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CHALLENGES OF PAIN
MANAGEMENT
JERRY L. DENNIS, M.D.
MEDICAL DIRECTOR
RIVERSIDE COUNTY DEPARTENT OF
MENTAL HEALTH
December 2009
PAIN: Scope of the
Problem

THE 21th CENTURY HEALTH CARE DISASTER:
– Chronic Pain: Lifetime Prevalence 60-80%
– Back-Related Disability of Epidemic Proportions
– Psychological, Social and Cultural Factors Play
Prominent Roles in Pain and Pain-Related Disability
– Pain Promotes Emotional and Behavioral
Regression, and Inhibits Ability to Cope
– Pain Often Initiates Cycles of Narcotic Addictions
PAIN: Scope of the
Problem

Back pain is the most prevalent medical
disorder in industrialized societies

Affects ~6 million Americans each year

70% of people with acute back pain
recover within one month
Psychological Components of
Chronic Pain

Disease Onset:
– Job Dissatisfaction and Poor Performance
Appraisals Predict Pain:




Dissatisfied with work: 2X as likely to seek Tx for
pain
Feel underpaid: 4X as likely to seek Tx for pain
Lowest socioeconomic status: 5X as likely to seek
Tx for pain
First back injury at work: Predicts physical work
stress and psychological intolerance of the job
Psychological Components of Chronic
Pain

Disease Progression:
– Chronic low back pain is the leading cause of
disability in industrialized nations
– Progression from acute to chronic pain is more
dependent demographic, psychological and
occupational factors than on medical pathology







Blue collar jobs
Labor beyond individual’s capacity
Job dissatisfaction
Poor performance ratings
High job stress
Somatization and Depression promote progression
to chronic pain
Sickness payments and litigation reinforce chronic
pain
Psychological Components of
Chronic Pain

Workers Compensation Systems Issues:
– Delays in Dx and Tx
– Continually must prove sickness to obtain care and
compensation
– Patients receiving compensation benefits fare
worse with virtually any and all interventions
attempted
– Study of 2000 back pain patients:


100% returned to work except
Those in litigation 0%
– The longer the duration of sick/disability leave, the less
likely it is that the person will ever return to work
Psychological Components of
Chronic Pain

Good Tx Outcome Associated with:
– Hx of good coping skills – Resiliency
– Psychological strengths
– Belief in self-efficacy
– Higher socioeconomic status
– Higher job satisfaction

Poor Tx Outcome
– Patients with active addictions and pain have
the worst outcome and are prone to:



Inordinate disability
Symptoms exaggeration
Excessive health care utilization
Chronic Non-Malignant
Pain (CNMP) Syndrome
Persistent Pain
 Not associated with progressive tissue
destruction
 Substantial psychological overlay
 US Commission on Pain (1987):

– Intractable pain of 6 months duration or more
– Marked alteration of behavior with depression or
–
–
–
–
anxiety
Marked restriction of daily activities
Excessive use of medication and frequent use of
medical services
No clear relationship to organic disorder
Hx of multiple, nonproductive tests, Tx and surgeries
Psychological Components of
Chronic Pain

Chronic Pain Syndrome:
– Predominantly a behavioral syndrome
– Affects the minority of chronic pain
patients
– Preceding psychiatric illness and
personality disorder : 75%
– Less objective physical impairment
– Degree of disability varies with:
 Psychological strengths of the
individual
 Stress of the workplace
 Incentive and disincentives for
recovery
Cognitive Factors in Pain

Maladaptive Cognitions:
– Self-destructive thinking becomes automatic
and habitual
– Catastrophic Thinking: the worst case scenario
 Increases dysfunction
 Increases pain
 Hinders coping
– Learned Helplessness:
 Think they are unable to control events in their
lives
 Depression and passivity increase disability and
pain
Cognitive Factors in Pain
– Locus of Control:



