Special Management Challenges

2. Special Management Challenges Type in your name Type in name of your institution

3. Biopsychosocial Dimensions of Pain Culture, Social interactions, Sick role SOCIAL PSYCHOLOGICAL Neurophysiological changes + Physiological dysfunction BIOLOGICAL

4. Chronic Pain Definition • No international standard definition • Persists > 90 days ( > 3-6 months) • Often unrelated to time of initial injury • Poor/no response to treatments effective in acute pain • Complex structural and functional changes in the nervous system • Generally purposeless, often irreversible • Estimated incidence worldwide 20–25%

5. Chronic Pain Definition Chronic pain is a disease Acute pain is a symptom Poor understanding of the mechanisms implicated in the transitionfrom acute injury to chronic pain

6. Differences: Acute versus Chronic Acute • Simple assessment(s) • Unidimensional tools • Usually responds to analgesics and/or treatment of the underlying cause • Often resolves spontaneously Chronic • Complex assessment(s) • Multidimensional tools • Underlying causes may be difficult to identify or isolate • Often refractory to analgesics • May never resolve

7. Chronic Pain Assessment • Absence of abnormal findings on exploration cannot rule out pain and does not mean normal physiology • Changes in vital signs and behavior are unreliable • Assess multiple dimensions of pain experience with emphasis on function and mood • Establish a pain diagnosis when possible, and determine the type of pain and contributing factors

8. Case Study • 55 year old black female • History of low back pain „all her adult life“ • Described as continuous, severe, localized, and interfering with her ability to work • No relevant findings on physical exam and imaging • Treated with increasing doses of opioid therapy for the past 2 years • Declined to try an antidepressant • Requesting an increase dose of morphine

9. Chronic Pain Assessment A body diagram colored by the patient may be helpful to determine location(s) and assess quality and type of pain, as well as help establish and adequate treatment plan Yellow = Aching Blue = Burning Red = Stabbing Black = Numbness Green = Tingling pins & needles Orange = hurts to touch Purple = Other

10. Predictors of Pain Chronicity

11. Transition from Acute to Chronic Pain Predicting Factors • cumulative trauma exposure (LBP) • acute pain intensity, duration, and disability • level of education, female sex, older age • early use of prescription opioids (acute LBP) • negative beliefs on chronic pain severity & disability • high baseline fear, anxiety, depression • repeated environmental stress

12. Differences in Pain Treatment Acute • Medical-treatment model • Primary goal: Reduce pain intensity • Prevent chronic pain • Generally successful • Treatment ends when pain resolves Chronic • Rehabilitation-disease management model • Primary goal: Improve function • Physical • Psychological • Social • Patients must actively participate

13. Case continued… • Non-steroidal anti-inflammatory drugs (NSAIDs) and heat have not been helpful • She has self-increased her morphine from 15mg (5 tablets a day) to doses of 45mg as often as every 3 hrs • She seems depressed • Sleep is poor • Smokes tobacco • Her mother was an alcoholic Does the patient have a job?

14. Chronic Pain: Analgesic Management • A multimodal approach using a combination of drugs may be necessary • Combine drugs of different groups and with different mechanisms • Frequently assess how the patient is taking the analgesic medication, the level or degree of pain relief and side effects • Start with the lowest effective dose • Discontinue if side effects are intolerable or if treatment is not helpful • Consider cost of treatment

15. Chronic Pain: Opioids • Chronic opioid therapy remains controversial due to misconceptions, regulatory barriers, and uncertainty about effectiveness / safety • Ongoing investigations into potential negative effects on quality of life and endocrine adverse events

16. Use of Scheduled versus PRN Opioids • It is unclear whether scheduled around-the-clock opioid therapy is better than PRN dosing • Assess the need for additional rescue doses • Are they being taken for psychological reasons ? • Do increased doses of the long-acting opioid eliminate the need for some of the rescues doses? • Evaluate the risk / benefit (improvement in function) that the additional doses will produce

17. Types of Episodic or Increased Pain “Breakthrough” pain • Transitory flare of moderate-to-severe pain occurring in patients with persistent pain otherwise controlled by analgesics (often opioids). May be incident related, due to end-of-dose failure, or idiopathic “Flare” pain • Term used in chronic non-cancer pain to describe an exacerbation of pain that may last days to weeks • Treatment may have to be adjusted, often adding other drugs, in order to control pain and other symptoms

18. Chronic Pain: Treatment Goals • Restore function • Physical, emotional, social • Decrease pain • Treat underlying cause where possible • Correct secondary consequences of pain • Postural deficits, weakness, muscle overuse • Maladaptive behavior, poor coping

19. Chronic Pain: Treatment Approach • Together with the patient, set realistic goals about pain control • Brief motivational interviewing • Acknowledge feelings (e.g., grief, loss, frustration) • Use a multimodal approach • Medication, exercise, sleep, nutrition, counseling • Flare plan

