Survey
* Your assessment is very important for improving the work of artificial intelligence, which forms the content of this project
Download click here to download
Transcript
11/7/2014 John Hendrick, MD, DFAPA CHIEF OF PSYCHIATRY MOUNTAIN HOME VAMC AND CLINICAL ASSOCIATE PROFESSOR OF PSYCHIATRY EAST TENNESSEE STATE UNIVERSITY Disclosure Statement of Financial Interest JOHN HENDRICK, M.D., DFAPA; DOES NOT HAVE A FINANCIAL INTEREST/ARRANGEMENT OR AFFILIATION WITH ONE OR MORE ORGANIZATIONS THAT COULD BE PERCEIVED AS A REAL OR APPARENT CONFLICT OF INTEREST IN THE CONTEXT OF THE SUBJECT OF THIS PRESENTATION. 1 11/7/2014 2 11/7/2014 3 11/7/2014 4 11/7/2014 Psychiatric Factors in the Management of Chronic Pain Acute Pain Chronic Mood Pain and Affect Coping Skills 5 11/7/2014 Different Categories produce different management strategies Acute and not habituated Chronic with defined and documented chronic pain syndrome with extended habituation Substance abuse profile with documented instances of aberrant behaviors and chronic drug seeking and/or doctor shopping Especially vulnerable patients with history of substance abuse but demonstrated extended abstinence with evolving chronic pain scenario Acute pain in the abstinent substance abuser at risk of recurrence Titrating up The Philosophy of “Therapeutic Nihilism” is a best option. the minimum amount of analgesic to obtain the goal of pain relief is an initial consideration. That decision depends on potency, dose and frequency of administration of the medication concerned. The context of the situation, reliability of the patient and the expected length of exposure. Undertreatment is not uncommon and is counterproductive, side effects versus benefits represent too much risk, outcome is ineffective and can produce pseudoaddictive behavioral outcomes. Giving 6 11/7/2014 What to choose, how much and at what pace? I tend to consider a dose of 10 mg of hydrocodone a commonly sufficient dose for ongoing, non acute pain. Twice that dose is not uncommon inpatients habituated over 2 or more years in serious and definable pain syndromes associated with objectified findings. When choosing a medication consider the half life, patient’s likelihood of effective adherence and the morphine equivalent potency of the drug. In general, for habituated patient’s it is wise not to offer a prescription at the initial appointment. Consider a dose equivalent of 5 mg of oxycodone (without acetaminophen) BID as the initial starting dose with a plan of titration to 10 TID to QID over the course of the first few days. Halt progression at 10 QID and begin supplementations with ancillary agents. Within 2 weeks at this dose after instituting ancillary support, consider the weaning process by reducing the dose by 5 mg in one of the dosing time frames. For instance, if sleep is improved then the qHS dose may be tolerated at 5 mg. Or the midday or evening dose may be able to reduce with little decrease in efficacy. Remember: Is the patient showing signs of oversedation, inappropriate dosing, poor adherence? Family Collateral? Weaning off When reducing analgesics physicians should think graphically in regard to percentages of dose. The patient will not be likely to think in terms of either percentages and graphic relationships, nor will they have an awareness of pharmacokinetics. In fact, if a patient is aware of such considerations, one might consider how this knowledge developed. Maybe as a health care professional, but otherwise it could be a red flag of aberrant drug seeking behavior. Addicts are often intelligent and some have licensure level knowledge and insight into drug activity, especially heroin addicts. 7 11/7/2014 Use Opiate Equivalency Tables Generally, a decrease of 5-10% in morphine equivalents will produce only a mild reduction in overall analgesia and is unlikely to precipitate a strong withdrawal reaction. Typically, 5 dose intervals are necessary for a new equilibrium to become established. So, do this facts stand up to scrutiny when decreasing dosing or is the patients response inconsistent with the process? Once this initial assessment of response occurs, it will facilitate decisions regarding the pace of reduction. Assessing Tolerant Habituation versus Drug Seeking Behaviors Any patient long habituated to a given dose will undergo withdrawal as tapering occurs. Attention to the physical misery of this allows motivated patients to tolerate the detoxification process. Some may tolerate detox as outpatients but most need the structure and nursing capacities of an inpatient setting. Those whose underlying motives are drug seeking typically will discontinue the process spontaneously, often by AMA discharge. Many patients are highly ambivalent and want success but may be fearful or simply lose their initial round of motivation. 8 11/7/2014 John Hendrick, MD 9 11/7/2014 10 11/7/2014 11 11/7/2014 Dissociation 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. In this manner, a person who dissociates can “disconnect” from the real world for a time, and live in a different world that is not cluttered with thoughts, feelings or memories that are unbearable. * A body can pretend to care, but they can’t pretend to be there. 