Presented by Dr. JoAnna Harper, PharmD at the Scleroderma Patient Education Conference hosted by the Scleroderma Foundation Greater Chicago Chapter on April 27, 2019 in Oakbrook, IL.

1. Pain Management:
How to Empower Yourself
Without Reliance on Opioids
Dr. JoAnna Harper, PharmD
Pain Management Pharmacist/Patient Advocate
Pain Partners, LLC/ Park Nicollet
April 2019

2. Objectives:
• Acknowledge that pain management is complex,
utilizing the “car analogy.”
• Understand concerns regarding opioid pain
medications
• Determine other medication options for pain
management.
• Discuss complementary treatments for pain.
• Learn “outside-of-the-box” options for pain
management
• Leave with what tools you want to start developing
for your own pain management toolbox.

3. About Me
• Chronic Pain Medication Therapy Management Pharmacist,
Park Nicollet, St Louis Park, Minnesota
• Consultant Pharmacist, Pain Partners LLC
• Patient Advocate and Educator, Scleroderma Foundation and
American Pain Foundation
• Doctorate of Pharmacy, Oregon State University
• Created the pharmacist-led pain management service at Tucson
Medical Center
• Developed a program for post-op pain management plan
development prior to surgery, St Luke’s Regional Medical
Center, Boise, ID
• Empower my patients to become active members of their
healthcare team and to develop various tools that they can use
in pain management
• Scleroderma patient

4. Disclosures
• Nothing to disclose
• No involvement with industry/organizations that
may potentially influence this educational
presentation.
• I will be discussing “off-label” uses of
medications

5. Patient Comments
• “Why is the opioid epidemic affecting me?”
• “All doctors think I am drug-seeking”
• “Pain Medications are the only thing that
helps”
• “Pain has power over me.”
• “I never knew I could feel this good taking
so little medication”

6. Pain
• “… an unpleasant sensory and emotional experience associated with actual or
potential tissue damage, or described in terms of such damage.”
– Brain makes up a story based on past experience or what others around you have felt.
– Can be emotional or psychospiritual (Trauma?)
• Pain is complex-We need a complex solution
• Nervous system is always adapting- HOPE
– Change our your brain perceives pain (dimmer switch)
– Fight or Flight response
• Other causes for pain:
– Nausea/Vomiting/Gas
– Sleep Deprivation
– Poor Coping Skills
– Stress
– Social Concerns
• Financial problems
• Relationship difficulties
– Psychological Conditions
• Anxiety
• Depression
– Untreated persistent pain
• Explanation of Pain: Tame the Beast
https://www.youtube.com/watch?v=ikUzvSph7Z4&vl=en
• Low Back Pain Video: https://www.youtube.com/watch?v=BOjTegn9RuY

7. Car Analogy for Pain Management
• Imagine a car with four totally flat tires
• 1 tire=Medications
• Other 3 tires?
• Living a full life with pain = YOU taking an active role
• Each person’s needs differ. Develop your TOOL BOX
– Learn various tools
– Determine when to use what tool
– Assess who they want on their team
– Maintain car
• Pain takes a team effort, with the patient being the driver, to live a full
life despite pain
• “Successful” treatment of a person with chronic pain
– Learn how to independently manage their condition
– Maximize participation in everyday life activities
– Minimize discomfort and side effects
– Avoid other bad consequences of treatment

8. Misconceptions About Pain
• Pain is “all in your head”
• You just have to live with pain
• Pain is a natural part of getting older
• The best judge of pain is the RN or MD
• Seeking medical care for pain is a sign of
weakness
• Using pain meds leads to addiction
• Providers do not see me as a whole person
• None of my providers agree

9. Importance of Pain Treatment
• Poorly managed pain can compromise
– Physical and Mental Health
• Decreased Appetite
• Weakened immune system
• Aggravate other health problems
• Depression, anxiety leads to more pain
• Difficult to concentrate
– Social or intimate relations
– Ability to sleep and perform daily tasks
– Work productivity and financial well being
– Loss self-esteem and independence

11. Unintended Nocebo Effect
• Nocebo- inert therapy that creates
harmful effects
• Degeneration, stenosis, inflammatory
does NOT equal life-long pain
• Good sayings:
– Motion is lotion
– Nerves in smaller houses
– Fussy joints
– Crabby tissues
– Spine changes like wrinkles on the inside

12. Why Are Opioids So Bad?
• Opioid pain medications do not treat the pain
• They block the brains perception of pain
• Long-term use often leads to:
– Decrease in immune function
– Depression
– Weight gain
– Changes in hormones (6 that are vital for life)
– Decrease in sex drive
– Fatigue
– Long term disability
– Development of tolerance-meds become less effective
– Decreased coping skills-psychologically NEED the opioids for your pain
– Fear and isolation
– Increased complications as you age
– Drug-Drug interactions
• Even if stable, add ABX CAN = OD
• “If meds aren’t improving function, they may not be appropriate for
you”

13. Dependence and Addiction
• Physical dependence-withdrawal symptoms if
sudden stop (sweating, inc HR, nausea,
goosebumps, diarrhea, anxiety)- NORMAL
• Tolerance- the need to take more medication
for same effect-less likely with persistent pain-
NOT ADDICTION
• Addiction-continue to use the drug when it is
no longer needed (continued use despite
harm, craving)
• Pseudo-addiction- result of inadequately
managed pain

14. Role of the Pharmacist
• Detailed information on the differences between
medications in the same class
• Right drug for THAT patient
• Evaluate drug-drug and drug-disease interactions
• Comprehensive Medication Review (or MTM)
– Different providers
– OTC
– Herbals
• Assess Barriers and find solutions
• Collaborative agreements - limited prescribing
• Prescribe Naloxone when appropriate?

