When Chronic Pain When Chronic Pain Comes KnockingComes Knocking

Kenneth R. Goldschneider, MD, FAAPKenneth R. Goldschneider, MD, FAAP

Director, Division of Pain ManagementDirector, Division of Pain Management

Cincinnati Children’s HospitalCincinnati Children’s Hospital

Medical CenterMedical Center

The Chronic Pain Patient Arrives…The Chronic Pain Patient Arrives…

DisclosureDisclosure

2006 Pfizer Pain Visiting professorship2006 Pfizer Pain Visiting professorship No promotional activityNo promotional activity

Case #1Case #1

12y.o. female presents with 3 months of 12y.o. female presents with 3 months of severe, constant abdominal pain, epigastric, severe, constant abdominal pain, epigastric, sometimes wakes her, interferes with school. sometimes wakes her, interferes with school. Looks a little uncomfortable. VSS, abd Looks a little uncomfortable. VSS, abd diffusely tender, o/w (-)diffusely tender, o/w (-)

PMHx: headaches 1-2/week, o/w (-)PMHx: headaches 1-2/week, o/w (-) Meds: PPI, MVits; NKAMeds: PPI, MVits; NKA FHx: Aunt with “spastic colon”FHx: Aunt with “spastic colon”

Functional Gastrointestinal Functional Gastrointestinal Disorders (FGIDs)Disorders (FGIDs)

Pain anywhere in abdomenPain anywhere in abdomen Usually constant or frequent, may waken from Usually constant or frequent, may waken from

sleep. Many descriptors.sleep. Many descriptors. Exam non-focalExam non-focal Often start with infectious or stressful eventOften start with infectious or stressful event Stress exacerbatesStress exacerbates

Alarm SymptomsAlarm Symptoms

Weight loss, vomiting, focal exam or Weight loss, vomiting, focal exam or complaint, decelerating growth curve, GI complaint, decelerating growth curve, GI blood loss, dysphagia, fever, arthritis, delayed blood loss, dysphagia, fever, arthritis, delayed puberty, perirectal disease; FHx of IBD, Celiac puberty, perirectal disease; FHx of IBD, Celiac Dz; Eosinophilic DzDz; Eosinophilic Dz

Pediatric FGIDsPediatric FGIDs

Functional DyspepsiaFunctional Dyspepsia Irritable Bowel SyndromeIrritable Bowel Syndrome Abdominal MigraineAbdominal Migraine Childhood Functional Abdominal Pain+/- Childhood Functional Abdominal Pain+/-

SyndromeSyndrome Functional ConstipationFunctional Constipation Nonretentive Fecal IncontinenceNonretentive Fecal Incontinence

Gastroenterology 2006; Vol 130:1537Gastroenterology 2006; Vol 130:1537

They’ll fool ya’They’ll fool ya’

Myofascial painMyofascial pain Intercostal neuralgiaIntercostal neuralgia Slipping rib syndromeSlipping rib syndrome Umbilical herniaUmbilical hernia XyphoidalgiaXyphoidalgia

Treatment of FGIDsTreatment of FGIDs

Behavioral MedicineBehavioral Medicine Biofeedback, coping, lifestyle adaptations, Biofeedback, coping, lifestyle adaptations,

parental coachingparental coaching Avoid obvious triggersAvoid obvious triggers

Fatty foods, NSAIDs, prolonged NPOFatty foods, NSAIDs, prolonged NPO MedicationMedication

TCAs, antispasmodics, PPIs, TCAs, antispasmodics, PPIs, anticonvulsants, peppermint oilanticonvulsants, peppermint oil

Case #2Case #2

14 y.o. WF presents with a two week history 14 y.o. WF presents with a two week history of burning foot pain that started after twisting of burning foot pain that started after twisting her ankle playing soccer. The foot is cyanotic, her ankle playing soccer. The foot is cyanotic, a bit puffy, and she won’t let you near it. a bit puffy, and she won’t let you near it. Straight-A student, good family.Straight-A student, good family.