Internal locus of control = better functioning
External locus of control (government, employer,
family, doctors, lawyers) =
– Depression and anxiety
– Feel helpless to deal with pain
– Rely of maladaptive coping mechanisms
Blaming others for pain/injury =
– More mood and behavioral disturbance
– Poorer response to Tx
– Lowered expectations for future benefits of
Tx
Behavioral Components of Pain

Operant Conditioning:
– Behavior that is reinforced increases the
frequency of the behavior
– Elimination of reinforcement leads to
“extinction” of behavior
– Much pain behavior and dysfunction are
maintained by environmental rewards:
“Secondary Gain”

Caretaking, drugs, money
– Incentives:
 Financial compensation associated with greater
pain and reduced efficacy of Tx
 Tertiary Gain: Others defend person’s disability
and support helplessness
Cycle of Fear and Deconditioning
Physical injury
and
Impairment
Inactivity
↑ Susceptibility
to
strains/sprains
Depression
Anxiety
Helplessness
Fear of Injury
Isolation
De-Conditioning
↑ Fragility
↓ Strength
↓ ROM
Behavioral Components of Pain
Affective Distress
Depressed Mood:
Pain, Loss of gratifying activities, Loss of selfesteem/identity, powerlessness, drug-induced
affective changes
Anxiety:
Amplifies physical Sx, disincentive for recovery,
illness permits escape from feared situations,
bracing/guarding injured part, chronic tension
worsens pain
Anger:
Increases pain-related suffering, interferes with
life activities, reduces response to Tx
Psychiatric Disorders in Pain Patients

Chronic Pain Patients:
– Most common psychiatric illnesses :
 Anxiety
 Depression
 Substance Abuse
– Depression (10 - 83%)
 Marked variation related to setting and overlap of
symptoms of pain and depression
 * Somatic pain is a common symptom of Major
Depression
 Depression in Chronic Pain Syndromes is highly
responsive to non-pharmacological interventions
– Chronic Pain Rehab Unit Study (1989)
– 98% resolved by discharge and recovery persisted
at 1-yr f/u
Psychiatric Disorders in Pain Patients

Anxiety Disorders:
– Anxiety itself is mostly painless
– Panic attacks often present with chest or
abdominal pain


Autonomic arousal:
Moist palms, tremors, tight facial muscles, rapid
pulse
– Because chronic pain is often associated with
trauma, PTSD is commonly co-occurring
– Severe trauma promotes somatization and
anxiety
– Somatoform Disorders:


Non-physiological pain and “Psychogenic” pain
Pain of various sorts that do not correlate well
with actual anatomical findings and known
pathophysiology
Somatoform Disorders
Psychogenic Pain

Psychogenic pain:
– Analogous to Conversion Disorder
 (Hysterical blindness, aphonia, paralysis)
– Person may appear euthymic, animated and sleeps
well, or may experience extreme dysfunction,
suffers and may become suicidal
– May be dramatic, claim extreme denial of non-
medical problems, and appear cheerful despite
perceived disability
– Demonstrate behaviors that are incompatible with
the degree of impairment they claim
– Reliable indicator: Patient’s inability to discuss
non-somatic issues
Dx and Tx of Fibromyalgia

Dx:
– Pervasive unexplained physical Sx:
 Involving at least 3 of 4 body quadrants
 Of at least 3 months durations
– Point tenderness at 9 bilateral locations
 Chronic pain and pain behavior
– Distorted ambulation
– Rubbing painful body parts
– Increased “Down time”
– Pain behaviors are reinforced and maintained by
others response to the patient
• Strong Operant Conditioning
• Become stuck in the “sick role”
Dx and Tx of Fibromyalgia
– Report of Sx, functional limitations and
psychological dysfunctions:


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
Fatigue
Sleep disturbance
Stiffness
Headaches
Depression and anxiety
Irritable bowel disorders
78%
76%
76%
54%
45%
36%
– Plus


Cognitive impairments
Malaise
– Patients often do not accept possible
psychological basis; Not psychologically minded
– 70+% meet criteria for depression
– 85% % report some degree of anger
Dx and Tx of Fibromyalgia