15. Medication Options
• Muscle “Relaxers”
• Anticonvulsants (Nerve Pain, etc)
• Antidepressants
• Joint Pain (anti-inflammatories)
• Acetaminophen
• Opioids

16. Muscle Pain

17. Muscle Spasticity Muscle Spasms (short-term use rec)
Baclofen
• (Side Effects: dry mouth, sedation, W/D)
Cyclobenzaprine
 No direct skeletal muscle activity, similar to TCA
 SE: sedation, dry mouth, urinary retention, fatigue, tachycardia,
cardiac conduction disturbances, drug interactions
Tizanidine
 Take with food
 Tabs DO NOT EQUAL Caps
 SE: dry mouth, low BP, weakness, increase liver function tests
 Decrease slowly (2-4 mg/day)
 Interactions (increased w/ Fluvoxamine, Cipro, birth control)
Metaxolone
 Mechanism unknown
 SE: dizziness, headache, nervousness, epigastric discomfort,
muscle cramping, less drowsiness or cognitive defects, inc risk of
resp depression
 Holy Trinity of Death- opioids+ anxiety med (benzo) + this
 Avoid with renal or hepatic impairment
Diazepam
 Approved for both spasticity and muscle spasms
 SE: sedation, potential for abuse/dependence, W/D
 Caution with opioids- risk of respiratory depression
Methocarbamol- like guaifenesin
 Mechanism unknown
 Less sedation than cyclobenzaprine, brown or green urine, less
muscle coordination, grand mal seizures possible
Chlorzoxazone
 Acts at the spinal cord and subcortical areas of the brain
 SE: orange, red, or purple urine, dizziness, somnolence,
possible overstimulation, possible liver toxicity (need LFTs)
Dantrolene
 like phenytoin
 SE: muscle weakness, dyspnea, dysphasia, somnolence,
diarrhea, may be toxic to liver (>800mg/d for 3-12 months)
Orphenadrine
 Like a stronger diphenhydramine
 Anticholinergic and NMDA receptors in CNS
 SE: dry mouth, sedation, constipation, ocular hypertension,
palpitations, sinus tachycardia
Botulinum toxin (BOTOX)
 Onset 14 days
 Duration 3 months
 Body develops new nerve terminals
 Potential autoimmune response
Carisoprodol
 Alters interneuronal activity, reduce perception of pain
 Metabolite-meprobamate (barbiturate-like activity)- psychoactive
 Poor CYP 2C19 metabolizers – 4 x carisoprodol
 SE: drowsiness, headache, vertigo, insomnia, an inc risk of resp
depression, more dizziness, less anticholinergic
 Holy Trinity of Death- opioids+ anxiety med (benzo) + this

18. Nerve Pain
• Gabapentin
• Pregabalin (Lyrica)-can be increased
quicker than gabapentin
• Anti-seizure meds
– Carbamazepine (Tegretol)
– Phenytoin (Dilantin)
• Lidocaine patch
• Ketamine Cream

19. Anticonvulsants
Co-morbid anxiety
• Gabapentin
– First line therapy for Diabetic Peripheral Neuropathy, CRPS
– Dec painful dysthesias, hyperalgesia, centralized pain and improve sleep
– Possible to enhance morphine efficacy
– Smaller dose adjustments possible (Titration based on tolerability)
– Can dose BID with bigger dose at bedtime
– SE: somnolence, dizziness, and infection (safer than TCAs-esp elderly)
– Treatment dose 2400-3600 mg/d (Max 4800 mg),
• Renal dysfunction: 1400mg/d (CrCl 30-59), 700mg/d (CrCl 15-29), 100-300 mg/d (CrCl < 15)
• Pregabalin- more predictable PK
– FDA approved -neuropathic pain associated with DPN, PHN, and fibromyalgia, and
as adjunctive for partial seizures
– Improves sleep
– SE: dizziness, somnolence, peripheral edema, infection, and dry mouth
– Treatment dose 300-600 mg/d
• Renal dysfunction: Max 300mg/d (CrCl 30-60), 150mg/d (15-30), 75mg/d (< 15)
• Efficacy with spasticity (1200-3600mg gabapentin/d or 150-600 mg
pregabalin/d)