PMHx (-); Meds (-); NKA; FHx (-)PMHx (-); Meds (-); NKA; FHx (-)

CRPS Type ICRPS Type I

FormerlyFormerly::

Reflex Sympathetic DystrophyReflex Sympathetic Dystrophy

AlgodystrophyAlgodystrophy

AlgoneurodystrophyAlgoneurodystrophy

Sudek’s AtrophySudek’s Atrophy

Reflex Neurovascular DystrophyReflex Neurovascular Dystrophy

OsteodystrophyOsteodystrophy

CRPS Type I: DiagnosisCRPS Type I: Diagnosis1. Develops after initiating noxious event1. Develops after initiating noxious event2. Spontaneous pain 2. Spontaneous pain oror allodynia occurs allodynia occurs

not necessarily dermatomalnot necessarily dermatomal disproportionate to inciting eventdisproportionate to inciting event

3. Evidence 3. Evidence oror history of: history of: edemaedema sudomotor abnormalitysudomotor abnormality skin blood flow abnormalityskin blood flow abnormality

4. Excluded by existence of conditions otherwise 4. Excluded by existence of conditions otherwise accounting for degree of pain and dysfunctionaccounting for degree of pain and dysfunction

RSD: Stages (?)RSD: Stages (?)

1. Acute: weeks to months1. Acute: weeks to months warm, dry, most warm, dry, most

responsive to treatmentresponsive to treatment

2. Dystrophic: months2. Dystrophic: months cool, cyanosis/mottling, cool, cyanosis/mottling,

sudomotor changessudomotor changes

3. Atrophic: years3. Atrophic: years cool, white, atrophy of cool, white, atrophy of

muscle/skinmuscle/skin

Traditional sequential stages Traditional sequential stages may not existmay not exist

May be subtypes:May be subtypes:− Limited vasomotor Limited vasomotor

predominantpredominant− Limited neuropathic Limited neuropathic

pain/sensorimotor pain/sensorimotor abnormalities predominantabnormalities predominant

− Florid presentation “Classic Florid presentation “Classic RSD”RSD”

Bruehle, et al 2002Bruehle, et al 2002

PresentationPresentation

Age range: 3 years and upAge range: 3 years and up

Female:Males = 5:1Female:Males = 5:1

Lower:Upper extremity ~5:1Lower:Upper extremity ~5:1

Sports-related injury: ~50%Sports-related injury: ~50%~85% involved in sports or dance~85% involved in sports or dance

Spontaneous painSpontaneous pain

Mechanical allodynia, edema, cold extremity, Mechanical allodynia, edema, cold extremity, cyanosiscyanosis

CRPS

Ancillary Findings Ancillary Findings CRPSCRPS

Bone scan: mixed results, not usefulBone scan: mixed results, not useful

Radiography: non-specific demineralizationRadiography: non-specific demineralization

Psychological profile: stress seems to exacerbatePsychological profile: stress seems to exacerbate

Wilder, et al, 1992

RecommendationsRecommendations

Central themeCentral theme: functional restoration: functional restoration

Objective and Reachable rehab goals essentialObjective and Reachable rehab goals essential

PT is keyPT is key

Psychological treatment essentialPsychological treatment essential

Neuropathic meds and occasional blockNeuropathic meds and occasional block

All components subserve the central themeAll components subserve the central theme

Self-management is emphasizedSelf-management is emphasized

OutcomeOutcome

Younger patients have Younger patients have milder coursemilder course less pain, higher less pain, higher

function, fewer function, fewer remaining autonomic remaining autonomic signs on follow-up, signs on follow-up, shorter duration, more shorter duration, more likely to return to sportslikely to return to sports

School days missedSchool days missed

in first year after injuryin first year after injury

No effect:No effect:

Duration of symptomsDuration of symptoms

GenderGender

Relation to sportsRelation to sports

ImmobilizationImmobilization

Number of SNSNumber of SNS

Wilder, et al, 1992

Figure from Reg Anes 23(3)

