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Current Concepts and Strategies in Pain Management
1. Current Concepts and Strategies
in Pain Management
Raymond G. Tatevossian, MD
Chair, Pain &Palliative Care Committee, PSJMC
Clinical Assistant Professor of Anesthesiology,
USC Keck School Medicine
2. Lecture Objectives
ā¢ Current Understanding Of Pain
Mechanisms
ā¢ Current Treatment Strategies
ā¢ Medication Update
ā¢ Controversies Surrounding Opioids
ā¢ Prudent Opioid Prescribing
ā¢ Advanced Interventional Techniques
3. Pain: The Statistics
ā¢ 2nd leading cause of medically related lost
work days
ā¢ $100 billion/year cost to US economy
ā¢ 42% adults experience daily pain
ā¢ 50% of population see a doctor with āPainā
as the chief complaint
ā¢ 66% of US veterans report persistent pain
attributable to military service
4. Is All Pain āBad?ā
The Gift of Pain by Dr. Paul Brand
ā¢ āThe Beloved Enemyā
ā¢ Pain is evolutionarily necessary for survival
ā Acute pain is protective
5. The āGiftā of Pain--an Example
ā¢ Mycobacterium leprae
ā Disfigurement
ā¢ Infectious processes or
painlessness?
ā¢ The Cat Test
ā Sensory Neuropathy
http://bhavanajagat.files.wordpress.com/
6. Classification of Pain
Acute Chronic
ā¢ Generally protective ā¢ Generally no useful fnctn.
ā¢ Relieved when healing ā¢ Persists after healing
complete complete
ā¢ Short duration ā¢ Long duration
ā¢ Predictable pathology ā¢ Unpredictable Pathology
ā¢ Predictable prognosis ā¢ Unpredictable prognosis
ā¢ Tx with analgesics ā¢ Tx multidisciplinary
8. Factors Contributing to
Chronic Pain
āChronic Pain Loadā
ā¢ Intensity of injury
ā¢ Duration of injury
ā¢ Repetitiveness of injury
ā¢ Chronicity of underlying disease
ā¢ Genetic predisposition
ā BH4 enzyme production
ā¢ Other factors:
- Psychological
- Socioeconomic
- Cultural
9. Mechanisms of Pain: Neuroplasticity
How does a Chronic Pain State Develop?
ā¢ Peripheral Sensitization
- Injury causes release of
āsensitizing soupā
- Reduction in threshold and
increase response of nocioceptors
ā¢ Central Sensitization
- Membrane excitability, synaptic
recruitment and decreased
inhibition
- Uncoupling of pain from
peripheral stimuli
http://www.aafp.org/afp/2001
13. Goals of Treatment
ā¢ Reduce pain
ā¢ Increase activity level
ā¢ Improve quality of life
ā¢ Pre-emptive analgesia
ā¢ Stay within āTherapeutic
Windowā
ā Avoid undertreatment
ā Avoid toxicity
ā¢ How?
ā Synergism with Meds
ā¢ Morphine + Gabapentin
ā Apply multimodal pain
strategies when possible
14. Analgesic Medication Update
FDA Advisory Panel Recs/Trends:
ā¢ Acetaminophen- ā max daily dose, ā
max single dose
ā¢ Vicodin, Percocet - ban in current form
ā¢ Propoxyphene (Darvocet)- push for
phased withdrawal
Abuse Deterrent Opioids:
ā¢ Morphine ER+ Naltrexone (Embeda)
ā¢ Oxycodone IR+ Naltrexone (Oxytrex)
ā¢ Oxycodone IR + Niacin (Acurox)
15. Emerging Analgesic Medications
ā¢ IV Acetaminophen
(Paracetamol)
ā opioid sparring, phase 3
completed
ā¢ Tapendatol (Nucynta)
Āµ-opioid agonist, NE reuptake
inhibitor
ā GI effects, ER phase 3
ā¢ Hydromorphone Extended
Release (Exalgo)
ā FDA approved 3/1/2010,
awaiting REMS
16. Opioids--The Evolving
Controversy
Past: Decreased Scrutiny
ā¢ 1990: Pain becomes āfifth vital signā
ā¢ 1990: Intractable Pain Act
ā āno physician or surgeon shall be subject to disciplinary action ā¦
for prescribing controlled substances for intractable painā
ā¢ Medical Board CA defines under treatment of pain as
āinappropriate prescribingā
ā¢ Bergman vs Chin: $ 1.5 million dollars awarded for under
treatment of pain
ā¢ 2000-2005 a 35-50% increase in opioid prescribing
17. Opioids--The Evolving
Controversy
Present: Increased Scrutiny
ā¢ Most common class of medication prescribed