20. Gabapentin to Pregabalin
• Gabapentin ≤900 mg/day →
pregabalin 150mg/day
• Gabapentin 901 mg/day to 1500 mg/day →
pregabalin 225 mg/day
• Gabapentin 1501 mg/day 2100 mg/day →
pregabalin 300 mg/day
• Gabapentin 2101 mg/day 2700 mg/day →
pregabalin 450 mg/day
• Gabapentin >2700 mg/day →
pregabalin 600 mg/day

21. Anticonvulsants
• Obese or seizure history
– topiramate (Topamax)
• Co-morbid bipolar or seizure history
– Carbamazepine (Tegretol)
– Oxcarbazepine (Trileptal)-analog of
carbamazepine-
– Phenytoin
– Lamotrigine (Lamictal)
– Valproic acid (Depakote)

22. Topicals
• Lidocaine
– Lidocaine 5% patch- Rx (often not covered)
– Lidocaine 4% patch- OTC
– Lidocaine cream
– FDA approved- post-herpetic neuralgia,
diabetic neuropathy
– Off-label- Neuropathic pain
• Ketamine 5%/Lidocaine 5% cream-
compounded cream
• Biofreeze

23. Shingrix Vaccine
• Prevention of Herpes zoster (shingles) for patients 50 years
or older
• GOAL: avoid potentially chronic pain
• Local Adverse Reactions: pain, redness, swelling
• General: muscle pain, fatigue, headache, shivering, fever, GI
symptoms
• 2 doses 2-6 months apart (SHORT SUPPLY)
• Recommended to complete series
– Reaction to first doesn’t predict response to 2nd
• At least 2 months after Zostavax
• Can be administered with other vaccines
• Delay if active herpes zoster
• Moderate to high immunosuppressive doses excluded from
trials-more to come

24. Antidepressants
 SNRI
 Duloxetine (Cymbalta)–more NE, 5HT
 Start 20mg daily if sensitive to medications
 Max dose 60mg/day for pain (120mg for GAD and MDD)
 SE: nausea, increased anxiety, dry mouth, insomnia, sedation, fatigue, sexual
SE (less than SSRI)
 Milnacipran (Savella)- 3:1 NE:5HT
 Start 12.5 mg QD x 1d, then 12.5mg BID x 2d, 25mg BID x 4d, then 50mg BID
 Max 200mg/d
 Baseline kidney function
 Venlafaxine (Effexor)
 higher doses needed for NE effect, inc BP more with IR, do not stop suddenly
 Desvenlafaxine (Pristiq)
 less drug interactions of metabolism concerns
 Atypicals
 Bupropion
 less sexual SE, wt loss, stimulating, inc risk of seizures skinny and/or elderly,
avoid w/ sz or bulimia
 Mirtazapine
 Antihistamine, Anticholinergic, less sexual SE, wt gain
 Trazodone
 sedation, “messy drug” more 5HT, minimal anticholinergic

25. Sleep
• Tri-cyclic Antidepressants-TCAs
• Includes:
– Nortriptyline (Pamelor)– less anticholinergic and antihistamine, potential nerve pain treatment
– Amitriptyline (Elavil)- most serotonin, mod anticholinergic
– Imipramine (Tofranil)– middle of the pack for receptor activity
– Desipramine - best for pain- most NE
• What to expect: 4-5 weeks at full-dose to see effects with slow titration (1-2 weeks between dosage increases),
dosed 1-3 times daily
• Side effects: mod to high sedation, morning hangover effect, weight gain, dry mouth, urinary retention, constipation,
orthostasis, QTc prolongation?, cardiac conduction disturbances, not recommended for elderly
• Interactions: anti-fungals, chloroquine, Cymbalta, some antibiotics
• May also be effective for migraines
• Trazodone
• What to expect: 4-5 weeks at full-dose to see effects with slow titration (1-2 weeks between dosage increases),
dosed 1-3 times daily
• Side effects: orthostasis, priapism, dry mouth
• Interactions: other antidepressants or sleep aids
• May reduce anxiety
• Antihistamine (diphenhydramine)
• Hypnotics
• zolpidem (Ambien), zaleplon (Sonata), eszopiclone (Luneta)
• Suvorexant (Belsomra)
• Ramelteon (Rozerem)
• Benzodiazepines (alprazolam, clonazepam, lorazepam)

26. Serotonin Syndrome
• Serotonin syndrome symptoms within several hours new drug or increasing a
dose of a drug
• Signs and symptoms include:
– Agitation or restlessness
– Confusion
– Rapid heart rate and high blood pressure
– Dilated pupils
– Loss of muscle coordination or twitching muscles
– Muscle rigidity
– Heavy sweating
– Diarrhea
– Headache
– Shivering
– Goose bumps
• Severe serotonin syndrome can be life-threatening. Signs and symptoms
include:
– High fever
– Seizures
– Irregular heartbeat
– Unconsciousness

27. Joint Pain
• Cox 1 selective anti-inflammatories
– Ketorolac
– Ketoprofen
– Indomethacin
– Naproxen
– Ibuprofen
– Fenoprofen
• Cox 2 selective
– Etodolac
• Turmeric