20. Chronic Pain: Exercise • Many patients are fearful of movement and exercise • Improves physical functioning, decreases secondary sources of pain, and improves general health and wellbeing • Different types of exercise each with specific goals • For example: strengthen, stretch, preserve range of motion, recondition • Recommend a consult with a physical therapist

21. Exercise and Chronic Pain Common Misperceptions • „Exercise should fix my problem!“or „I‘ve tried physical therapy (PT) and it didn‘t help“or „Activity makes my pain worse!” • 30 minutes/day of exercise will not overcome 16 hours/day of poor posture and poor body mechanics • Repetitive practice and lifestyle change are crucial

22. Chronic Pain it is not clear what a “flair”is. Would be good to provide an example How to Manage Flares • Short term increase in usual level of pain • Temporary, may last hours to days or weeks • Distinct from „breakthrough pain“ how? • Look into what triggered the flare • Stress, injury, lack of sleep, exercise, hormonal changes, additional / new pathology • Use a flare plan • Medication, ice or heat, increase or decrease activity, distraction, other coping skills

23. Case continued: Treatment Plan Diagnostic Impression: • Low back pain, acute flare • Major or moderate depression, single episode • Tobacco abuse Goal: Increase Functional Activity • Counsel on stretching, strengthening and endurance exercises, supervised physical therapy if available initially • Help with development of pain coping strategies/skills, brief motivational interview, counselor or health psychologist if available

24. Case continued: Treatment Plan Goal: Reduce Pain by 25% or more • As self-increased doses of morphine have not helped to reduce pain or improve function, reduce as previously prescribed • It should be made clear that morphine should not be “self-increased” under any circumstances • Consider re-introduction of NSAID or paracetamol. • Consider: if they were not effective before, might not improve pain now. • If there is a neuropathic component in her LBP, gabapentin or antidepressants could be added to the opioid • Trial of tricyclic antidepressant to reduce pain why TCA ?

25. Case continued: Treatment Plan Goal: Diminish Psychological/Social Disruption • Depression counseling • Reduce anxiety, facilitate sleep • Smoking cessation counseling Goal: Reduce Interference with Work • Attempt modification in work flow and body mechanics • Give examples of how to modify “body mechanics”, e.g. position, bearing, sitting

26. Summary: Chronic Pain • Chronic pain is a complex biopsychosocial condition that differs widely from the symptom of acute pain • A multidimensional assessment is essential to establish a pain diagnosis to guide the treatment plan

27. Summary: Chronic Pain • The goals of chronic pain treatment are to: • Maintain or restore function, diminish psychological/social disruption. • Often only partial pain relief can be achieved. • A disease management model that aims to empower the patient to self-manage pain with less reliance on medications and on invasive procedures seeking cure is likely best suited.

28. Chronic Pain: Take Home Messages • Involves complex changes in the brain and nervous system that lead to dysfunction • May be difficult to detect underlying mechanisms • Assessment and treatment address al dimensions of the biopsychosocial experience • Complete relief and cure often unrealistic • Treatment is aimed on empowering the patient to manage the pain using positive coping skills, lifestyle changes and judicious use of medications.

29. Addiction: Definition Substance dependence is defined as: • When an individual persists in use of alcohol or other drugs despite problems related to use of the substance, substance dependence may be diagnosed. Compulsive and repetitive use may result in tolerance to the effect of the drug and withdrawal symptoms when use is reduced or stopped. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)

30. Addiction – A Neurobiological Disease • Involves the brain’s reward (limbic) center • An area of the brain that is associated with the affective responses to pain • Involves dopamine and neurochemical stimulation What does it mean? • Susceptible individuals may have an alteration of the limbic or related systems that causes sensitization to the reinforcing effects • Genetic factors account for about half the likelihood of developing addiction

31. Prevalence of Substance Abuse in Pain Management Populations • Prevalence studies reveal variable results based on non-uniform definitions of abuse and addiction • Reported as less prevalent in cancer pain (0% - 5%) • More prevalent in the chronic non-cancer pain population (0% - 50% depending on criteria used) • (confirm figures)

32. Prevalence of Substance Abuse in Pain Management Populations • Risk factors include high opioid doses, concomitant use of alcohol or benzodiazepines, younger age, previous depression and low educational level • Fear and misunderstanding about addiction are barriers to adequate pain management

33. Addiction • Physical dependence • Tolerance • Pseudoaddiction • Pseudotolerance … Are NOT addiction

34. Physical Dependence - Definition • „Physical dependence is a state of physical adaptation that is manifested by a drug-class specific withdrawal syndrome. Withdrawal can be induced by abrupt cessation or rapid dose reduction decreasing blood level of the drug, and/or administration of an antagonist.“ • Dependence is an expected manifestation of opioid administration • Manifested by withdrawal symptoms