Dx
– Insidious onset without identifiable cause
– Course is chronic and non-progressive
– Sx fluctuate in severity and worse under stress
– Report decreased sense of well-being
– High utilizers of healthcare services
– Pain does not follow known neuro-anatomical
–
–
–
–
pain pathways
Labs and radiologicals are normal
Feel “exhausted” and “burned-out”
Have a low pain threshold
Hypersensitive to cold, noise and environmental
irritants
Dx and Tx of Fibromyalgia

Tx: No known cure
– Tx focused on:
 Relieving pain, improving sleep and
physical/emotional functioning
– Non-medication Tx
– Lyrica (Pregabalin) – FDA approved
– Neurontin (Gabapentin) – generic alternative Rx
– NSAIDS
– Antidepressants
– Sedative-hypnotics or non-addictive medication
alternatives for insomnia
– Anticonvulsant Mood Stabilizers (Depakote, etc.)
Avoid any PRN medications
– TX OF FIBROMAYALGIA SHOULD NEVER
REQUIRE OPIATE NARCOTICS!
Addiction in Pain Syndromes

Prevalence of Addictive Disorders in Chronic
Pain Syndromes:
– Difficult to determine:
– Estimate 25% have a current Substance Use
Disorder
– Every chronic pain evaluation should include a
screen for substance use disorders
– Patients of conceal substance abuse by
substituting prescription drugs

Less negative perception if taking/using prescribed
analgesics, benzodiazepines and sedatives (“muscle
relaxants” or “sleep aids”)
– Dx is hindered by lack of consensus as to what
constitutes appropriate use of opioids and
sedatives
– DENIAL, DENIAL, DENIAL
PAIN AND ADDICTIVE BEHAVIOR
Pain and Addictive
Behavior
Physiological Pain
Behavior

Physical S/Sx of pain
proportionate to
anatomical/physiological
findings

Physical complains may be
exaggerated

Frequent intoxication: slurred
speech, sedation

No S/Sx of intoxication

Impaired coordination

Manages/rations
medication supplies
between f/u appts

Irritability and mood changes

Taking too many pills at once

Forgetting how many pills
taken

Requesting increasing
dosages, early or more
frequent refills needed
PAIN AND ADDICTIVE BEHAVIOR
Physiological Pain
Behavior
Pain and Addictive
Behavior

More attentive to
personal/self care

Inattention to hygiene,
inappropriate behaviors

Functions better with
pain Tx

Functioning may be worse
or does not improve

“Sick role”
disproportionate to
pathology

Family/SO/Caretaker
concerns

Prescriptions from
multiple providers

Rejects “sick role”

Family/SO/Caretakers
note less irritability and
mood changes
Pain and Malingering

Willful deception is quite uncommon??
– 20-46% of people surveyed said they considered
purposeful misrepresentation of compensation
claims to be acceptable (Weintraub 1995)
– No good information how frequently this occurs
– More common in individuals seeking
compensation or opioids than in those seeking
other treatments
Developmental Trauma and Pain

Hx of:
–
–
–
–
–

May lead to difficulties with:
–
–
–
–

Neglect loss
Abuse
Molestation
Excessive Early Responsibility
Children of Alcoholics/Drug Addicts
Anger
Dependency
Helplessness
Low Self-Esteem
Women with Hx of:
– Physical abuse > 5X increase in C/O
pronounced pain
– Sexual abuse > 4X increase in C/O
pronounced pain
Trauma and Pain

Marked Adult Trauma, e.g.,:
– Military combat
– Natural disasters
– Serious accidents and injuries
– Significant personal losses
– Etc.