28. Anti-inflammatory Medications
 Dec prostaglandins-less inflammation= less pain
 COX 1 Inhibitors + PPI- Increased risk of GI bleeds
 Aspirin products
 ASA 400 mg+ Caffeine 32 mg/ tablet (Anacin)- 2 tabs/dose
 ASA 250mg, ASA 250mg, Caffeine 65 mg- 2 tabs/dose
 Indomethacin
 Naproxen
 Ibuprofen
 Ketorolac- limit to 5 days for severe acute pain, max 40mg/day
orally, usually only following IV therapy
 COX 2 Inhibitors- Increased heart attack risk
 Sulindac
 Diclofenac
 Celecoxib
 Meloxicam
 Etodolac
COX1COX2

29. Anti-inflammatory Medications
 Topical
 Diclofenac 1% topical gel- limited whole body effect-dose four times daily
 Ketoprofen, naproxen, salicylate products (Salon-Pas), Tiger-Balm
 Allergies
 Diclofenac, nabumetone, meloxicam/piroxicam, aspirin-all SEPARATE classes
 Etodolac, indomethacin, ketorolac, sulindac- SAME CLASS
 Ibuprofen, ketoprofen, naproxen, and oxaprozin- SAME CLASS
 Additional concerns
 Kidney problems
 Avoid in elderly or pregnancy
 High blood pressure
 Swelling
 Abdominal pain
 GI bleeding (esp w/ pred or aspirin)
 History of stomach ulcers
 Take with food, monitor kidneys, watch for signs of bleeding, take
with PPI (ie omeprazole, etc)

30. Stop Anti-inflammatories Before Surgery
Ibuprofen
=1 day
Naproxen
= 4 days
Celecoxib
= 3 days

31. Acetaminophen
• Max 4 grams per day (8 extra strength!)
• 3 grams for liver dysfunction or elderly
• Include ALL acetaminophen (sleep aids,
cold meds, etc)

32. Elephant In The Room- OPIOIDs
• CDC Guidelines- multimodal approach
• Avoid with Benzodiazepines
• MORE AND MORE restrictions- manufacture supply, pharmacy supply,
insurance coverage, provider willingness (FEAR)
• **Often will want urine drug screens
• Pure Mu agonists
– Morphine, codeine, hydrocodone, oxycodone, oxymorphone
• Partial Mu agonists
– Buprenorphine, butorphanol
• Central (Mu+NE/5HT)
– Tramadol, tapentadol
• Methadone

33. Opioids
• Central (Mu+NE/5HT)
– Tramadol
• opioid receptor, weak NE and serotonin reuptake inhibitor
• max 400mg/day (severe renal disease 200mg/day)
• Caution with seizure history
– Tapentadol
• opioid agonist, NE activity
• Start 50mg every 4-6 hours as needed
• Avoid with acute or chronic pancreatitis
• Not recommended for severe renal or hepatic dysfunction
• SE: Nausea, Dizziness, Vomiting, Somnolence, Dry mouth, Headache
• Methadone
• Buprenorphine
– Butrans
– Suboxone, Subutex

34. Methadone
• 5HT, NE, NMDA antagonist, Mu-opioid agonist
• Good for neuropathic pain
• QTc prolongation-consider baseline EKG, 30 days, and
annually
– More if >100mg/day, seizures, or QTc 450-500ms
(D/C at >500ms?)
• T1/2 7-49 hours
• Cyp 3A4, 2B6, 2C19
• Monitor K+
• Wait 5-7 days between dosage changes
• Conversion not linear (higher morphine dose=less
methadone needed)
• 2.5mg Q12H for opiate naïve

35. Buprenorphine
• Butrans patch does NOT require special addiction licensing
• Less risk of respiratory depression
– still risk with other sedating meds
• Less hyperalgesia and tolerance
• Possibly help with depression
• May be used with opioids
– caution when starting Butrans if already on opioids
• CYP3A4 and CYP 2D6 metabolism = many drug interactions
– Caution w/ amitriptyline, fluoxetine, sertraline, anxiety or sleep meds, erythromycin, and
antihistamines
• QTc prolongation (congenital, other QTc prolongation drugs, or >20mcg/hr patch)
• **CONCERN for surgery- continue buprenorphine if can’t D/C 1 week prior
– Increased risk of OD after 2-3 days after patch removal
• Butrans Patch 7 day matrix patch
– Available in 5mcg/hr, 10mcg/hr, and 20mcg/hr
• Buprenorphine+ Nalaxone- Suboxone