ā 800% increase in 10 years
ā¢ Fatal opioid poisonings have tripled 1999-2006
ā¢ Food & Drug Administration Act (2007)
ā Creation of REMS for new and existing drugs
ā¢ McLellan and Turner, Annals On Internal,
Editorial, Jan 2010
- āprescribing opioids at high doses is both dangerous amd
questionableā
- White House Office of National Drug Control Policy
19. Strategic Opioid Prescribing
Prescription Monitoring Opioid Contract
ā¢ CURES (CA) ā¢ Call it āOpioid Consentā
ā¢ Pharmacists, physicians, ā¢ Discuss risks and
and law enforcement benefits of opioids
officials ā¢ Educational
ā¢ Real time, S II ā IV ā¢ Establish rules of
ā¢ https://pmp.doj.ca.gov/pm prescribing
preg
20. Intrathecal Drug Delivery
Systems
AKA: Pain pump
Mechanism of Action:
ā¢ Drug delivered directly to the
intrathecal space
Drugs:
ā¢ Morphine
ā¢ Baclofen
ā¢ Ziconotide (PrialtĀ®)
http://www.medtronic.com/IN/images/intro_intrathecal1.gif
ā¢ Bupivicaine
ā¢ Clonidine
ā¢ Ketamine
21. Intrathecal Drug Delivery
Systems
PROS CONS
ā¢ Short reversible trial ā¢ Short reversible trial
ā¢ Delivery of drug ā āopioid benefit with
directly to the site of time (40% failure with
action time)
ā¢ 1mg IT Morphine = ā¢ Contraindications to
300 gm oral Morphine placement
ā¢ Cancer Pain: āpain, ā¢ Complications
ātoxicity, āsurvival (granuloma)
6mo
22. Spinal Cord Stimulation
ā¢ Production of electrical
field over dorsal columns
by epidurally placed
electrodes
ā¢ Gate Control Theory
ā Gate exists in dorsal horn that governs pain
signal transmission
ā Closing gate decreases pain
ā¢ Parasthesia produced
over painful body area
23. Spinal Cord Stimulation
Grade A Evidence
ā¢ Failed Back Surgery
ā¢ Arachnoiditis
Grade B Evidence
ā¢ CRPS I
ā¢ CRPS II
Other Indications
ā¢ Phantom limb, post herpetic
neuralgia, spinal cord injury
www.medscape.com
24. References
1. Arthritis Foundation. (2000) Pain in America. http://www.arthritisfoundation.org
2. American Pain Foundation. http://www.painfoundation.org.
3. National Institutes of Health. NIH Guide: New Directions in Pain Research: Bethsea.1998.
4. Brand P and Yancey P. The Gift of Pain. Michigan: Zondervan Publishing House, 1997.
5. Turk D. Pain Hurts-Individuals, Significant Others, and Society. APS Bulletin. 2006;16:1.
6. Payne J. Pain medications: What you need to know about acetaminophen, darvon, and darvocet. US News
and World Report 2009.
7. Jamison R and Clark D. Opioid Medication Management:Clinician beware. Anesthesiology 2010; 112:777-8.
8. Tucker K. Promoting good pain management in california. California Health Law News 2004;22:1-4.
9. McLellan T. Chronic noncancer pain management and opioid overdose: Time to change prescribing
practices. Annals of Internal Medicine 2010;152:123-4.
10. http://cdc.gov/nchs/data/databriefs/db22.htm
11. http://www.painmed.org/pdf/rems_comments.pdf
12. Cousins M, Carr D, et al. Neural blockade in clinical anesthesia and pain medicine. New York: LWW,
2009.
13. American Society of Anesthesiologists Task Force on Chronic Pain Management. Practice guidelines for
chronic pain management: an updated report by the ASA. Anesthesiology 2010;112:810-33.
14. Gilron I, Bailey J, et al. Morphine, gabapentin, or their combination for neuropathic pain. NEJM
2005;352:1324-34.
15. Smith T, Staats P, et al. Randomized clinical trial of an implantable drug delivery system compared with
comprehensive medical management for refractory cancer pain:impact on pain, drug-related toxicity, and
survival. J of Clinical Oncology. 2002;20:4040-9.
16. Barolat G, Massaro F, et al. Mapping of sensory responses to epidural stimulation of the intraspinal neural
structures in man. J. Neurosurg 1993;78:233-239.