Currently, we are in the middle of an epidemic. More people die from addiction to pain medications then die from car accidents. This lecture explores the biopsychosocial model of chronic pain. It includes pharmacotherapy, psychotherapeutic and other treatment modalities.

1. A B I O P S Y C H O S O C I A L A P P R O A C H T O C A R E
CHRONIC PAIN TREATMENT
MANAGING RISK

7. TREATMENT LEVELS
• Level I treatment encompasses the standard approaches to
the treatment of chronic pain including pharmacologic
management, intervention management, non-
pharmacologic management and complementary medicine
management
• Level II treatment includes referral for interdisciplinary pain
rehabilitation or surgery for placement of a spinal cord
stimulator or intrathecal pump.
• Level II treatments may be effective interventions for patients
with chronic pain who have failed more conservative
treatment options.
• Level II treatments are designed for the most complex and
challenging patients with chronic pain

8. PAIN ASSESSMENT
• Functional Assessment Including: pain location, intensity,
quality, onset/duration/variations/rhythms, manner of
expressing pain, pain relief, exacerbation triggers, effects
of pain and response to previous treatments.
• General Assessment: history, stressors, support, health
beliefs, physical comorbidity, and psychiatric
comorbidities.
• Assessment Screeners: Function and Quality of Life and
pain scales.
• Assess Biological Mechanism of pain.
• Assess for Comorbid Psych: DIRE Score, PHQ9, PC-PTSD,
GAD7, SBIRT, CAGE, AUDIT, MDQ etc. Sleep Disorders.

9. TYPES OF PAIN - NEUROPATHIC
• Neuropathic Pain: Pain caused by damage to the
somatosensory nervous system e.g. periferal neuropathy,
sciatica, trigeminal neuralgia, post-stroke neuropathic
pain.
• Clinical Indications:
• Neuropathic pain is usually described as burning or
shooting/stabbing.
• neuropathic pain is usually described as burning or
shooting/stabbing.
• Neuropathic pain often follows a specific nerve path e.g.
stocking/glove distribution of peripheral neuropathy.
• numbness in the pain territory, sensitivity to a non-noxious
stimulus like light touch or rubbing (allodynia), or coolness of
the skin in the pain territory (sympathetically mediated pain).

10. FIBROMYALGIA – A SPECIAL CASE
• Fibromyalgia syndrome: widespread musculoskeletal aching,
stiffness and tenderness.
• Current research indicates fibromyalgia is a centrally (brain)
mediated neuropathic pain syndrome
• It can be considered a special case within neuropathic pain.
• The 2010 American College of Rheumatology Criteria Diagnostic
Criteria for Fibromyalgia:
• Presentation of widespread pain and symptoms for three months or
more
• Presentation of widespread pain and symptoms for three months or
more
• Symptom Severity Scale that assesses the severity of fatigue, waking
unrefreshed and cognitive symptoms, as well as the extent of other
somatic symptoms

11. PHARMACOTHERAPY
NEUROPATHIC PAIN
• First goal – Manage or eliminate the underlying causes of
pain e.g. better managed diabetes or cancer treatment.
• Gabapentin and pregablin: Growing consensus as first
line treatment. 1/3 of patients had significant
improvement (multi-site study).
• Excretion – 100% Renal (Kidneys) dosage modulation needed in
those with poor renal fxn.
• Mechanism - Modulates alpha2delta subunit of the N-type
voltage-gated calcium channels, regulating influx of calcium
into the nerve reducing the outflow of excitatory
neurotransmitters that transmit pain.
• Indications: Pregabalin is indicated for treatment of diabetic
neuropathy, postherpetic neuralgia and fibromyalgia, (possibly
for spinal chord inj) as well as for partial onset seizures.
• Indications: Gabapentin has an indication for diabetic
neuropathy pain, postherpetic neuralgia, fibromyalgia, and
partial onset seizures

12. PHARMACOTHERAPY
NEUROPATHIC PAIN
• ANTICONVULSANTS
• LCarbamazepine: Indicated in idiopathic trigeminal
neuralgia (lack of other evidence).
• topiramate, lamotrigine, oxcarbazepine and tiagabine may
be effective and evidence is still developing.
• Tricyclic Antidepressants
• Tricyclic antidepressants (amitriptyline, nortriptyline,
desipramine, imipramine and others)have a role in pain
treatment.
• Their mechanism of action is believed to involve
potentiation of descending inhibitory pathways, especially
at the level of the lower brainstem.

13. PHARMACOTHERAPY
NEUROPATHIC PAIN
• Opioids
• Mechanism: In general opioids are not thought to have an
antineuropathic mechanisms, they are nevertheless potent
analgesics.
• Methadone and tramadol, may be more effective than
others in neuropathic pain.
• Methadone blocks: NMDA receptor is involved in central
sensitization, windup, neurogenic hyperalgesia, and
development of opioid tolerance
• Tramadol: weak opioid analgesic that also causes serotonin
reuptake inhibition like tricyclic's

14. MUSKOSKELITAL PAIN
• Skeletal muscle pain is a common cause of chronic
pain.
• Failure of proper dx can lead to result in poor treatment
outcomes, unnecessary surgery etc.
• Myofascial pain is regional muscle pain
• Characterized by painful muscle dysfunction with loss of range
of motion; and by tenderness at muscle sites that causes
referred pain.
• Treatment:
• Restoring muscle balance and function through physical therapy
not medication management.
• Managing factor perpetuating problem e.g. posture, repetitive
stress or work place factors.
• Trigger point injections, acupuncture can be effective adjunct.

15. PHARMACOTHERAPY
MUSCULOSKELETAL PAIN
• Screen for serious medical pathology, and for
psychological and social factors that may delay
recover.
• Pain Assessment: Rate location, duration, intensity on
pain scale, screen for medical pathology, social factors
and psychological factors that could impact course.
• Screen for serious medical pathology, and for
psychological and social factors that may delay
recovery.
• A graded exercise program starting within baseline and
gradually increasing in a time-contingent manner works
best.

16. BIOPSYCHOSOCIAL APPROACH
MUSCULOSKELETAL PAIN
• Physical Rehabilitation:
• Fitness Program: Graded strength, Cardio, Flexibility, Balance.
• Body Mechanics: Head position, posture etc.
• Modalities: Ice, Heat, Massage, Pacing.
• Aquatic therapy
• Behavioral:
• Psychoeducational
• Mood/Emotions: Stress management, relaxation tech, Anger tx
• Biofeedback
• CBT
• Pharmacotherapy Targets
• Pain and sleep: Tricyclic's, Anticonvulsants
• Depression and pain: Tricyclic's
• Opioids are rarely indicated

17. INFLAMMATION PAIN AND
COMPRESSION PAIN
• Inflammatory Pain:
• Arthritis, tendonitis and chronic infections are common examples
• Indications: swelling and warmth of tissue and sometimes redness of
the skin
• Mechanism: activation of nociceptors by inflammatory mediators like
prostaglandins or sensitization.
• Treatments:
• NSAID (Non-Steroidal Anti-Inflammatory Drugs)
• Corticosteroids
• Compression Pain:
• Mechanical/compressive pain refers to tumors or cysts that may
compress pain sensitive structures.
• Treatments: Surgical decompression or stabilization, splinting,
strengthening and use of assistive devices can all address mechanical
pain
• Medications: Play less of a role and are less effective. Opioids can be
used to manage pain during treatment process.

18. TREATMENT PLAN OVERVIEW
• A plan of care for all patients with chronic pain should
address all of the following five major elements:
• Set personal goals
• Improve sleep
• Increase physical activity
• Manage stress
• Decrease pain
• Motivation Matters
• Connect to values
• Adapt to stage of change
• Role with resistance
• Support intrinsic movement toward change
• Use change talk

20. PAIN MEDICATIONS
• Opioid Characteristics
• Codeine often has dose-limiting GI side effects and is
therefore not a good choice for chronic use. Ultra rapid
and no effect patients mediated through CYP2D6 Gene for
liver metabolism.
• Transdermal fentanyl patch: Stabilizes levels of medication
in body has high risk of lethality particularly in opiate naïve
patients.
• Hydrocodone is partial synthetic opioid derived from
codine. Takes 20 – 30 min to act and lasts 4-8 hrs.
• Hydromorphone a semi-synthetic μ-opioid agonist.
• Meperidine is metabolized to an active metabolite
normeperidine, which has neurotoxic side effects. It is not
an appropriate choice for chronic use.

21. PAIN MEDICATIONS
• Opiate Medications Cont.
• Morphine is available in rapid-acting and long-acting oral,
injectable and rectal dosage forms. There are 12-hour sustained-
release and 24-hour sustained-release dosage forms of morphine
available.
• Methadone has a long half-life, initially 12-16 hours but may be 90-
120 hours after one week of therapy. Due to the complexity of
dosing and potential for cardiac adverse effects.
• Methadone has a long half-life, initially 12-16 hours but may be 90-
120 hours after one week of therapy. Due to the complexity of
dosing and potential for cardiac adverse effects,
• Oxymorphine is available in intramuscular (IM) and subcutaneous
(SQ) injections, IV use, as well as oral 12 hour extended-release (ER)
dosage forms. It is indicated for use in moderate to severe chronic
pain.
• Tramadol is a weak mu-opioid agonist and also is a serotonin and
norepinephrine reuptake inhibitor. Doses should not exceed 400 mg
daily.

22. PAIN MEDICATIONS
• Buprenorphine acts on the mu opioid receptors.
• It elicits two specific dose dependent therapeutic
responses. within the brain cells, depending on the dose.
• At low doses buprenorphine has effects like methadone, b
• At high doses it behaves like naltrexone, blocking the
receptors so strongly that it can precipitate withdrawal.

24. PAIN MEDICATIONS
• SSRI’s Have some efficacy but not as effective as TCA.
They have less cardiac events.
• Tricyclic antidepressants have a role in the treatment of
neuropathic pain, especially if the patient has co-
existing insomnia, anxiety or depression
• Analgesic effects of TCAs are independent of their
antidepressant effect, and analgesia may be seen with lower
doses.
• Start low and increase doses gradually over several weeks to
months. Maximum analgesic effect may takes several weeks or
longer to be seen.
• Baseline ECG is indicated in patients at risk for cardiac adverse
effects.

25. PAIN MEDICATIONS
• Anticonvulsant or Antiepileptic Drugs
• Carbamazepine is approved for the treatment of trigeminal
neuralgia, and benefits are well established.
• Pregabalin is indicated for treatment of diabetic neuropathy,
postherpetic neuralgia and fibromyalgia.
• Oxcarbazepine is chemically similar to carbamazepine and
may have benefits in the treatment of neuropathic pain,
including trigeminal neuralgia and diabetic neuropathy.
• Gabapentin is approved for the treatment of postherpetic
neuralgia but has been shown to have analgesic effects in
many cases of neuropathic pain syndromes (titrate dose up
slowly to reduce side effects).
• Lamotrigene has efficacy in trigeminal neuralgia, neuropathies
associated with human immunodeficiency virus infection, and
poststroke pain.

26. PAIN MEDICATIONS
• Topical Applications
• NSAIDs can provide acceptable levels of pain relief in knee
and hand osteoarthritis, and are available through a
diclofenac 0.3% topical patch and 1% topical gel.
• Topical lidocaine 5% patches are FDA approved for
postherpetic neuralgia and have shown efficacy in other
neuropathic pain syndromes.
• Capsaicin, the active ingredient in the herbal product
cayenne, is used topically to deplete the pain mediator
substance-P from afferent nociceptive neurons.

27. PAIN MEDICATIONS
• Muscle Relaxants
• Cyclobenzaprine, which is structurally a tricyclic muscle
relaxant, has shown benefits in the treatment of
fibromyalgia at doses of 10 to 40 mg daily.
• Tizanidine is a muscle relaxant that may be used for longer
periods of time due to its mechanism of action (alpha-2
sympathomimetic), so it may cause hypotension. It may
provide benefits as an adjunct in the treatment of
fibromyalgia.
• Baclofen may have benefits in the treatment of lancinating,
paroxysmal neuropathic pain.

28. PAIN MEDICATIONS
• Anxiolytics
• Buspirone is an anxiolytic that is relatively low sedating. It
may take several weeks to see maximum benefits.
• SSRIs or SNRIs are generally the drugs of choice for
treatment of anxiety. Onset of effect is slow and may take
several weeks for maximum benefits.
• Benzodiazepines are beneficial for treatment of acute
anxiety and muscle spasms associated with acute pain but
have minimal benefits in treating chronic pain.
Benzodiazepine side effects of sedation and respiratory
depression may limit the amount of opioids that can be
used safely. They also result in physical dependence when
used long term

29. PAIN MEDICATIONS
• Insomnia Management
• Tricyclic antidepressants are a good choice in the
treatment of insomnia, especially if the patient has anxiety
or depression
• Tricyclic antidepressants are a good choice in the
treatment of insomnia, especially if the patient has anxiety
or depression
• The sedative antidepressant trazodone may be effective in
treating insomnia associated with chronic pain.
• Benzodiazepines generally should be limited to short-term
management of insomnia.

30. ADDICTION OPIATES
• Tolerance occurred in all use of opioids.
• Withdrawal occurs in all opioid use.
• Addiction is a complex set of behaviors that includes
tolerance, withdrawal, drug seeking and lack of regard
for consequences.
• Psuedoaddictive Behaviors: Behaviors that appear
addictive due to under treatment of pain. In one dual
clinic there were 25% of individuals under medicated for
pain.

31. WITHDRAWAL AND OPIOIDS
Early symptoms of
withdrawal include:
• Agitation
• Anxiety
• Muscle aches
• Increased tearing
• Insomnia
• Runny nose
• Sweating
• Yawning
Late symptoms of
withdrawal include:
• Abdominal cramping
• Diarrhea
• Dilated pupils
• Goose bumps
• Nausea
• Vomiting

32. C A S E D I S C U S S I O N
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