36. Low dose Naltrexone (LDN)
• LDN- reduce pain in inflammatory conditions
– Fibromyalgia
– Crohn's disease
– Multiple sclerosis
– Complex regional pain syndrome
• Anti-inflammatory properties on microglial cells
– Toll-like receptor-4 (TLR4) antagonism found on microglia
– Microglia produce inflammatory and excitatory factors = increase pain sensitivity, fatigue, cognitive
disruption, sleep disorders, mood disorders, and general malaise
• Enhances endogenous opioid production
• Possible modulation of immune function
– Studies indicate treatment for autoimmune conditions?
• LDN has antagonist activity on
– mu, delta and kappa (lesser degree)
• Co-administered with opioid analgesics, dose is too low to compete well
– Synergistic effect on pain relief - less opioids and less adverse effects
• Contrave (bupropion 90 mg+ naltrexone 8mg)
• Start 0.5-1 mg daily in a solution form (compounded)
– Double every 1-2 weeks
– Usual dose 4.5-6mg. Max 9mg
– Titration to effect for pain
• https://www.ldnscience.org/patients/find-a-doctor
• https://www.ldnscience.org/patients/where-to-buy-ldn

37. Credit to: Dr AZ Tahir

38. NMDA antagonists
• Ketamine- topical, oral
– hypnotic, analgesic, amnesia
– SE: hallucinations, confusion, delirium
– Concerns for diversion, harm to patient
• Dextromethorphan
– SE: reduce opioid dose in surgery
– diabetic neuropathy

39. Medical Cannabis
• Cannabinoid receptors
– CB1: psychotropic action of THC and its analgesic effects
– CB 2: modulate persistent inflammatory and neuropathic pain conditions
• CBD- Anti-inflammatory, possible decrease anxiety and nerve pain
– Hemp (OTC)- need testing (Consider CBD Plus or Medterra)
• THC
– Inhaled: peak effect 2-30 min and rapid decline for 30 min
– Oral: Low bioavailability. Peak 1-6 hours, and half-life 20-30 hours
– Psychoactive
• Dosing
– There is no standardized dosing
– Variable as each person is different (genetics of endocannabinoid system, metabolism, tolerance, past exposure)
– Conversion from smoked to oral dosing unknown
– Titrate slowly
• Research
– RCT are limited to short time frames of the study and small patient populations
– Another study showed no therapeutic effect against a pain stimuli at 2% THC but increased pain experience at 8%.
Suggestion of a therapeutic window. (Only low strength approved for studies)
– Multiple studies looking at HIV neuropathy or neuropathic pain are promising for decrease in VAS pain rating
– The most popular theory is that the more neuropathic pain issues do better with higher THC while the most
chronic, intractable while spread pain/inflammatory pain does better with higher CBD.

40. Medical Cannabis
• Concerns
– Cost prohibitive
– Legal issues: Federal Vs. State
– Exchanging one epidemic for another??
– Long term effects are unknown
• Drug-Drug Interactions
– Potentiate CNS depressant effects with benzodiazepines, alcohol, opioids
– Possible mania induced when combined with SSRIs
– Increased tachycardia and delirium with TCAs and sympathomimetic
– Increase risk of immunosuppression with corticosteroids
– May decrease effectiveness of anti-psychotics
• Side Effects
– Impairments of memory (cognitive change), decrease motor coordination, altered judgement
– High dosing my cause psychosis
– Increased heart rate
– Nausea and vomiting (“cannabinoid hyperemesis syndrome”)
– Dry mouth
– Dizziness and headache
– Sedation
– Dependence and addiction/Withdrawal symptoms
– Increased risk of pulmonary issues (similar to smoking)
– Increased risk of lower birth weights, possible affect on neurodevelopment
– Possible increased risk of cancer
– Increased risks of traffic accidents
– May cause acute pancreatitis

41. Topicals
• Biofreeze- 6 times daily, avoid mucous membranes
– Consists of Menthol 10%, Amica Montana, Calendula,
chamomile, dimethyl sulfone (MSM), echinacea, ethanol, ilex
paraguariensis, isopropyl myristate, Juniper Berry, white tea.
– Classified as topical analgesics- a ‘counter irritant’ mechanism
– Menthol may stimulate cold receptors in the skin that may help
regulate pain
• Capsaicin- cream and patch
• Essential Oils
– Oral possible-avoid high doses

42. Vitamin D
• Low vitamin D levels associated with increased:
– Muscle pain
– Joint pain
– Fatigue
– Headaches
– Difficulty sleeping
• Monitoring ?
– Initial necessary?
– Every 1-2 years once stable or if pain worsens
• Supplementation?
• Avoid if Phos is high
• Goal 40-60 ng/ml blood levels (controversial)
• Sun exposure is MOST appropriate way to get Vit D

43. Medication considerations
• Sometimes, we just have to start over.
• Starting dosage too high
• Titrate slowly
• Change 1 med at a time
• Use side effects as potential benefits
(sedation, hypertension)
• Use med peak times and space out
medications

44. Pharmacogenomic testing
• PK biomarkers -CYP2D6, CYP2C9, CYP3A4, CYP3A5, and CYP2B6
• PD biomarkers included are OPRM1 and COMT
• Poor vs rapid metabolizers
• Poor CYP2D6 metabolizer-like having a CYP2D6 Inhibitors
• APAP/Codeine + Paxil= no conversion to morphine= less effective

45. Allergies To Medications
• True Allergy-Anaphylaxis
• Concerns- hives, facial swelling
• Intolerances are not allergies

46. Interventions
• Epidural Blocks
• Radio-Frequency Ablations (RFA)
• Steroid injections
• ETC ETC ETC

47. Complementary Treatment
• Exercise/Yoga
• Breathing
• Meditation
• Essential Oils
• Nutrition
• Psychology
• Energy-Based
• Manipulative and Body-Based Care
• Functional Medicine

48. Essential Oils for Pain
• DISCLAIMER: The information contained
in this handout has not been evaluated or
approved by the FDA or any other
regulatory agency. The information is not
intended to diagnose, treat, cure, prevent
or otherwise reduce the effects of any
disease or ailment.

