Download Psychiatry and Pain Management

4/5/2011
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Fractal Model of Neural Input and Output Circuits
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Acute
Pain in the undiagnosed or currently
unimpaired
Acute Pain in the Newly Diagnosed
Psychiatric Case
Acute
A t P
Pain
i iin Ch
Chronic
i P
Psychiatric
hi t i
Impairment
Chronic Pain in the Resilient
Chronic Pain in those vulnerable to
Psychopathology
Chronic Pain in Psychiatric Impairment
Special Vulnerability of Substance Abusers
Addiction
Pseudoaddiction (inadequate analgesia)
Other p
psychiatric
y
diagnosis
g

• Encephalopathy
• Borderline personality disorder
• Depression
• Anxiety
• Psychosis
Criminal
intent
Headache
Back
Pain
Nonarticular
Pain Syndromes
(Fibromyalgia)
Osteo and Rheumatoid Arthritis
Neuropathic Pain
Sympathetically Mediated Pain
Phantom Limb Pain
Cancer and HIV Associated
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Pain
• Nociceptive Input
• Prior Injury
• Inflammation
Suffering
Meaning of Pain
• Disease Process
• Physical Disability
• Social
• Financial
Nociceptive
pain
Neuropathic
pain
Psychogenic
pain
Idiopathic
pain
 Explained
by ongoing
tissue injury
 Believed to be
sustained
by abnormal
processing
in the PNS or CNS
 Believed to be
sustained
by psychological
factors
 Unclear mechanisms
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Level 1. Pathological – appears “crazy” to others
Level 2. Immature – Developmental but inefficient
Level 3. Neurotic – Core Conflicts combine with
paradoxical behaviors
Level 4. Mature – Very efficient but are complex to
master and require limited influence by
historical negative enablers
The purpose of the Ego Defense Mechanisms is to protect the
mind/self/ego from anxiety, social sanctions or to provide a refuge
from a situation with which one cannot currently cope.
Generally defense mechanisms are unconscious but can be
rendered more conscious in some successful therapies to be less
primitive and more effective in the future
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














Dopamine
Serotonin
Norepinephrine
Acetylcholine
GABA
Endocannabinds
Melatonin
Neuropeptides
Somatostatin
Vasopressin
Angiotensin
Neurohormones
Atrial Naturetic Hormones
Endothelin
TrkB














CRF
BDNF Relaxin
Angiotensin II
Histamine
Adenosine
Endorphins
Nitric Oxide
Melanopsin
Dynorphin
Orexin
Galanin
Neurotropin
Neurotensin
Substance P
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
Chronic Pain Assessment
Collect the data
•
•
•
•
Pain history - Pain characteristics, Pain impact
Medical history
Physical exam
Integrate the findings -Known etiologies and treatments, Record
review, Appropriate laboratory and radiological tests, Prior prescribed
and nonprescribed (illicit) treatments,Current therapies and who is
administering them, understand the severity and nature of alleged or
potential
t ti l disability
di bilit
Explain that you do not give opiates or other
controlled substances for chronic conditions in the
initial visit (or visits)
 Consider writing policy and leave yourself options
 Develop the therapeutic strategy

• Single modality
• Multimodality
Chronic
pain
• Prevalence: 15%-20% of adult population
• Very diverse presentations in the elderly
• Undertreatment is common
• Rational selection of single modality or
multimodality treatment strategy requires
a comprehensive assessment
• Begin considering the context as regards the
underlying pathology
• Consider the patient’s history and apparent veracity
• Consider obtaining family network collateral
information
“PQRST”6
• Provocative/palliative factors (eg, position,
activity, etc.)
• Quality (eg, aching, throbbing, stabbing, burning)
• Region (eg, focal, multifocal, generalized,
deep superficial)
deep,
• Severity (eg, average, least, worst, and current)
• Temporal features (eg, onset, duration, course,
daily pattern)
Medical
history
• Existing comorbidities (including substance
abuse,especially in in remission, or partial
remission)
• Current medications
• Lifestyle factors
 Long-acting
agents +/ short-acting opioids?