12 11/7/2014 Direct evidence of nociceptive input to human anterior cingulate gyrus and parasylvian cortex Many lines of evidence implicate the anterior cingulate cortex (ACC, Brodmann’s area [BA] 24) and parasylvian cortex in pain perception. Clinical studies demonstrate alterations in pain and temperature sensation after lesions of these structures. Imaging studies reveal increased blood flow in ACC and parasylvian cortex, both ipsilateral and contralateral to painful stimuli. Additionally, painful stimuli evoke potentials that seem t arise from these cortical structures. Short-duration cutaneous stimulation with a CO2 laser evokes painrelated potentials (LEPs) with a vertex maximum and an initial negative peak followed by a positive wave. The cutaneous laser stimulus evokes a pure pain sensation due to selective activation of cutaneous nociceptors. Electrical source modeling has suggested that the vertex maximum of the scalp LEP arises, in part, from generators in the cingulate gyrus and parasylvian cortex. Thus, imaging and electrophysiologic studies suggest that these cortical structures are activated by painful stimuli. However, these studies incorporate multiple assumptions and therefore do not establish the presence of nociceptive inputs to ACC and parasylvian cortex. We review our recent reports of intracranial potentials evoked by painful stimuli. These studies provide direct evidence of nociceptive inputs to the human ACC and parasylvian cortex Neuroanatomy of Pain ProcessingMain brain regions that activate during a painful experience, highlighted as bilaterally active but with increased activation on the contralateral hemisphere (orange). The Descending Pain Modulatory SystemNCF (nucleus cuneiformis); PAG (periaqueductal gray); DLPT (dorsolateral pontine tegmentum); ACC (anterior cingulated cortex); +/− indicates both pro- and anti- nociceptive influences, respectively. 13 11/7/2014 Current Hypothesis Regarding the Central Role of the Descending Pain Modulatory System during Different Pain ExperiencesRVM (rostroventromedial medulla); PAG (periaqueductal gray); +/− indicates both proand anti- nociceptive influences, respectively. 14 11/7/2014 Pain perception “Is it all in my head?” Emotional aspects of pain Biology of pain perception Cultural factors 15 11/7/2014 Assessment of chronic pain and depression Clinical interview (Biopsychosocial factors) – Do not avoid or overlook the Social context – It is the most common indicator of substance abuse versus legitimate pain control needs – Collateral information from family or friends may be highly enlightening – but can also be biased Substance abuse evaluation (prescription and/or illicit) Suicide assessment – Social context critical Case management – Should responsible others be engaged ? Facts about depression Affects about 10% of the U.S. population with nearly three out of four in the workplace (Gemignani, 2001) Prevalence among school age children and adolescents is 4.6% (Wagner, 2003) Millions do not seek treatment due to inadequate benefits and the stigma associated with depression (U.S. Surgeon General, 2000) Effective pharmacotherapy combined with psychotherapy has been shown to reduce healthcare costs and the rate of suicide attempts (Ballenger, 1999) Average disability length as well as disability relapse are greater for depression than most comparison medical groups (Conti and Burton, 1994) Symptoms of depression Depressed mood, Occurring over a two week period Tearfulness Irritability Low energy level Guilt Helplessness/hopelessness Anhedonia Poor concentration Sleep disturbance (initiating and/or maintaining sleep) Suicidal ideations Appetite disturbance (typically weight loss, but in a small subgroup, weight gain). 16 11/7/2014 Psychological management of chronic pain: Medication use (indications/contraindications) Cognitive-behavioral approaches Family systems approaches Case Management The role of attention focus and complaint Treatment personnel The faith factor Accessing support systems Lifestyle changes Locus of control (internal vs. external) Stress Management Assertiveness Training Exercise Barriers to treatment: Inadequate assessment/missed diagnoses Co-morbid conditions (such as diabetes, stroke, cancer etc) Substance abuse Lack of available resources Poor continuity of care Inappropriate medication dosing/titrating Lack of behavioral health treatment providers in rural areas Common Chronic Pain Disorders Headache Back Pain Nonarticular Osteo Pain Syndromes and Rheumatoid Arthritis Neuropathic Pain Sympathetically Phantom Cancer Mediated Pain Limb Pain and HIV 17 11/7/2014 Chronic Pain Assessment Collect the data History Pain characteristics Pain impact Known etiologies and treatments Physical Record examination review Appropriate Prior laboratory and radiological tests prescribed and nonprescribed treatments Current therapies Chronic Pain Assessment “PQRST” Provocative/palliative factors (eg, position, activity, etc.) Quality (eg, aching, throbbing, stabbing, burning) Region (eg, focal, multifocal, generalized, deep, superficial) Severity (eg, average, least, worst, and current) Temporal features (eg, onset, duration, course, daily pattern) Medical history Existing comorbidities Current medications Inferred Pain Pathophysiology Nociceptive pain Neuropathic pain Psychogenic pain Explained by ongoing tissue injury Believed to be sustained by abnormal processing in the PNS or CNS Believed Idiopathic to be sustained by psychological factors Unclear mechanisms pain 18 11/7/2014 Therapeutic Approaches for Chronic Pain Pharmacotherapy Rehabilitative approaches Psychological approaches Anesthesiologic Surgical approaches approaches Neurostimulatory approaches Complementary and alternative approaches Lifestyle changes Pharmacotherapy for Pain Categories of analgesic drugs Opioid analgesics Nonopioid Adjuvant analgesics analgesics Headache medications Non-Opioid Analgesics Cyclooxygenase-2 Anticonvulsant Inhibitors Drugs Antihistamines Mexilitine Alpha 2-Adrenergic Agonists Corticosteroids Muscle Antispasmodics 19 11/7/2014 Duloxetine Can be very effective in mild to moderate neuropathy, blends reasonably well Often a trial of gabapentin or duloxetine required prior to use of pregabalin Use for depression not much enhanced with dose above 60 mg/d but this is not true for neuropathy Topical Agents Capsaicin Lidocaine Patch Compounded Local Anesthetics 20 11/7/2014 Tramadol Synthetic Analog of Codeine, binds to mu receptors and inhibits NE and 5HT3 reuptake Analgesia is due to parent compound and the M1 metabolite Well absorbed GI (bioavailability 75%), 20% bound Metabolic Pathways – N and O demethylation/conjugation – Formation of M1 metabolite is CYP 450 dependent – 30% excreted unchanged Peak plasma level at 2.3 hours and t1/2 is 6.7 hours – In hepatic insufficiency 1.9 hours and 13.3 hours Increased seizure risk with SSRI/TCA/MAOI or opioids use 50 – 100 mg q6h with a 400 mg limit on total daily dose Opioid Therapy: Side Effects5,11 Common: Constipation Less and somnolence common Nausea Myoclonus Itch Headache Sweating Amenorrhea Sexual dysfunction Urinary retention 21 11/7/2014 Substance Use Disorder versus the Typical Pain Patient on Opioids A maladaptive pattern of substance use leading to significant impairment or distress as manifested by 3 or more of the following 9 symptoms: Need for markedly increased doses to achieve effect effect with same dose syndrome Taking substance to relieve or avoid withdrawal symptoms Dose escalation or prolonged use Persistent desire or unsuccessful efforts to cut down or control substance use Excessive time spent obtaining, using, or recovering from use of the substance Activities abandoned because of substance use Use despite harm Diminished Withdrawal What is Addiction? Medical Model - Habituation with withdrawal symptoms - Tolerance with dependency - Dose escalation into tachyphylaxis AA Model - Dependence on psychoactive substances for stabilization (more strictly constructed in some groups than others) Things to do - Psychopharmacology Treat Unipolar Depression to Remission Manage 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 Stahl refers to SSRI (or SNRI) plus mirtaepine and bupropion as “California Rocket Fuel” Notice Psychotic Decompensation Consider Benzodiazepines as a trade off for opiates. Think the process through – Use common sense Never be unwilling to say “NO” or just “No” 22 11/7/2014 Psychopharmocology Don’ts 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 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! Things To Do – General Supportive Care Gabapentin, pregabalin and duloxetine can be very helpful – Gabapentin can contribute to Vit D def. Use a stepwise model and insist on 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 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 Things Not To Do 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 Don’t tell patients that medications have actions which they don’t Don’t forget to document informed consents and initial treatment agreements Don’t skimp on UDS and Pill Counts Don’t think tramadol cannot be addictive, but it is low liability 23 11/7/2014 Clinical Conclusions Chronic pain continues to affect the quality of life of many patients Healthcare providers need to appropriately assess, treat, 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 Conclusions Chronic pain continues to affect the quality of life of many patients Healthcare providers need to appropriately assess, treat, 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 24 11/7/2014 First ever 3D map of a brain’s neurons. This is a map of an owlmonkey brain. First map of the human brain reveals a simple, grid-like structure between neurons PGY I Mood Disorders Clinical Neurotransmission 25 11/7/2014 New Developments -Optogenetics and CLARITY 26 11/7/2014 Psalm 139 – In part For you formed my inward parts; you knitted me together in my mother's womb… I am fearfully and wonderfully made.…My frame was not hidden from you, when I was being made in secret, intricately woven in the depths of the earth. 27 11/7/2014 28 11/7/2014 29 11/7/2014 30