35. These concepts may be difficult to grasp unless an example is given e.g. opioids Tolerance - Definition • „Tolerance is a state of adaptation in which exposure to a drug induces changes that result in diminution of one or more of the drug’s effects over time.“ • Tolerance is an expected manifestation during opioid administration • Opioid tolerance is manifested by a decrease in analgesia that requires increasing the doses to obtain a similar effect. • In cancer pain, the most common need for increased dosage is disease progression, rather than drug tolerance

36. Pseudoaddiction is • Manifested by behaviors similar to addiction • Clock watching • Focus on obtaining the drug • Illicit behaviors can occur • Associated with the under-treatment of pain • Behaviors resolve when the pain is effectively managed • these behaviours could be included in the description of addiction

37. Pseudotolerance • Need to increase the dose that is not related to the development of tolerance such as: • Disease progression • New disease • Increased activity • Lack of drug adherence • Addiction ? For opioids, addicted subjects are tolerant slide not clear

38. Precautions • Differential diagnosis • Screen for risk of addiction (simple clinical interview /or screening tool) • Obtain „informed consent“ (explain risk and benefits) • Use a treatment agreement (verbal or written / signed) • Regularly assess the „Four As“; Analgesia, Activity, Adverse Reactions, and Aberrant Behavior • Periodically re-assess the pain diagnosis and co-morbid conditions including addictive behaviour

39. The Four “As”: Patient Level Outcomes Used to Guide Treatment Goals and to Reassess for Development of Addiction • Analgesia • Improve analgesia or Comfort • Activities of Daily Living • Physical and emotional function should be preserved or improved • Adverse Events • Should be minimized • Aberrant Drug-taking Behaviors • Potential aberrant drug-taking behaviors should be monitored

40. Aberrant Behaviors observed during the development of addiction • Drug hoarding when symptoms are improved • Acquiring drugs from multiple medical sources • Aggressive demands for a higher dose • Unapproved use of a drug to treat a symptom, e.g. use of an opioid to treat anxiety • Unsanctioned dose escalation (1-2x) • Reporting psychic effects • Requesting specific drugs

41. More Obvious Aberrant Behaviors • Selling prescription drugs • Forgery of prescriptions • Concurrent illicit drug use • Multiple prescription/medication losses • Ongoing unsanctioned dose escalations • Stealing and borrowing drugs • Obtaining prescription drugs from nonmedical sources • Repeated resistance to changing drug type – inflexibility

42. Aberrancy Risk Factors • Family history of substance abuse • Legal problems • Drug or alcohol abuse • Mental health problems • Multiple motor vehicle accidents • Cigarette smoker • Fewer adverse events of what ? • High opioid dose

43. Differential Diagnosis When Aberrant Behavior is Observed • Addiction • Pseudoaddiction • Psychiatric pathology • Encephalopathy • Personality disorder • Depression, anxiety, high level of stress • Chemical coping (give examples) • Criminal intent (give examples)

44. Take Home Message: Pain Management in Patients with Risk of Substance Abuse • Fear of addiction hinders pain management in all patient populations • Risk screening should must be performed at onset of opioid therapy and aberrant behaviors repeatedly assessed • Goals of pain management similar to thoose for chronic pain &include improving analgesia & activities of daily living, and controlling adverse events and aberrant behaviors • Patients with addiction also present tolerance, and usually require higher doses of opioids to obtain effective analgesia

45. Pregnancy and Substance Use • Neonates exposed to heroin, prescription opioids, methadone, or buprenorphine during pregnancy are monitored closely for symptoms and signs of neonatal withdrawal (neonatal abstinence syndrome) • ADD signs and symptoms of neonatal withdrawal

46. Pregnancy and Chronic Pain • Almost all drugs cross the placenta • Where possible, non-pharmacologic treatment options should be considered first • Exercise reduce back and pelvic pain during pregnancy. • Paracetamol and codeine are generally considered safe • NSAIDs and aspirin should be used with caution in the last trimester of pregnancy and avoided after the 32nd week

47. Pregnancy and Chronic Pain • Most adjuvant anticonvulsants are associated with birth defects • At best, chronic opioids provide mild to moderate analgesia and are associated with lower Apgar scores (and potential newborn withdrawal) • explain why this is so, analgesia is dose-dependent regardless if a patient is pregnant or not.

48. Lactation and Analgesics • The choice of drugs should be based on transfer in human milk and likely effects on the infant • The lowest possible effective maternal dose of analgesic is recommended • Breastfeeding is best avoided at times of peak drug concentration in milk, and the infant should be observed for effects of medication transferred in breast milk. • Lactating women having surgery are generally advised to discard their milk for 24hours after operation

49. Lactation and Analgesics • Local anaesthetics, paracetamol and several non-selective NSAIDs, in particular ibuprofen, are considered safe in the lactating patient • Morphine and fentanyl are considered safe in the lactating patient and are preferred over pethidine • SSRIs and TCAs can beused in postnatal depression • See specific information on use of anticonvulsants ?

50. Pain in Older Adults • Aging affects every aspect of health • risk • mechanisms • symptoms • psychosocial adaptation • treatment efficacy • survival