Differentially chosen for cause
 Is there a true need for rescues? Often not
• Are they being taken for psychological factors
(ie, when additional doses of the long-acting drug do
not eliminate the need for even some of the rescues,
rescues
this is a tell-tale sign)
 Evaluate the additional risk vs. the functional
enhancement that the additional dose will bring
 The relative potency or even antagonism potential of
some meds (tramadol, stadol) may actually worsen the
outcome
 Synergy of side effects is also a distinct possibility.
Deciding which drug is doing what can be difficult and
unclear even to a specialist.
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Therapeutic Approaches for Chronic Pain
 Don’t
get bamfoozled, you can shift strategy if you
think you need to.
 Remember - The Physician controls the
prescribing 100%, the patient can control the
choice of the Physician, but not the content of the
prescription – Don
Don’tt make the Board remind you
of this simple, yet complicated, fact.
 The solution they will propose will be anything
but simple.
 If you feel unsafe telling a volitile or labile patient
about a limit setting plan, do it in a safe situation
such as the ER, you do not have to see the patient
in an isolated office alone, order some pertinent
X-Rays and meet them in the ER to discuss the
next steps
Pharmacotherapy
Rehabilitative
approaches
approaches
Anesthesiologic approaches
Surgical approaches
Neurostimulatory approaches
Complementary and alternative
approaches
Lifestyle changes
Psychological
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Categories of analgesic drugs
Opioid
analgesics -Tramadol
N-Methyl-D-Aspartate Antagonists
• Methadone
• Ketamine
• Dextromethorphan (Sign of abuse?)
analgesics
Adjuvant analgesics
Headache medications
Morphine actions are mediated through
more than one receptor
Different receptors mediate systemic morphine
analgesia compared to respiratory depression
and constipation
Nonopioid
Opioids relieve the subjective suffering
component of pain, without interfering with
basic
b i sensations
ti
“The pain is still there,
but it doesn’t bother me”
3. Pasternak GW. The clinical implications of genetics in opioid therapy. Presented at: New Perspectives in Therapy:
Understanding the Liabilities in Assessing and Managing the Total Patient; July 19-21, 2002; New York, NY.
Dissociation is when a person loses track of time
and/or person, and instead finds another
representation of their self in order to continue in
the moment. A person who dissociates often loses
track of time or themselves and their usual
thought processes and memories. People who
have a history of any kind of childhood abuse
often suffer from some form of dissociation.
People who use dissociation often have a
disconnected view of themselves in their world.
Time and their own self-image may not flow
continuously, as it does for most people.
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Prescribing principles
Drug
selection
Dosing
D i to optimize
i i effects
ff
Treating side effects
Managing the poorly responsive patient
Long-acting
opioids
• Preferred because of improved treatment
adherence and the likelihood of reduced risk in
those with addictive disease
• Extended-release preparations
 eg, morphine, oxycodone, fentanyl
• Methadone
Immediate-release preparations
Combination
products, single-entity drugs,
and tramadol
Used mainly for acute pain,
pain for dose finding
during initial treatment, and for “rescue”
dosing
Can be used for long-term management in
selected patients
Not preferred: meperidine, propoxyphene,
and agonist-antagonist drugs
Long-acting
opioid “around-the-clock”
plus a short-acting opioid “rescue” dose
“PRN”
• Preferred approach for patients with cancer pain
and selected others with chronic pain
• Rescue dose may or may not be appropriate for
all patients, depending on syndrome and ability
to use the drug responsibly
• Rescue is 5%-15% of total daily dose; usually
prescribed “q2-3h prn” when oral
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Individualization
of the dose is critical to
successful opioid therapy; there is no one
“correct” dose
po
eq e p
e e o
oe
e
Endpoint:
Adequate
pain relief
or intolerable
and unmanageable side effects
Dose increments: 25%-150% depending on
circumstances, or equal to the daily “rescue”
during prior days
Pure opioid and mu agonists have no ceiling;
thus there is no maximal dose
Analgesia
(pain relief)
y living
g (p
y
Activities of daily
(psychosocial
functioning)
Adverse effects (side effects)
Aberrant drug-related behavior
(addiction-related outcomes)



Patients respond differently, and unpredictably, to
different mu opioid analgesics, requiring
individualization of treatment
• Genetic issues are involved
Side effects from mu opioids vary among patients
• Are side effects mediated through the same
receptors as analgesia? Probably not
Clinically, patients show incomplete cross-tolerance
when switched from one “mu” analgesic to another
• Can incomplete cross-tolerance explain
the advantages of “Opioid Rotation”?