Any significant physical or emotional
trauma can lead to somatization and
increased pain
Diagnosing Psychogenic
Components of Pain

Functional Impairment:
– Patient’s own pain drawing/diagram
– Assessment of “down time”:
 Hrs/day spent reclining
 House-bound, bed-bound, couch-bound
 Spending days in night clothes

Emotional Symptoms:
– Ask about S/Sx of depression, anxiety, irritability
 Refer to DSM-IV criteria for Major Depression,
Generalized Anxiety Disorder, PTSD, Panic Attacks,
Agoraphobia
– Ask about Hx of trauma:
 Childhood/Developmental
 Adult
Diagnosing Psychogenic
Components of Pain

Family, SO, Caregiver Response:
– Supportive, encouraging function
– VERSUS
– Enabling, promoting “sick role”

Identify Stressors

Litigation/Pursuing Disability?
Diagnosing Psychogenic Components
of Pain

Collateral Information:

– Actively seek info from other sources
– **HIPAA:


Supports/allows for direct provider to provider
communications without release
Does not limit ability to listen and ask
questions of those who call
Diagnosing Psychogenic
Components of Pain

Physical Examination and Testing:
– Impairment should not exceed pathology
 Do observed signs of impairment change with
distraction?
– Obtain and review actual reports of labs,
radiologicals, MRI/CT scans
– Don’t depend of patient reports of findings
– Obtain reports from other providers:

Ask about pain medication prescriptions
– MSE:
 Is affect appropriate and congruent with the degree
of pain alleged?
 Check for cognitive impairments/memory loss
Diagnosing Psychogenic
Components of Pain
– Internal vs. External Locus of Control
 Does patient accept responsibility to actively
participate in his/her recovery?
 Is everything contingent upon the government, the
company, doctors, lawyers, spouse?
 Psychogenic pain patients focus more on blame,
retribution, and compensation than recovery
 Is there a Hx of non-compliance with reasonable
medical expectations or lack of active effort to
recover?
– Presence of secondary gain does not validate
psychogenic nature of pain
– Presence of secondary gain does not invalidate
organic basis of pain
Diagnosing Psychogenic
Components of Pain

Psychological Testing:
– MMPI may be useful to identify psychological
components or validate observed findings

Personality styles, S/Sx of mental disorders
– Neuropsychological Assessments:
 Most helpful in sorting out cognitive impairments and
perceptual abnormalities
 Results still must be correlated with actual physical
findings and clinical observations
Psychological Approaches
to Pain Tx

Non-pharmacological Treatment:
– Physical Therapy:
 Chronic pain causes deconditioning
 PT is a form of systematic desensitization
 Helps overcome “Learned Helplessness”
 Pt actively participates in rehab to achieve success
and is empowering
– Behavioral Modification:
 Behavioral changes are initiated by changing the
environmental consequences of pain
– Rewards, social reinforcements contingent upon
healthy behaviors
– In PT, praise, rest and other “rewards” follow actual
completion of a goal, not just for trying.
Psychological Approaches to Pain Tx
– Behavioral Modification:
 Family/SO/Caregiver may promote invalidism by
unnecessary coddling, over-accommodating pain
behaviors
 Must learn to ignore pain behaviors and get out of
caretaker role
 Reinforce patient self-sufficiency and change roles
from caregiver to companion, friend, partner
– Education:
 Pathology of pain including the brain
 Difference between “hurt” and “harm”
– Reconditioning programs may initially increase
pain
 Family/SO/Caregiver:
– Worst Tx is rest/inactivity; Activity is beneficial
Psychological Approaches to
Pain Tx
– Cognitive Behavioral Therapy:




Patient learns to identify negative, harmful and
inappropriate patterns of thinking
Patient learn to challenge these thoughts and
substitute more positive, self-supportive and helpful
thoughts
Patient learns to gradually alter automatic
inappropriate thinking and their resulting negative
behaviors
Patient learns to develop an internal locus of control
that helps empower success in rehab
Psychological Approaches to Pain
Tx
– Stimulus Reinterpretation:

Learn to replace catastrophic thinking and
statements with more realistic, rational
thinking
– Assertiveness Training:

Positive self expression helps overcome
remaining in the “sick role”
Psychological Approaches to Pain Tx
– Biofeedback/Relaxation Training:
 Various methods/electronic devices helps regulate
skeletal muscle tension, GI motility and pulse, e.g.
TENS units
 Thermal Biofeedback:
– Training in warming extremities (Raynaud’s Syndrome)