49. How Do Essential Oils Work?
• Mechanisms of action:
– Aromatic: Olfactory nerve via limbic system
– Topical: superficial and systemic effects
– Internal: via pathways unique to each oil
• The chemical makeup of the oils determine their
physiological properties
– Terpines (i.e. mono/sesquiterpines) → Functional group
(alcohols, ketones, etc) → chemical constituent name (i.e.
linalool) → Essential Oil (i.e. Lavender) → Physiologic
effect (i.e. calming)
– Oils for pain management:
• Sesquiterpines: Ginger, copaiba, myrrh, lemongrass
• Monoterpines: Lavender, roman chamomile, bergamot
• Reference: Oil Chemistry Wheel

50. How Do Essential Oils Work?
• Mechanisms of action:
– Aromatic: Olfactory nerve via limbic system
– Topical: superficial and systemic effects
– Internal: via pathways unique to each oil
• The chemical makeup of the oils determine their
physiological properties
– Terpines (i.e. mono/sesquiterpines) → Functional group
(alcohols, ketones, etc) → chemical constituent name (i.e.
linalool) → Essential Oil (i.e. Lavender) → Physiologic
effect (i.e. calming)
– Oils for pain management:
• Sesquiterpines: Ginger, copaiba, myrrh, lemongrass
• Monoterpines: Lavender, roman chamomile, bergamot
• Reference: Oil Chemistry Wheel

51. Essential Oil Chemistry Wheel:
Monoterpenes
Resource: https://www.doterra.com/US/en/blog/science-research-news-doterra-oil-chemistry-wheel

52. Essential Oil Chemistry Wheel:
Sesquiterpenes
Resource: https://www.doterra.com/US/en/blog/science-research-news-doterra-oil-chemistry-wheel

53. How Do Essential Oils Work for
Pain?
• Aromatherapy enhances the parasympathetic
“rest and digest” response, encouraging
relaxation1 and the perception of pain2
allowing one to let go.
• Application of EOs via massage in
combination with the pleasurable odor can
cause deep relaxation
• Some essential oils affect neurotransmitters
and their receptor sites in the brain. Example:
Bergamot3
1. Weil 1996, 2. Beck & Beck 1997, 3. Bagetta et al 2010

54. Essential Oil Administration
• Analgesia (pain relief) through various routes by
different mechanisms:
• Topical- local and systemic effects through
warming and cooling properties, and chemical
makeup of certain oils when applied directly to
skin
• Internal- local and systemic effects. Therapeutic
grade (pure) oils only, dilute “hot” oils (phenol-
based). Not all oils can be taken internally. Max
recommended daily dose 0.05 → 1.3 mL4
• Inhalation- primarily affects the perception of pain
in the brain via the limbic system and
neuroplasticity (reprogramming pain story!)
4. Tiesserand & Young 2013

55. Research With Essential Oils
• Pain
– Soothing Blend (ex. Deep Blue or Cool Azul)
– Lavender- Sodium and/or Calcium Channel blockade
• Anti-inflammatory
– Black Pepper - free radical scavenging and anti-inflammatory properties
– Frankincense (alone) - Anti-inflammatory and analgesic by inhibition of
inflammatory (COX-2) pathways
– Frankincense/ Myrrh -Shown to reduce inflammatory pain in mice
– Ginger - inhibits prostaglandin release and COX-2
– Lemongrass - Anxiolytic effect via GABA receptor, Anti-inflammatory
activity
– Peppermint (as Soothing Blend) - effect signaling pathways related to
inflammation, immunomodulation and wound healing
– Roman Chamomile- Inhibits prostaglandin synthesis by a mechanism
similar to that of NSAIDs (anti-inflammatory)
• Both analgesic and anti-inflammatory
– Bergamot- anti-nociceptive, anti-hyperalgesic and anti-inflammatory
properties
• Nerve Pain
– Frankincense/ Myrrh -reduce nerve pain in mice.
• Peppermint (alone) - for GI discomfort, IBS