Common: Constipation
Less common
• Nausea
• Myoclonus
• Itch
• Headache
• Sweating
• Amenorrhea
• Sexual dysfunction
• Urinary retention
and somnolence
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 Based
on large intraindividual variation in the response
to different opioids
 Reduce equianalgesic dose by ≥50% with provisos5,10:
• Reduce less if pain severe
• Reduce more if medically frail
• Reduce less if same drug by different route
• Reduce fentanyl less
• Reduce methadone more: 75-90%
5. Portenoy RK. Opioid prescribing to patients with and without chemical dependency. Presented at: The International
Conference on Pain and Chemical Dependency; June 6-8, 2002: New York, NY.
10. Hewitt DJ. Principles of opioid therapy (dosing). Presented at: The International Conference on Pain and Chemical
Dependency; June 6-8, 2002; New York, NY.
Cyclooxygenase-2
Anticonvulsant
Inhibitors
Drugs
Antihistamines
Mexilitine
Alpha
2-Adrenergic Agonists
Corticosteroids
Muscle Antispasmodics
Learn
how to assess patients with pain
and make reasoned decisions about a
trial of opioid therapy
Learn prescribing principles
Learn principles of addiction medicine
sufficiently to monitor drug-related
behavior and address aberrant behaviors
Antidepressants
• Tricyclic Antidepressants
• Monoamine Oxidase Inhibitors
• Selective Serotonergic Reuptake Inhibitors
Other Categories – Muscle antispasmodics, Mood
Stabilizing ACDs, Lithium, usually not Benzodiaepines - except
as sedative/hypnotics sometimes, but only rarely as anxiolytics.
First
and Second Generation Antipsychotics
Stimulants
Placebo
Effects – Potent, but short lived,
analgesic effects
Many of these choices are seriously off label
and need documented informed consent
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 Treat
Unipolar Depression to Remission
Bipolar D/O to stability
 Don’t mix SSRI’s – Central Serotonergic
Syndrome, anticholinergic synergy, side
effects
 Bupropion mixes well and is a good
supplement
 Mirtazepine is sedating and covers much
like amitriptyline does, but it is a much
better mood elevator, especially better
than trazodone
 Manage
Capsaicin
Lidocaine
Patch
Compounded Local Anesthetics
 Stahl
refers to SSRI (or SNRI) plus
mirtaepine and bupropion as “California
Rocket Fuel”
 Not
Notice
ce Psychotic
syc ot c Decompensation
eco pe sat o
 Consider Benzodiazepines as a trade off
for opiates.
 Think the process through – Use common
sense
 Never be unwilling to say “NO” or just
“No”
 Gabapentin, pregabalin
and duloxetine can
be very helpful – Gabapentin can
contribute to Vit D def.
 Use a stepw
stepwise
se model
ode a
and
d insist
s st o
on a
an
operational demonstration that a simple
plan cannot work
 In assessing the outcomes of simple plans,
assess the veracity of the patient’s report
 Use and assess the context of family
collateral information
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 Muscle
Relaxers have a place, sometimes
with NSAIDS
 Assess the use of and value of
physicomechanical interventions
 Use Consultants and Communicate Plans
in Writing
 Insist on Standard Medical Care and Use
Your Usual Routines
 You can always terminate care if you must
 If
mixing several psychiatric meds, look up
interactions and THINK them through
 Usually more than one drug per category is
a poor plan
 Buspirone treats Generalized Anxiety but is
ineffective in Phobic Anxiety (unless it is
Double Anxiety)
 Don’t use meds off label without informed
consent and documentation
 CSS, NMS, hyperpyrexia, muscular rigidity
with elevated CPK require accurate
diagnosis and urgent treatment
 The
value for your services is your routine
fee, don’t cross boundaries
 Don’t be doggedly stubborn - Refer if out
of your comfort zone or area of expertise
 Don’t be a Cowboy - Ask the opinion of
valued colleagues in difficult situations
 Do not engage in Pain Management with
patients in which you have a dual role
 Do not accept valuable gifts or
reimbursement other than fees
 Do
not assume that the relative safety of
newer meds means they cannot be
dangerous, especially in combination
 Always consider orthostatic hypotension in
combos
 Don’t assume trazodone can’t worsen
anxiety or produce a substantial amount of
headaches.
