never be
given or sold to others because it may endanger that persons 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.
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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.
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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.
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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
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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.
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There are several good examples of opioid treatment agreements
to be found on the internet.
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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)