56. OILS for Pain
(list is not all inclusive)
Animal (A)
Human (H)
Studies
Type of Pain:
Acute (A) Chronic (C)
Inflammation (I) Nerve (N), Other
(O)
Administration
Topical (T)
Internal (I)
Aromatic (A)
Safety
Bergamot A I, N T, I, A Avoid Sun x 12hrs. May increase concentrations of
certain medications (buproprion, methadone,
ketamine) when taken by any route
Black Pepper A A, C, I T, I, A May cause skin sensitivity- Dilute. Possible increase in
blood pressure
Copaiba A I T, I, A Dilute. Avoid if pregnant. Avoid contact with
eyes/ears. May induce liver stress
Frankincense A, H A, C, I, N T, I, A No Known Safety Concerns
Ginger A A, C, I T, I, A May cause skin sensitivity- Dilute
Lavender A, H A, C, I T, A No Known Safety Concerns
Lemongrass A, H C, I T, I, A May cause skin sensitivity- Dilute. May interact with
certain medications (buproprion, methadone,
ketamine) when taken by any route
Myrrh A A, I, N T, I, A No Known Safety Concerns
Peppermint A, H O (abdominal pain) T, I, A May cause mucus membrane sensitivity. May
decrease breast milk supply
Roman Chamomile A, H I, C T, I, A May increase the concentration of certain medications
(simvastatin, amlodipine, amiodarone, sirolimus,
warfarin, ibuprofen) when taken internally
Soothing Blend (ex:
Deep Blue)-
Wintergreen, Camphor,
Peppermint,
Blue Tansy, German
Chamomile,
Helichrysum, and
Osmanthus.
A A, C, I T Due to possible convulsant activity of camphor and
wintergreen- avoid if seizure history

57. Medications Compared W/ Essential Oils
• Sodium Channel Blockade
– Medications: Lidocaine
– EOs: Lavender
• Prostaglandin +/- COX-2 inhibition
– Medications: NSAIDS (ibuprofen, celbrex)
– EOs: Ginger, frankincense, roman chamomile
• Mu-receptors or CB2
– Medications: OPIOIDS! Or THC
– EO: Copaiba?
• GABA inhibition:
– Medications: Valium (benzodiazepines), gabapentin
– EO: Lemongrass

58. Exercise/Yoga
• Ask yourself
– Is this safe for my body?
– Will I be okay later?
• Stay at the edge while you:
– Keep your breathe as calm as you can
– Keep your body and muscle tension low
– Monitor your pain.
– **DO NOT IGNORE IT or pay too much
attention
• Pain is a moving target so practice
necessary

59. Daily Pain Care Planning
• What is your plan for success today?
• How will you take breaks and how
many times?
• How will you calm your nervous system
and how many times?
• How will you challenge your ability and
how many times?

60. Breathing
• 3 compartment breathing
• Longer, smoother, softer
• Alternate nostril breath-color/words
– Or open and close hands
• Ujjayi- relax eyes, cheeks, mouth, tongue
• Body Scan
• App/Website:
– Breathe2Relax and Tactical Breather-
Diaphragmatic Breathing
– Stopbreaththink.org

61. Meditation or Mindfulness
App/Websites
• CALM – meditations
• Cleveland Clinic Stress Free Now
• Headspace
• http://marc.ucla.edu/mindful-meditations -
free guided meditations in English and
Spanish
• Mindfulness Coach

62. Mind-Body Approach
• Behavior modifications
• Positive Affirmations
• Stress Management
• Distraction
• Guided Imagery
• Cognitive Behavioral Therapy
– Apps: SHUTi, Sleepio, RESTORE
• Biofeedback
• Hypnotherapy
• Music Therapy

63. Nutrition
• Avoid inflammatory foods
– Sugar
– Dairy (Fairlife is better tolerated)
– Gluten
– Fried Foods
– Artificial Additives
– Saturated Fats
• FODMAP diet

64. Comprehensive Self-Management
Websites
• https://masteringpaininstitute.com (highly
recommend)
• https://www.instituteforchronicpain.org/

65. Energy-Based Healing
• Biofield, Healing Touch Therapy
• Qigong
• Reiki
• Magnet Therapy
Where attention goes-energy follows

66. Manipulative and Body-Based Care
• Chiropractor-Osteopathic Manipulation
• Massage- Deep Tissue, Thai
• Myofascial work-FDM
• Physical and Occupational Therapy
• Acupuncture
• Heat/Ice
• Topicals

67. Myofascial tools
• Theracane
• Jack Knobber

68. Functional Medicine
• Determining "root causes" of diseases
based on interactions between the
environment and the gastrointestinal,
endocrine, and immune systems to
develop "individualized treatment
plans".

69. Myofascial Pain
• WORK IT OUT
• NSAIDs
– Oral
– Diclofenac patch
– Cox-2 inhibitors
• Lidocaine patch/cream
• Tizanidine, cyclobenzaprine, and diazepam
• Duloxetine
• Sumatriptan
• Tramadol?
• TENS, Trigger point inj, manual therapy, US, steroid
injections

70. Fibromyalgia Guidelines
• Non-pharmacological with active patient participation
– Aerobic exercise, Tai Chi, Yoga
– CBT, Mindfulness
– Possible acupuncture, chiropractor, and therapeutic massage
– FDM/myofascial release
• Other triggers: mood or sleep disorders (CPAP??)
• Duloxetine or milnaciprin
• Amitriptyline and cyclobenzaprine
• Gabapentin or pregabalin (Lyrica)
• Opioids are NOT preferred and OFTEN makes this worse
• Avoid Benzodiazepines or sleep aids (like zolpidem)
• Sleep!