EMG Biofeedback
Progress Muscular Relaxation Training
Meditation, Yoga, Tai Chi
Self-Hypnosis
– Family Therapy:
 Family members learn to overcome being controlled by
illness, impairment and disability
Psychological Approaches to Pain Tx
– Self-Help Groups:
 American Chronic Pain Association
– Multidisciplinary Pain Rehabilitation
Programs/Clinics:

Multiple modalities of treatment tailored to maximize
comfort and improving functioning
– Results of studies:
• 14-60% reduction in pain
• Up to 75% reduction in opioid use
• Dramatic increase in functioning
• 43% more were working after Tx
• 90% reduction in physician visits
• 50-65% fewer surgeries
• 65% fewer hospitalizations
• Major health care cost savings
Non-Opioid Medications in Pain
Tx

Non-Opioid Analgesics:
– NSAIDS:
 Most widely used for mild-moderate pain
 Used alone or in conjunction with opioids
 Mechanism of action: Prostaglandin inhibition
 Ceiling level beyond which increasing dose is not
effective
 GI side effects: Nausea, vomiting, GI bleeding
 Renal and hematological toxicity
– Antidepressants:
 Efficacy better demonstrated for TCAs; SSRIs less
effective
 Analgesic effects independent of antidepressant
action:
– Enhance opioid effect at opioid receptors
 Most effective for neuropathic pain
Non-Opioid Medications in Pain Tx
– TCA antidepressants:
 Side effects great; Often poorly tolerated:
– Dry mouth, burred vision, constipation, sedation,
orthostatic hypotension, cardiac arrhythmias
– Anticonvulsants or Anti-Epileptic Drugs:
 Mechanism of action unknown
 Most effective for paroxysmal or lancinating pain, e.g.,
Trigeminal Neuralgia, Post-Herpetic Neuralgia
 Medications:
– Carbamazepine, Valproic Acid, Gabapentin
– Clonazepam (Benzo and Anticonvulsant): Painful
Spasms
– Alfa-Adrenergic Agonist:
 Clonidine: Limited use for neuropathic pain
Non-Opioid Medications in Pain
Tx
– Muscle Relaxants:

Spasmolytic Agents:
– Baclofen, Tizanidine, Benzodiazepines
– Useful in MS and upper motor neuron
lesions from trauma, CV disease,
degenerative disease
– Cyclobenzaprine: Sedating; short term use
only
– Methocarbamol, Carisoprodol, and
Chlorzoxazone:
• Abuse potential with no demonstrated
efficacy
Sleep and Pain:




Pain interfere with sleep
Sleep deprivation increases pain intensity
Sleep problems worsen other emotional
difficulties: depression and anxiety
Insomnia needs to be addressed to help
decrease pain and suffering:
– Educate patient on sleep hygiene
– Avoid combining benzos + opiates!
– Instead try:
• NSAIDS
• Hydroxyzine
• Diphenhydramine
• Trazadone
Interventional Procedures
–
–
–
–
–
–
–
Anesthetic Infusions
Trigger Point Injections
Local Nerve Blocks
Spinal Steroid Injections and Facet Injections
Sympathetic Nerve Blockade
Spinal Cord Stimulation
Physical Medicine and Rehab Therapies







Heat
Cold
TENS (Transcutaneous Electrical Nerve Stimulation)
Massage
Exercise
Acupuncture
Botulinum Toxin
Opioids in Pain Management
– **Concerns:
– Physical dependence
– Tolerance
– Addiction
– Abuse
– Diversion
– Physical Dependence:
 Occurs 2-10 days after continuous use
 Characteristic withdrawal syndrome:
– Diarrhea, piloerection, sweating, mydriasis, mild
increased BP and P, CNS arousal, irritability,
anxiety, insomnia
– Abdominal cramps, deep bone pain, diffuse
muscle aching
– Intense craving to relieve withdrawal syndrome
– Intensification of pain
Pathophysiology of Addiction
– Mesolimbic Dopaminergic System of the brain is
the primary site of dysfunction caused by
abused drugs
– Substitution of a drug reward for a natural
reward:

