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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 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 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 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 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) 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 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 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)