 Don’t forget the PDR warns that mixing ALL
tranquilizers with opiates must be done with
caution
 Don’t forget, if it isn’t written down, it didn’t
happen!
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~45%
Behavior Therapy
Cognitive-Behavioral Therapy
Supportive Therapy
Marital, Couples, Family Therapy
Group Therapy
Biofeedback
Relaxation and Imagery Training
Hypnosis
Vocational Rehabilitation
<1%
HIGH
Long-term
exposure to
opioids in
addicts
LOW
Short-term
exposure to
opioids in
non-addicts
Dunbar and Katz
Porter and Jick
Where is your patient?
 Medical
Model
- Habituation with withdrawal symptoms
- Tolerance with dependency
p
y
- Dose escalation into tachyphylaxis
 AA Model
- Dependence on psychoactive
substances for stabilization (more strictly
constructed in some groups than others)
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 Pharmacologic
Pharmacologic
effect characteristic of opioids
Withdrawal or abstinence syndrome manifests
upon abrupt discontinuation of medication or
administration
d i i
i off antagonist
i
Assumed to be present with regular opioid use
for days to weeks
Becomes a problem if :
• Opioids not tapered when pain resolves
• Opioids are inappropriately withheld
Pattern
of drug-seeking behavior of pain
patients
receiving inadequate pain management
that can
be mistaken for addiction
•
•
•
•
Cravings and aberrant behavior
Concerns about availability
“Clock-watching”
Unsanctioned dose escalation
Resolves
with re-establishing analgesia
effect characteristic of opioids
to increase dose to achieve the same effect or
diminished effect from same dose
 Tolerance to various opioid effects occurs at differential
rates
 Tolerance
to
T l
t non-analgesic
l
i effects
ff t often
ft beneficial
b
fi i l to
t
patients (sedation, respiratory depression)
 Analgesic tolerance is rarely the dominant factor in the
need
for opioid dose escalation
 Patients requiring dose escalation most often have a
change
in pain stimulus (disease progression, infection, etc.)
 Need
Better
side-effect management
strategy to lower opioid
requirement
Pharmacological
• Spinal route of administration
• Add non-opioid or adjuvant analgesic
Opioid
rotation
Nonpharmacologic
strategy added to
lower opioid requirement
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Diversion
Addiction/chemical
coping
Fear
Lack
L k
off additional
dditi
l coping
i strategies
t t i
of perceived control
True physiologic effect of the drug on their pain
Loss
4. Passik SD, Whitcomb L, Kirsch K, et al. Pain outcomes as assessed with a pain assessment and monitoring tool in
chronic non-malignant pain patients treated with opioids: results of final analyses. Paper presented at: The
International Conference on Pain and Chemical Dependency; June 6-8, 2002; New York, NY.
Confidentiality
Informed
Consent, Capacity,
Competency
Pain and Litigation
Disability Compensation
•
•
•
•
Worker’s Compensation
Social Security Disability
Veteran’s Administration Benefits
Disability and Doctor Patient Alliance
Probably less predictive
Probably
more predictive
• Selling prescription drugs
• Prescription forgery
• Stealing
g or borrowing
g another p
patient’s drugs
g
• Injecting oral formulation
• Obtaining prescription drugs from non-medical
sources
• Concomitant abuse of related illicit drugs
• Multiple unsanctioned dose escalations
• Recurrent prescription losses
• Aggressive complaining about the need for
higher doses
• Drug hoarding during periods of reduced symptoms
• Requesting specific drugs
• Acquisition of similar drugs from other medical
sources
• Unsanctioned dose escalation 1-2 times
• Unapproved use of the drug to treat another symptom
• Reporting psychic effects not intended by the
clinician
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 Chronic
pain continues to affect the quality of life
of many patients
 Healthcare providers need to appropriately assess,
treat,
t eat
and reassess chronic pain
 Opioid therapy is one effective treatment modality
for chronic pain
• Long-acting opioids help control chronic pain better
and increase compliance
 All healthcare practitioners prescribing opioids should
be aware of potential aberrant behavior
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