Biological rewards (e.g., sex)

Cultural rewards (e.g., stable relationships)
– Effects of drugs in the Amygdala involve multiple
neurotransmitters





Dopamine (D-2)
Opioid Peptides
Serotonin (5-HT)
GABA
Glutamate
Pathophysiology of Addiction
– Most drugs cause reward/pleasure by:



Disinhibiting the dopamine system
Increasing dopamine stimulation
Increasing glutamate release
– Affect the mid-brain and limbic
structures:



Ventral Tegmental Area (VTA)
Amygdala/Nucleus Accumbens
Cortical Connections
– Pre-frontal Cortex
Pathophysiology of Addiction

Mu Opioid Receptors:
– High concentration in the Ventral Tegmental
Area (VTA), Amygdala and Nucleus Accumbens
GABA-ergic neurons
– Progressive drug use causes changes in
structure and function of the Mesolimbic
circuitry
– Progressive drug exposure cause changes in
neuroplasticity leading to addition/addictive
behaviors
Pathophysiology of Addiction
– Stimulation of Mu Opioid Receptors :




Inhibits release of GABA
Increases firing of Dopamine neurons in the
Nucleus Accumbens
Increased levels of Dopamine in the Nucleus
Accumbens elicits behaviors characteristic of
addiction
Drug (Opiate)-Induced neuroplasticity changes
sustain behaviors characteristic of addiction
(craving, increase tolerance, affect drug satiety)
Pathophysiology of Addiction
– Explanation of Addiction:





Recreational drug use cause physiological
adaptations of the mid-brain
Amygdala/Nucleus Accumbens
Brain reward/pleasure circuitry is
altered/reset
User must increase the amount of drug used
to create the same reward/pleasure response
Reward/pleasure circuitry may be
permanently altered
The best indicator of drug satiety is the level
of dopamine in the Nucleus Accumbens
Opioids in Pain Management
– Tolerance:

Need to increase doses to achieve the same effects

Tolerance can develop for analgesic effects and
respiratory depression, sedation or nausea



**Increase opioid doses are needed for progression of
underlying disease (e.g., cancer) but not for stable
disease or Tx of painful tissue pathology
Absolute tolerance to analgesic effects does not occur
Massive dosages can be given safely and with good
effect
– **Must monitor for over-sedation and respiratory
depression**
Addiction: In Pain Treatment
– Presence of adverse consequences due to use of
the drugs:
– Over-sedation, euphoria
– Deteriorating functioning despite relief of pain
– Increasing pain despite increasing dosages
– Increase in pain-associated distress: anxiety,
insomnia, depression; negative affect
Addiction: In Pain Treatment
– Loss of control over drug use:
– Fails to bring unused mediation to appts
– Requests early refills
– Lost or stolen scripts
– Appear in clinic without appt and in distress
– Frequent additional visits to the ED requesting
opiate narcotics (and benzos)
– Family reports overuse or intoxication
Addiction: In Pain Treatment
– Preoccupation with obtaining opioids despite the
presence of adequate analgesia:
– Non-compliance with non-opioid treatment
– Failure to keep appts.
– Show interest in relief of symptoms, not rehab
– Perception that no intervention other than
opioids have any effect
– Seeks prescriptions from multiple provider
– Will not actively address addiction recovery
Addiction: In Pain Treatment
– Tx of Addictions in Chronic Pain Patients:
 Often futile if the patient won’t commit to achieving
addiction/substance abuse recovery




First must confront and overcome denial of substance use
disorder
Pain impedes detoxification due to hyperalgesia of
withdrawal
Focus on similarities of between chronic pain and
substance use disorders:
– Neither is the patient’s fault
– Recovery is their responsibility
– Both can be managed but not necessarily cured
12-step recovery programs and AA, NA or Chronic Pain
Anonymous (CPA) are necessary
Opioids in Pain Management