Case #2 againCase #2 again

Your CRPS patient returns a couple weeks Your CRPS patient returns a couple weeks later complaining of sleepiness, dizziness, dry later complaining of sleepiness, dizziness, dry mouth, and (per her mom) significant mood mouth, and (per her mom) significant mood swings. Her pain is a little better. HR: 115; swings. Her pain is a little better. HR: 115; mucous membranes dry, cerebellar signs OK; mucous membranes dry, cerebellar signs OK; no SI.no SI.

Rx: PT; Bmed; gabapentin; amitriptyline; Rx: PT; Bmed; gabapentin; amitriptyline; TENS unitTENS unit

Pain Meds?Pain Meds? AnticonvulsantsAnticonvulsants

Neuropathic, abdominal pain, headacheNeuropathic, abdominal pain, headache

AntidepressantsAntidepressants Neuopathic, headache, abdominal painNeuopathic, headache, abdominal pain

AntihypertensivesAntihypertensives Neuropathic pain, headacheNeuropathic pain, headache

Local AnestheticsLocal Anesthetics Neuropathic, back painNeuropathic, back pain

AnaesthesiaUK

Adjunct Meds

Anticonvulsant Side EffectsAnticonvulsant Side Effects

Minor:Minor: Sedation, dizziness, trouble with memory or Sedation, dizziness, trouble with memory or

concentration, extremity swellingconcentration, extremity swelling Major:Major:

Renal stones (Topiramate)Renal stones (Topiramate) Rash, Stevens-Johnson Syndrome (any)Rash, Stevens-Johnson Syndrome (any) Liver dysfunction (valproate, carbamazepine)Liver dysfunction (valproate, carbamazepine) Pancreatitis (valproate)Pancreatitis (valproate) Mood swings (gabapentin)Mood swings (gabapentin)

Antidepressant Side effectsAntidepressant Side effects

Minor:Minor: Sedation, mood swings, weight gain/loss, Sedation, mood swings, weight gain/loss,

insomnia, dry mouthinsomnia, dry mouth Major:Major:

Suicidal ideation (any, more prominent in SSRIs)Suicidal ideation (any, more prominent in SSRIs) Prolonged QT, Torsades de Pointe (tricyclics)Prolonged QT, Torsades de Pointe (tricyclics) SSRI interactions (CYP 2D6)SSRI interactions (CYP 2D6)

Topical TreatmentsTopical Treatments Lidocaine patch Lidocaine patch

(Lidoderm)(Lidoderm) Approved for PHNApproved for PHN Used for back pain, Used for back pain,

localized localized neuropathic painneuropathic pain

Systemic toxicity Systemic toxicity unlikelyunlikely

Clonidine patchClonidine patch CapsaicinCapsaicin

TENSTENS

Transcutaneous

Electrical Nerve Stimulation

Descending Inhibition

Small Fibers

Large Fibers

SG

Cognitive Control

Action

HerbsHerbs

Not your Parents’ Nuts and Not your Parents’ Nuts and BerriesBerries

Dietary Supplement and Health Dietary Supplement and Health Education Act, 1994Education Act, 1994

Created the dietary supplement Created the dietary supplement categorycategory

Herbs may claim effect but not Herbs may claim effect but not promise curepromise cure

No standard for qualityNo standard for quality

No proof needed of efficacy or safetyNo proof needed of efficacy or safety

DSHEA: ImplicationsDSHEA: Implications

Potency can varyPotency can vary

Contaminants may existContaminants may exist

Additives can be usedAdditives can be used No mention needed on the labelNo mention needed on the label Active ingredient need not be containedActive ingredient need not be contained One preparation may be vastly more or less One preparation may be vastly more or less

potent than anotherpotent than another

HerbsHerbs

May apple May apple (podophyllum): (podophyllum): recommended for recommended for pediatric pediatric constipation reliefconstipation relief