71. Geriatric Pain
• APAP (For ALL…except liver failure)
• Anti-inflammatory- risk vs benefit (+ PPI)
– PRECISION study- celecoxib similar CV risk to IBU
• Opioids
• Gabapentin, Pregabalin (decrease dose for renal
dysfunction)
• Topical lidocaine, diclofenac, capsaicin, menthol
• AVOID cyclobenzaprine, metaxalone,
orphenadrine, methocarbamol, carisoprodol,
chlorzoxazone
• AVOID TCAs, if possible (amitriptyline,
nortriptyline, doxepin)
• Adequate therapeutic trial before discontinuation

72. End Stage Renal Disease
• APAP
• Antidepressants
• TCAs
• Savella (increased half-life?)
• Tapentadol
– highly protein bound
– larger molecular weights
– higher lipophilicity
• It is recommended to avoid duloxetine and
venlafaxine, if possible.

73. Liver Dysfunction
• APAP – 2-3 g per day
– Prolonged t ½
– No accumulation if stable disease
• AVOID NSAIDs
• Gabapentin and pregabalin
• TCAs-low dose and gradually titrate
• AVOID carbamazepine
• Fentanyl and hydromorphone
• Methadone-avoid with alcohol

74. Pain Conversation
• Describe your pain
– Sharp, stabbing, pins and needles, numb, aching, burning, dull
– Show where it hurts
– How did it start
– Describe what makes it better or worse
• Ask for recommendations (think 4 wheels)
• Address your concerns or worries
• Develop a back-up plan
• Ask all your medication questions
– Side effects of meds
– What is the long-term effect?
– Will medicines lose their effectiveness?
– Drug interactions
– What to monitor

75. Communication Tips
u Become the expert of your pain
u Start a pain journal; take notes about your pain
u Write your questions and concerns
u Take them with you to the doctor
u Express yourself clearly and directly
u Be assertive and listen to other side
u Strive for a win-win solution
u Take someone with you
u Take responsibility to reach goals

76. Patient Empowerment
• What is your role?
• Maintain a pain diary or log
– Apps
– Chart
• Bullet journaling and bullet journal charting
• Document what you learned
• Develop different tools
• Always continue to learn (reputable sources)
• Join support groups-get involved
• Celebrate successes
• Dietary and lifestyle changes
• Learn something new from every provider
• www.PainToolkit.org

77. www.paintoolkit.org/tools

78. Goals of Treatment
• Decrease frequency and/or severity of pain
• Improve quality of life
• General sense of feeling better
• Gain independence
• INCREASED LEVEL OF ACTIVITY
• Return to work or other meaningful activity
• Discontinue or decrease medication use

79. Summary
• ♥ Pain is complex. Think outside the box
• ♥ EVERYONE is different and responds differently to treatment
• ♥ Treat pain at the source
u ♥ There are MANY options available
u ♥ Effective treatment requires addressing all 4 tires on your car,
and maintaining your car
u ♥ Developing and mastering different tools takes time and patience
u ♥ Educating yourself, keeping notes, and remaining open-minded
will help you play an active role in your pain care decisions
u ♥ Listen to your body when it whispers, so you can avoid the
scream
u ♥ Awareness is the first step.
u ♥ Have compassion for yourself
u ♥ Persistent Pain doesn’t equal Chronic Pain
u ♥ YOU CAN INFLUENCE YOUR PAIN
u ♥ What will you put in your tool box?

80. Patient Resources
• American Chronic Pain Association www.theacpa.org
– https://www.theacpa.org/wp-content/uploads/2018/03/ACPA_Resource_Guide_2018-Final-v2.pdf
• Pain Toolkit www.paintoolkit.org
• National Fibromyalgia and Chronic Pain Association www.fmcpaware.org
• MedLine Plus: Drugs, Herbals, and Supplements -
http://www.nlm.nih.gov/medlineplus/druginformation.html
• American Society of Health-System Pharmacists: http://www.safemedication.com/
• Understanding Pain in Less than Five Minutes, and What to Do About It:
https://www.youtube.com/watch?v=C_3phB93rvI
• Back Pain Video
• https://internationalpain.org/
• Books:
• Books:
– Master Your Pain: A Comprehensive Science-based Method to Help You Live Well With Chronic Pain by
Jill B. Fancher PhD
– Full Catastrophe Living By Jon Kabat Zinn– Mindfulness approach to managing chronic pain
– The Body Keeps the Score by Bessel Van Der Kolk- discusses the relationship between trauma and
chronic pain (and other chronic conditions)
– Explanation of Chronic Pain: Book: Why do I hurt by Adriaan Louw

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83. Questions?
www.moodboard.com
Contact information:
JoAnna@PainPartnersLLC.com