Drug Selection:
– Mu, Kappa and Delta receptors stimulation
results in analgesia
 Mu receptor stimulants:
– Morphine, oxycodone, hydromorphone,
meperidine, fentanyl and methadone
– Interchangeable

Propoxyphene:
– Weak Mu agonist, low analgesia, abuse
potential

Methadone:
– Long half-life requires careful titration
– **WARNING: Analgesic effect is shorter in
duration than CNS respiratory depressive
effects: High risk for accidental
overdose/death
– Primary use in chronic opiate maintenance
programs
Opioids in Pain Management

Drug Selection Continued:
– Kappa agonist, Mu antagonist:

Pentazocine, nalbuphine, butorphenol
– Less potential for abuse and addiction
– Ceiling effect in terms of analgesia
– Dysphoric reactions common
– May precipitate withdrawal in patients of Mu
agonist drugs
Opioids in Pain Management
– Partial Mu receptor agonists:



Buprenorphine:
– Approved as an alternative to
methadone for chronic opiate
maintenance
Tramadol:
– 2nd mechanism of analgesia via
5-HT and NE reuptake
inhibition
Both with less abuse potential
than pure Mu receptor agonists
Opioids in Pain Management
– Administration Schedules:

Serial use of pain scales to titrate doses

Marked variability in patient response


If pain is constant, use regularly scheduled
intervals
If pain is chronic or patient has Hx of substance
abuse/dependence, avoid PRN administration
Opioids in Pain Management
– BOUNDARY SETTING WITH
SUBSTANCE ABUSERS

Written treatment plan
– Clear written goals of pain treatment

Informed Consent:
– Risks, benefits, side effects, alternatives
(include over-dosage and withdrawal)

Signed Agreement by patient and doctor

Identify only one provider and one pharmacy

Release of information for all providers

Use pills counts and UDS as needed
Opioids in Pain Management
– BOUNDARY SETTING WITH SUBSTNACE
ABUSERS – continued:

Establish mechanism for all refills (Avoid
PRNs)

Exclusion of any early renewals/refills
regardless of reason

Set intervals for f/u appts.

Establish conditions under which treatment
will be continued or discontinued

Violations may result in termination of
treatment and patient given a short tapering
dose supply
Opioids in Pain Management

BOUNDARY SETTING FOR PHYSICIANS
– Accept that pain management is extremely
difficult for the patient and for you.



Never state or imply that pain is “all in your head”
Acknowledge that pain and suffering are real
Pain causes true suffering and makes the person irritable
or even angry
– Listen and keep communications calm, direct
and professional


Don’t be bullied
Confront inappropriate statements or behaviors
– Acute pain should be treated and often does
require opiates temporarily
Opioids in Pain Management

BOUNDARY SETTING FOR PHYSICIANS
– Don’t be pressured into chronic opiate
prescribing as the only solution
– PAIN HAS TO MAKE SENSE!
 Yet, appreciate that there are marked individual
variations in the experience of pain:
– Pain threshold
– Pain intensity
– Pain tolerance
– BE ABLE TO SAY “NO”
 Prescribe only within your comfort level
 Don’t prescribe narcotics or benzodiazepines
unless you determine that they are necessary!
Opioids in Pain Management

BOUNDARY SETTING
– FOR Physicians
– **Remember that increase opioid doses are
needed for progression of underlying disease
(e.g., cancer) but not for stable disease or Tx of
painful tissue pathology
– When a patient refuses what you recommend,
this does not mean that you are required to give
them something you do not feel is necessary or
may be inappropriate
Practical Issues in Pain Management
– Barriers to Effective Management




Inadequate assessment:
– KNOW WHAT YOU ARE TREATING!
Fear of scrutiny from peer medical clinicians:
Fear of being scammed by a drug seeker
Fear of regulatory agencies
– Reports to medical boards, malpractice allegations



Fear of producing addiction
Fear of not adequately treating pain
Inadequate documentation:
– DOCUMENT, DOCUMENT, DOCUMENT!
Practical Issues in Pain Management