Library of Health, 1920Library of Health, 1920

VP-16 VP-16 (etoposide)(etoposide)

FoxgloveFoxglove As a poultice over the As a poultice over the

kidneys to induce kidneys to induce urination, over the joints urination, over the joints for inflammation, and as for inflammation, and as a tea, for heart failurea tea, for heart failure

DigitalisDigitalis

HerbsHerbs

Nicotinaea tabacum: Nicotinaea tabacum: touted for medicinal touted for medicinal purposespurposes

TobaccoTobacco

Indian Hemp: “used Indian Hemp: “used with benefit in with benefit in neuralgia”neuralgia”““for medicinal for medicinal purposes cannabis is purposes cannabis is used to quiet spasms used to quiet spasms and produce mental and produce mental quietude”quietude”

Library of Health, Library of Health, 19201920

So, what’s popular at the So, what’s popular at the herb shops?herb shops?

HerbsHerbs

ChamomileChamomile

(Chamaemelum nobile)(Chamaemelum nobile)

Mild sedative effect, antispasmodicMild sedative effect, antispasmodic

WorksWorks

Cross-allergenic with ragweedCross-allergenic with ragweed

Contains coumarinContains coumarin

Garlic Garlic

(Allium sativum)(Allium sativum)Treatment of familial Treatment of familial hyperlipidemia in children (8-18 hyperlipidemia in children (8-18 years)years)

Garlic oil or placebo TID x 8 Garlic oil or placebo TID x 8 weeksweeks

No effectNo effect

May increase bleeding risk May increase bleeding risk (PT/INR/platelet effects)(PT/INR/platelet effects)

HerbsHerbs

Ginger (Zingiber Ginger (Zingiber officinale)officinale)

Anti-nauseant and Anti-nauseant and antispasmodicantispasmodic

EffectiveEffective

May inhibit platelet May inhibit platelet functionfunction

May be mutagenicMay be mutagenic

Echinacea (Echinacea Echinacea (Echinacea purpurea)purpurea)

Immuno-stimulantImmuno-stimulant

Appears to workAppears to work

Hepatotoxic in long term use?Hepatotoxic in long term use?

Tachyphylaxis may developTachyphylaxis may develop

3 different species, effect?3 different species, effect?

HerbsHerbs

St. John’s WortSt. John’s Wort (Hyperecium (Hyperecium perforatum)perforatum)

Uses: depression, anxiety, Uses: depression, anxiety, sleep disorderssleep disorders

Adverse effects: Adverse effects: Photosensitivity, dry mouth, Photosensitivity, dry mouth, fatigue, dizziness, nausea, fatigue, dizziness, nausea, constipationconstipation

Drug interactions: Other Drug interactions: Other photo-sensitizers, SSRIs, photo-sensitizers, SSRIs, pseudoephedrine, MAOIspseudoephedrine, MAOIs

Feverfew Feverfew (Tanecetum parthenium)(Tanecetum parthenium)

Uses: migraine headachesUses: migraine headaches

Adverse effects: apthous Adverse effects: apthous ulcers, rebound headaches, ulcers, rebound headaches, GI irritability, increased GI irritability, increased bleeding riskbleeding risk

Drug interactions: NSAIDs, Drug interactions: NSAIDs, heparin, warfarin, inhibits heparin, warfarin, inhibits FeFe++++++ uptake uptake

Herb: risks and interactionsHerb: risks and interactions

BleedingBleedingChamomileChamomile

FeverfewFeverfew

GarlicGarlic

GinkgoGinkgo

GinsengGinseng

SedationSedationValerianValerian

Kava kavaKava kava

GE RefluxGE Reflux

PeppermintPeppermint

Case #3Case #3

17 y.o. with spondylolysis-based back pain 17 y.o. with spondylolysis-based back pain presents with increased pain, sweating, presents with increased pain, sweating, tachycardia. He is noted to be unpleasant to tachycardia. He is noted to be unpleasant to the RNs. He says he ran out of methadone a the RNs. He says he ran out of methadone a few days ago, and ran out of Percocet few days ago, and ran out of Percocet yesterday.yesterday.

