Chronic Pain Management

1. Chronic Pain Management An Overview for Health Professionals

2. Lecture Goals Discuss pain management techniques Clarify role of interventional pain management techniques Review options available Discuss appropriate timing of patient referral

3. Pain is a significant issue #1 Admitting diagnosis in US #1 Reason for missed work in US Chronic pain costs the US $100B / year in direct medical costs, lost income and productivity Pain is the 5th vital sign (JCAHO) Patients have a right to adequate pain control (JCAHO)

4. Prompt Pain Management is Vital The sooner pain is managed ? the more likely patients are to return to normal daily living activities

5. Chronic Pain Treatment Continuum

6. Medical Management Anti-inflammatories Steroids, NSAIDs, COX-2 antagonists Neuropathic pain agents Tricyclic antidepressants, anticonvulsants, antiarrhythmics Muscle relaxants Narcotics Short-acting vs. long-acting Alternative medicine Acupuncture, massage therapy, herbal remedies When we look at medical management, we have groups of medications that we're all familiar with that can be used to help treat the patient. Most pain complaints have an inflammatory component: something is irritated -- either a muscle, a nerve, a joint --and hence anti-inflammatories are the medications of choice for these problems Steroids [are] the best that we have, but have limited use in long-term pain problems due to the fact that you cannot give the patients steroids for a long period of time. The nonsteroidals and the COX-2 inhibitors are also very good to use, and can be used in a longer period of time. For neuropathic pain, anything that's sharp, shooting, or burning in sensation, the tricyclic antidepressants have been the mainstay of care, as have anticonvulsants and most recently antiarrhythmics. For diabetic polyneuropathy, mexiletine is the drug of choice now for the treatment of the stocking-glove neuropathy that is present with that disease state. Muscle relaxants are also important in the armamentarium of medications used in the treatment of pain. Most pain states, no matter what they are, have some reflex splinting or muscle spasm that can be best treated with a muscle relaxant. And, last but not least, the narcotics, both short-acting and long-acting, can be used when we are unable to control the pain with the nonnarcotic management. And it's important to realize that as narcotics have been developed, we now have a set of long-acting narcotics; we have a long-acting morphine, we have a long-acting oxycodone, we have methadone, and we have Duragesic, which is fentanyl in a patch. And for someone that is having pain 24 hours a day, the long-acting medications can sometimes be more appropriate than the use of the short-acting medications and also help in preventing the patient from getting to an addicted state due to the fact that they are not taking the pills on an ongoing basis and it's a more [regularly] scheduled dose. The medications can be used in conjunction with each other so that you have a long-acting for most pain and then a short-acting if there are any spikes of pain. The idea behind the long-acting is almost as though you're treating hypertension. We would never think to treat hypertension and waiting for the blood pressure to go up and then treat it as you would [pain] with a short-acting narcotic, instead of preventing the high blood pressure by using an antihypertensive. And the same holds true for the use of long-acting narcotics to prevent the pain rather than to treat it when it happens. When we look at medical management, we have groups of medications that we're all familiar with that can be used to help treat the patient. Most pain complaints have an inflammatory component: something is irritated -- either a muscle, a nerve, a joint --and hence anti-inflammatories are the medications of choice for these problems Steroids [are] the best that we have, but have limited use in long-term pain problems due to the fact that you cannot give the patients steroids for a long period of time. The nonsteroidals and the COX-2 inhibitors are also very good to use, and can be used in a longer period of time. For neuropathic pain, anything that's sharp, shooting, or burning in sensation, the tricyclic antidepressants have been the mainstay of care, as have anticonvulsants and most recently antiarrhythmics. For diabetic polyneuropathy, mexiletine is the drug of choice now for the treatment of the stocking-glove neuropathy that is present with that disease state. Muscle relaxants are also important in the armamentarium of medications used in the treatment of pain. Most pain states, no matter what they are, have some reflex splinting or muscle spasm that can be best treated with a muscle relaxant. And, last but not least, the narcotics, both short-acting and long-acting, can be used when we are unable to control the pain with the nonnarcotic management. And it's important to realize that as narcotics have been developed, we now have a set of long-acting narcotics; we have a long-acting morphine, we have a long-acting oxycodone, we have methadone, and we have Duragesic, which is fentanyl in a patch. And for someone that is having pain 24 hours a day, the long-acting medications can sometimes be more appropriate than the use of the short-acting medications and also help in preventing the patient from getting to an addicted state due to the fact that they are not taking the pills on an ongoing basis and it's a more [regularly] scheduled dose. The medications can be used in conjunction with each other so that you have a long-acting for most pain and then a short-acting if there are any spikes of pain. The idea behind the long-acting is almost as though you're treating hypertension. We would never think to treat hypertension and waiting for the blood pressure to go up and then treat it as you would [pain] with a short-acting narcotic, instead of preventing the high blood pressure by using an antihypertensive. And the same holds true for the use of long-acting narcotics to prevent the pain rather than to treat it when it happens.

7. Interventional Techniques Injection Therapy (steroids) Trigger point, joint, peripheral nerve, and epidural steroid injections Localizes delivery of the medication Nucleoplasty or percutaneous discectomy Outpatient procedure, needle aspiration of a portion of the nucleus propulsus (for small disc herniation) Intradiscal thermocoagulation Fusion to stop leakage of nucleus propulsus

8. Interventional Techniques RF Ablation Creates lesions to stop nerve conduction of pain Provides 4-6 months of pain relief Cryoablation Nerve ablation by freezing

9. Intrathecal Infusion Pain medication or antispasmodic medication in the form of baclofen is delivered to the subarachnoid space Bathes the spinal cord Localized drug delivery Minimizes systemic side-effects Enables lower doses without compromising effectiveness Reserved for patients who are unable to take in enough narcotics to be able to treat their pain effectively

10. Spinal Cord Stimulation Spinal cord stimulation (SCS) is a safe and effective therapy in use for over 35 years has helped thousands of people find pain relief Implantable Pulse Generator is implanted under the skin Leads are then placed under the skin next to the spinal cord Signals sent to spinal cord create paresthesia, masking the pain Reversible procedure � surgically implanted device can be removed When is SCS appropriate? For severe and long-lasting neuropathic pain When other treatments are not working well

11. PRECISION Plus SCS System

12. Precision� is the first long-lasting, rechargeable Spinal Cord Stimulation (SCS) system. Small - half the size of other SCS systems Only system with independent current control allows clinician to better control pain coverage Can cover multiple pain areas simultaneously Maintains therapeutic stimulation patterns regardless of impedance changes (scar tissue)

13. 13 Preparing the Patient for Test Stimulation Position and sedate the patient Mark interspinous intervals with fluoroscopy Mark desired entry level � Begin the test stimulation procedure by placing the patient in a prone position with a pillow under his or her abdomen. Administer sedatives and antibiotics intravenously and drape the patient in a normal manner. � Guided by fluoroscopy, mark the interspinous intervals on the patient�s skin and determine the desired entry level.� Begin the test stimulation procedure by placing the patient in a prone position with a pillow under his or her abdomen. Administer sedatives and antibiotics intravenously and drape the patient in a normal manner. � Guided by fluoroscopy, mark the interspinous intervals on the patient�s skin and determine the desired entry level.

14. 14 Percutaneous Lead Placement Insert Touhy needle Confirm needle location with fluoroscopy and loss of resistance Introduce guidewire Insert lead Confirm lead location with fluoroscopy � Under fluoroscopic visualization, make a small stab wound and insert a Tuohy needle at the spinal location corresponding to the patient�s pain pattern. Insert the needle at the shallowest angle possible, not to exceed 45 degrees. � