Slide 1 - USAFP Home Page

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  • How many of you take care of patients with chronic pain….how many of you like it? Why/why not?
  • Among the second group, goal is not to “coping” with pain, but teaching pt to cope without pain.
    90% respond well to treatment, 10% lead to drugs, compensation.
  • Daily life.
  • Simplified regimen. Continued benzos. Instructed will never increase dosage – goal is taper down to safer dosages.
  • A multidimensional tool to assess chronic pain should be utilized, since chronic pain affects a person' s entire being. Evidence rating C: Penny 1999, as cited in the ICSI guideline.

    Bedridden much of time, uses wheelchair outside of home
    Married, 4 yo daughter
    Medications: fentanyl, MS contin, MS IR, diazepam, lorazepam, piroxicam, venlafaxine

  • Other attributes of pain include:
    Duration of symptoms
    Onset and triggers
    Location
    Co-morbidity
    Previous episodes
    Intensity and impact
    Patient perception of symptoms


    Evaluate function related to pain, from the DoD/VA guideline, Quality of evidence: I, Overall quality: Good, Recommendation: A.
    Evaluate pain intensity using 0-10 scales: from the DoD/VA guideline, Quality of evidence: II-2, Overall quality: Fair, Recommendation: B.
  • - It is essential to elicit history of depression or other psychopathology that may affect perception of pain. Evidence rating B: Carragee, 2005; Schultz 2004, Zautra 2005, as cited in the ICSI guideline.
  • Example of not going to church
  • Goal of therapy is to help pt to acknowledge all of their major problems. Encourage them to let go of pain as an excuse to avoid achieving goals
  • Ask pts to identify ways for them to be a better person.
    Ask: what would you being doing if you did not have pain
    Ask pts what they would be doing if they did not have pain to help them identify goals.


    Consider short-term goals to be identified by the next visit, and long-term goals.
    Provide encouragement.
    Consider changing or tapering medication therapy if pt repeatedly fails to achieve goals or maintains a lack of motivation
  • NSAIDs and acetaminophen
    Corticosteroids
    “Muscle relaxants”
    Neuropathic pain meds
    Anticonvulsants – for neuropathic pain (DM neuropathy, trigeminal neuralgia)
    Anti-depressants
    Corticosteriod – polymyalgia rheumatica
    Abortive and prophylactic meds for migraine
    Opioids
  • Antidepressants with NE uptake are probably best choice for pain relief (Nortrip, buprprion, venlafaxine, mirtazapine)
    SSRIs, SNRIs do not generally improve sleep continuity.
  • Once you have completed your evaluation and a trial of non-opioid therapies, you may decide to consider a trial of chronic opioid therapy. Discussion of decussion phase (section 3.c.iii by Mary…)
  • Opioids
  • Both from the DoD/VA guideline; QE: III, Overall quality: Poor
  • A written plan for treating chronic pain should state objectives to determine success, state if further diagnostic tests are indicated, address psycholsocial and physical function, adjust therapy to meet needs of the patient, and use nondrug modalities in addtion to medication.
    Recommendation as quoted in The American Family Physician, Volume 78, number 10, November 15, 2008, page 1156.
    Original source was: Federation of State Medical Boards of the United States Inc. Model policy for the use of controlled substance for the treatment of pain. May 2004.
    Also cited in the DoD/VA guideline under sections G, H, I.
  • Refer to multidisciplinary pain clinic. Becker 2000, Flor 1992, Malone 1988, Guzman, 2001: QE: I, Overall quality: fair, R: B

    Refer to pain clinic I from DoD/VA

    Refer to substance abuse specialist C from DoD/VA
  • Once you have completed your evaluation and a trial of non-opioid therapies, you may decide to consider a trial of chronic opioid therapy. Discussion of decussion phase (section 3.c.iii by Mary…)
  • Caution with COPD, chr constipation
    IN opioid-naïve, start with low dose short acting, titrate slowly
  • Once you have completed your evaluation and a trial of non-opioid therapies, you may decide to consider a trial of chronic opioid therapy. Discussion of decussion phase (section 3.c.iii by Mary…)
  • Va/DoD Guideline
    http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=4812

    Clinical Guidelines for Use of Chronic Opioid Therapy in Chronic Noncancer Pain: Feb 2009
    http://www.jpain.org/article/PIIS1526590008008316/fulltext

    AAFP online: Assessment and Management of Chronic Pain: June 2008; link to podcasts
    http://www.aafp.org/online/en/home/cme/selfstudy/learninglink/pain1/paintract.html

    www.partersagainstpain.com
  • Slide 1 - USAFP Home Page

    1. 1. Embracing the Management of Chronic Pain COL Diane Flynn, MC, USA LTC Mary V. Krueger, MC, USA USAFP Scientific Assembly 7 April 2009
    2. 2. . .
    3. 3. Outline. • Chronic pain concepts • Initial evaluation of patient with chronic pain • Treatment – Nonpharmacologic – Pharmacologic • Helpful tools .
    4. 4. Key Distinction. Patients with Chronic Pain 90% of patients: easy to help Biomedical model is useful Pain is a problem Complex Chronic Pain Patients 10% of patients: difficult to help Biomedical model is iatrogenic Pain is a potential solution Chronic Pain
    5. 5. Red flags for Complexity. • Belief that “pain means harm” and “all pain must go before return to work” • Passive attitude toward rehabilitation, avoidance of normal ADLs • Overprotective spouse • Poor work history, frequent job changes
    6. 6. Case. • 24 yo active duty specialist, MEB pending • Chronic mechanical LBP, fibromyalgia, trochanteric bursitis, trigeminal neuralgia • PTSD related to sexual assault
    7. 7. History: Past Medical • Specific diagnosis of underlying etiology helps to direct adjunctive therapy • Past medical and surgical history • Comprehensive pain assessment* • Social history: Employment, legal history (pending litigation), social network • Evaluation of occupational risks and ability to perform duties Penny 1999; Level of Evidence : C
    8. 8. History: Pain Assessment Pain Related History • Prior pain treatment and results of this treatment • Adequate trial of non-opioid therapy • Pain related fear • Interference with function: Impact on work/family life • Review prior studies Comprehensive assessment • Intensity of pain: 1 - 10* • Response to current pain treatments • Other attributes of pain • Type of pain – Nociceptive – Neuropathic • Function in all domains* Caldwell, Jensen, Peloso, Roth; Level of evidence: A Breivik, De Conno, Jensen, Orgon, Serlin; Level of evidence: B
    9. 9. History: Psychiatric • Depression – Frequently co-morbid with chronic pain – Presence can complicate chronic pain treatment – Inquire about prior suicidal ideation/attempt • Anxiety disorders • Personality disorders – Presence may be associated with manipulation, noncompliance, and impulsiveness Carragee, 2005; Schultz 2004; Zautra 2005; Level of Evidence: B
    10. 10. History: Substance Abuse • At risk for developing addiction to opioids – Young age – More recent history of abuse • Consult with addiction specialist for co- management if history of substance abuse
    11. 11. Physical • Thorough physical exam in every patient – Etiology of pain – Physical signs of substance abuse • Mental Status Exam – Cognitive function – Anxiety – Depression – Other psychiatric disorders
    12. 12. Selected Studies • Review any studies relating to source of pain – EMG – Radiologic studies: MRI, CT, plain films, etc • Renal function • Liver function tests • Urine drug screen – Presence of illicit metabolites – Be familiar with local sensitivity and specificity
    13. 13. Treatment Plan. • Goal setting • Nonpharmacologic treatments • Pharmacologic treatment – OTC meds – Prescription non-opioids – Opioids
    14. 14. All other problems Pain Patient’s perspective.
    15. 15. Self-management perspective. Emotional problems Family problems Recreational goals Financial/ Vocational goals Drugs/ alcohol Pain
    16. 16. Goal Setting. • Help patients to identify their own goals, should be measurable and realistic • Get family members involved • Should include many facets of life – Exercise – Social/family – Vocation/avocational – Spiritual
    17. 17. Exercise Goals. • Avoid telling patients to let pain be their guide. • Quota system: – Set patient’s exercise baseline • Level of increased pain, weakness, fatigue. • Include aerobic, general strengthening, low level functional activity – Exercise program – six days per week • Start with ½ to ¾ of baseline • Increase incrementally with each exercise session, ie one repetition, one minute, one flight of stairs per day • If patient cannot meet expected exercise on a given day, maintain current level for a few days
    18. 18. Non-pharmacologic interventions. • Exercise • Osteopathic manipulation • Biofeedback • Acupuncture • Ice/heat • Cognitive behavioral approaches
    19. 19. Pharmacologic approaches.
    20. 20. Table 1. — Three-step Analgesic Ladder* Step Pain Medication III Moderate to severe pain Non-opioids plus strong opioids II Mild to moderate pain Non-opioids plus opioids for moderate pain I Mild pain Non-opioids *In each step, adjuvants should be prescribed according to the clinical situations. World Health Organization Analgesic Ladder.
    21. 21. Antidepressant use in Chronic Pain. • For psychologic disorders – >50% of patients with chronic pain have major depression – Depression decreases pain tolerance • For sleep disturbance – 50% of chronic pain patients have sleep disturbance • For neuropathic pain
    22. 22. Suggested Protocol for Opioid Therapy. Treatment Successful Dose Escalation Treatment Failed Stable Phase maintain stable moderate dose Dose Adjustment Phase (up to 8 weeks) Decision Phase
    23. 23. Table 1. — Three-step Analgesic Ladder* Step Pain Medication III Moderate to severe pain Non-opioids plus strong opioids II Mild to moderate pain Non-opioids plus opioids for moderate pain I Mild pain Non-opioids *In each step, adjuvants should be prescribed according to the clinical situations. When Pain Remains
    24. 24. Indications for Opioid Therapy • Failure of relief of moderate to severe pain with non-opioid therapies* – Pharmacologic – Adjunctive therapies • Inability to safely be treated with non-opioids • No absolute contraindications to opioids • Answers ethical imperative to relieve pain* Breivik; Level of evidence: I Joranson, Laval; Level of evidence: I
    25. 25. Contraindications to Opioids Absolute • Allergy to opioid agents • Co-administration of contraindicated drug • Active diversion of controlled substances Relative • Acute psychiatric instability • High suicide risk • Inability to manage opioid therapy responsibly • Unwilling to comply with treatment plan • Elderly patients • COPD patients • Patient with uncontrolled sleep disorders • Intolerable adverse effects
    26. 26. Opioid Use for Non-Malignant Pain • Tailor use to patient’s circumstances and characteristics of their pain • Consider continuing/initiating adjuncts – Opioids are rarely the only treatment – Therapeutic exercise, biofeedback, CBT • Acknowledge trial period of dosing • Choose initial dose and taper to effect/goals • Establish written plan to monitor progress* Federation of State Medical Boards: Level of Evidence: C
    27. 27. Referrals • Medical home key for success • Multidisciplinary team often necessary* – Development of integrated treatment plan – Routine communication between team members • Addiction specialist if evidence of substance abuse • Pain management specialist Becker, Flor, Malone, Guzman; Level of evidence: B
    28. 28. Patient Education • Risks – Addiction – Side effects • Benefits • Limitations • Importance of expectation management – Primary goal is restoration of function – Important to be realistic / have common ground
    29. 29. Treatment Agreement • Defines responsibilities of patient and provider • Ensures common goals in objective form • Resources on CD: – Sample pain agreements from MTFs – Sample agreement form – www.partnersagainstpain.com
    30. 30. Agreement Content • Goals of therapy • Requirement for sole provider • Limitation on dosage and number of pills • Prohibition for use with other substances • Need for periodic re- evaluation • Prohibition for medication sharing/sales • Responsibility for safe keeping of medication • Limitation on refills • Compliance with overall plan • Role of random UDS • Acknowledgement of safety issues • Consequences for non- adherenece
    31. 31. Suggested Protocol for Opioid Therapy. Treatment Successful Dose Escalation Treatment Failed Stable Phase maintain stable moderate dose Dose Adjustment Phase (up to 8 weeks) Decision Phase
    32. 32. Initiate Therapeutic Trial of Opioid. Opioid selection, initial dosing and titration based on • Patient heath status • Previous exposure to opioids – Low, standard dose for opioid-naïve patients – Previous effective dose for those with previous use Strong recommendation, low quality evidence Insufficient evidence to recommend • Short-acting vs long-acting opioids • As needed vs around-the-clock dosing
    33. 33. Choice of Agent. Long-Acting Agents Consider – Long acting morphine, ie MS contin – good standby strong recommendation, mod-quality evidence Caution with – Methadone – dosing tricky, long and varied half- life. Maximum recommend dosage 30-40 mg daily. Use only if familiar with its use and risks. – OxyContin – avoid – high abuse risk, high cost – Transderm fentanyl – avoid – high abuse risk, high overdose potential, high cost
    34. 34. Choice of Agent. Short-acting Agents • Consider – hydromorphone or oxycodone – Avoid prescribing more than 4 doses per day; consider long-acting if 4 doses insufficient • Avoid – Darvocet – major cause of drug-related deaths • Propoxyphene • Acetaminophen – Demerol – American Pain Society, ISMP recommends against use as analgesic • Unique neurotoxicity • If used, limit to <48 hrs, <600 mg daily
    35. 35. Choice of Agent Breakthrough Pain. Controversial – May consider for patients on around-the-clock opioids with breakthrough pain weak recommendation, low-quality evidence – If used, recommend no more than average of 1-2 tabs per day (30-60 tabs per month, in addition to long acting agent)
    36. 36. Ceiling opioid dosage?. • No evidence of benefit with opioid dosages >180 morphine-equivalents per day • Potential harms of high-dosage opioids: – Hormonal effects – Immunosuppression – Hyperalgesia Expert consensus
    37. 37. Monitoring • Progress towards goals • Titrate to effect • Assess adherence • Assess efficacy • Address adverse effects • Need for referral to specialized services
    38. 38. Progress Toward Goals • Ensure identification of medical home – Follow-up schedule based on patient risk factors, titration of medication, side effects, pain control – Frequency of follow up may change based on clinical course • Progress towards goals involves evaluation of: – Functioning in ADLs at home and at work – Sense of well being/worth – Control of pain to tolerable level
    39. 39. Titrate to Effect (1 of 2) • Utilize medication with best pain relief and fewest adverse effects at lowest dose • Optimal level of analgesia and function obtained in absence of unacceptable side effects • Utilize equianalgesic conversion table when switching between preparations
    40. 40. Titrate to Effect (2 of 2) • Evaluate breakthrough pain for new etiology • Repeated dose escalations may be marker for substance abuse or diversion • Consider opioid rotation if inadequate benefit or intolerable adverse effects – Incomplete cross tolerance to opioid effects – Reduce calculated equianalgesic dose by 20 – 25%
    41. 41. Assess Adherence/Abuse • Document adherence with medication – Pill counts – Urine drug screens • Document adherence to treatment plan – Compliance with adjunctive therapies – Follow-up with referrals • Assess patient motivation/barriers to adherence • Assess for behaviors predictive of addiction
    42. 42. Predictors of Misuse • Illegal or criminal behavior • Dangerous behavior: MVA, suicide attempt • Behavior suggestive of addiction – Multiple episodes of prescription “loss” – Refusal to perform UDS – Deterioration of home or work functioning • Aberrant behavior – Requesting more of the drug – Requesting specific drugs – Missing appointments
    43. 43. Adverse Effects (1 of 2) • Constipation – Initiate bowel regimen for those at risk – Increase fluid/fiber, consider stool softeners • Nausea and vomiting – Tends to diminish over initial weeks • Sedation or clouded mentation – Decreases over time – Patient must take precautions driving/operating machinery until this resolves
    44. 44. Adverse Effects (2 of 2) • Hypogonadism – Fatigue, decreased libido, sexual dysfunction – Test for hormonal deficiencies if symptoms present • Itching – Tends to diminish over initial weeks – Due to histamine release with morphine • Respiratory depression – Worse when doses titrated too quickly – Caution in patients with sleep apnea, COPD
    45. 45. Suggested Protocol for Opioid Therapy. Treatment Successful Dose Escalation Treatment Failed Stable Phase maintain stable moderate dose Dose Adjustment Phase (up to 8 weeks) Decision Phase
    46. 46. Stable Phase. • Maintain stable moderate dosage • Monthly refills – Assess and document pain score and side effects of opioid – Treat side effects – Recommend patient for comprehensive follow up if indicated • Comprehensive follow up – Require at least every year and optimally every 3 months – Assess pain relief, well being, achievement of treatment goals, functioning and quality of life – Toxicology screening, if indicated Low-quality evidence
    47. 47. Suggested Protocol for Opioid Therapy. Treatment Successful Dose Escalation Treatment Failed Stable Phase maintain stable moderate dose Dose Adjustment Phase (up to 8 weeks) Decision Phase
    48. 48. Indications to Stop Opioids. • Pain is resolved • No progress toward therapeutic goals • Inability to tolerate side effects • Serious or repeated aberrant behaviors –Request for early renewals – does not usually require discontinuation –Doctor/pharmacy shopping –Positive urine tox screen Strong recommendation, low-quality evidence
    49. 49. • Periodic requests for escalation of opioids • Periodic threats to find another doctor • Little sustained progress toward goals • Did not follow through on multiple referrals for mental health counseling Clinical Course.
    50. 50. Clinical Course. • Required mental health referral as condition of continued opioids – Social worker helped with goal setting • Required pain specialist referral – Suspected opioid associated hyperalgesia and recommended taper off opioids for 3+ months prior to evaluation for other treatment • Started slow taper late December 08 – Much support given, declined ASAP referral – Reached crisis off opioids – ASAP evaluation – inpatient program of detox and treatment of sexual trauma
    51. 51. Conclusion • Family physicians are well qualified to manage chronic pain in most patients • Medical home with team approach is key in chronic pain management • Emphasis on function and well-being, rather than pain level will increase chance of success • Use caution with opioid dosages over 120 morphine equivalents per day
    52. 52. Resources • VA/DoD CPG summary for the management of opioid therapy for chronic pain; March 2003 • Sample MTF pain agreements • Side effect tables for pain medications • Internet links to: – Clinical Guidelines for Use of Chronic Opioid Therapy in Chronic Noncancer Pain: Feb 2009 – AAFP online: Assessment and Management of Chronic Pain: June 2008; link to podcasts – Partners against pain website

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