Unconscious biases:
– Hispanics with fractures are 2X as likely to
receive no pain meds
– African Americans are more likely to receive
less than adequate Tx of pain
– Women and elderly with metastatic cancer
are more likely to receive less than adequate
analgesia than others.
Practical Issues in Pain Management

Polypharmacy:
– The norm of today in healthcare treatment
– High risk for drug-drug interactions
– High risk for adverse outcomes including
fatality:
• Accidental overdose
• Intentional overdose
– **Use great caution in combining
treatment with opiates, benzodiazepines
and other psychotropic or CNS
medications!
Abuse of Prescription
Opioids
– Drug Abuse Warning Network (DAWN)


Continually increasing emergency room
reports of heroin and other drugs as well and
drug-related deaths
Adolescent opiate abuse is rapidly increasing
– Potential factors:


Over-prescribing due to public/media
pressure of physicians to treat pain
Increasing use of long acting formulations
Abuse of Prescription Opioids
– Prescription drug abuse and dependency:


*Rapidly increasing illicit prescription drug abuse
and drug diversion*
Common factor in suicide and accidental drug
overdose deaths
– Alarming increase in opiate
abuse/dependency in adolescents

Primary source: **the family medicine cabinet**
– Substance abuse in the elderly is most
commonly prescription medication abuse
Basic Screening Tools
– Alcohol: CAGE or AUDIT

Cut down, Annoyed, Guilty, Eye opener
(CAGE)
– Or CAGE AID (Adapted to Include Drugs)

Alcohol Use Disorders Identification Test
(AUDIT)
– 10 questions:
• Alcohol consumption
• Drinking behavior
• Adverse reactions
• Alcohol-related problems
– PHQ-9: Patient Health Questionnaire
– 9 questions + impairment question
– Also screen for depression
Terminology and Context
– Misuse:
 Incorrect use of a medication
– For other than its intended purpose
– Taking too little or too much
– Taking it too often or for too long
– Abuse: (DEA)
 Use that is inconsistent with the medical or social
patterns of the culture
 Use outside the scope of sound medical practice
– Addiction:
 A primary, chronic, neurobiological disease with
 Impaired control over use, compulsive use, and
continued use despite harm
Terminology and Context
– APA DSM-IV TR Definitions:


Does not use “addiction”
Defines Substance Use Disorders:
– Abuse, Dependence, Intoxication, Withdrawal
– Substance Abuse:
– Maladaptive pattern of substance use leading
to clinically significant impairment with 1 or
more of the following in a 12- mo. period:
• Recurrent use resulting in failure to fulfill major
role obligations
• Recurrent use is situations that are physically
hazardous
• Recurrent substance-related legal problems
• Continued use despite having persistent or
recurrent social or interpersonal problems due
to use
Terminology and Context
– Substance Dependence







Development of tolerance
Characteristic withdrawal syndrome
Substance taken in larger amounts over a
longer period of time than intended
Persistent desire or unsuccessful efforts to
reduce/control use
A great deal of time spent obtaining, using or
withdrawing from effects of the substance
Important social, occupational, or
recreational activities given up or reduced
due to use
Use continues despite physical or
psychological problems due to use
Drug Abuse and Diversion
– “Abusability”:






I want a new drug!
Substance can be extracted or modified to
achieve a desired effect
Rapid onset of action
Short duration of action
High potency
Highly water soluble
Can be smoked, snorted, ingested or injected
– Brand name drugs yield a higher street
value, especially narcotics/controlled
substances
Drug Abuse and Diversion
– Roles of Physicians:

The Four Ds of Malpractice:
– DATED: Physician has not kept up
with changing standards of practice
– DUPED: Physicians who are easily
manipulated by substance abusers
– DISABLED: Physicians whose
judgment is impaired by their own
illness or substance abuse
– DISHONEST: Physicians (“script
doctors”)
• Willfully prescribe controlled
substances for other than
medical purposes
• Use their license as a franchise
to deal drugs
Questions?
Thanks for your attention!
Jerry L. Dennis, M.D.