Opioids in Pediatric Chronic Opioids in Pediatric Chronic PainPain

Few patientsFew patients Organic diagnosesOrganic diagnoses Stable regimens, once titratedStable regimens, once titrated Dx: Cancer, Ehlers-Danlos, JRA, EBD, CF, Dx: Cancer, Ehlers-Danlos, JRA, EBD, CF,

Sickle Cell, Sickle Cell,

WithdrawalWithdrawal

Usually a “red flag”Usually a “red flag” Lost/stolen Rx, misuse, not following directions, Lost/stolen Rx, misuse, not following directions,

Sx: same as for adultsSx: same as for adults Increased pain, tremors, sweating, tachycardia, Increased pain, tremors, sweating, tachycardia,

irritability, yawning, diarrheairritability, yawning, diarrhea

WithdrawalWithdrawal

Need to contact Pain ClinicNeed to contact Pain Clinic Usually, a bolus dose, then a few days of the Usually, a bolus dose, then a few days of the

prior dosing until they can get to clinicprior dosing until they can get to clinic If history of abuse is known, referral to detox If history of abuse is known, referral to detox

is appropriateis appropriate 3 day grace period3 day grace period

Opioid ContractsOpioid Contracts

Between Chronic doc and patient/familyBetween Chronic doc and patient/family Defines rules of engagementDefines rules of engagement All opioids to come from Pain ClinicAll opioids to come from Pain Clinic Usually requires pt to contact Clinic of need to Usually requires pt to contact Clinic of need to

go to ED/Urgent Care Clinicgo to ED/Urgent Care Clinic

PAIN MANAGEMENT SERVICES

CONTROLLED

SUBSTANCES CONTRACT

Controlled substances are sometimes a part of a pain treatment plan for chronic pain. It is our goal to treat pain in a medically sound and ethical manner. This contract is intended to outline clearly the terms under which controlled substances will be used to treat your/your child’s chronic pain condition.

1. I will use the medications only as prescribed by the doctor. 2. I will not receive any pain prescriptions from any other doctor or treating

facility (e.g. emergency room, urgent care facility). 3. All pain prescriptions are for my use only; I will not share them. 4. I will not take more medication than is prescribed. If my pain is not controlled, I

will contact the Pain Management Service. 5. Lost, damaged or destroyed prescriptions will not be replaced. 6. A stolen prescription may be replaced if a police report is filed. 7. Selling pain medication prescribed by the Pain Management Service will result in

immediate discontinuance of the medication, and a police report will be filed. 8. I agree to urine and/or blood drug screening at any time. 9. These medications can affect judgement, coordination, concentration and alertness.

I understand that it is not advisable to operate machinery, automobiles or make important decisions when starting or adjusting the medications.

10. I will not hold any member of the Pain Management Service responsible for problems caused by stopping the prescription of controlled substances.

I understand the above information and agree to follow the medical plan and rules for the use of controlled substances. If I break this contract, the doctor may stop prescribing the medication in question. Medical care will continue to be provided. ___________________________________ ___________________________________ Patient Date Physician Date ___________________________________ ___________________________________ Parent/Guardian Date Witness Date

Interacting with Pain TeamsInteracting with Pain Teams

ReferralsReferrals Pt should return to PMD for referral to ClinicPt should return to PMD for referral to Clinic

FeedbackFeedback Note or call to Pain Clinic helpfulNote or call to Pain Clinic helpful

AdmissionsAdmissions Should not be done for a chronic pain condition Should not be done for a chronic pain condition

without consultation with Clinic (for without consultation with Clinic (for established patients)established patients)

Thank YouThank You

Kenneth.goldschneider@cchmc.orgKenneth.goldschneider@cchmc.org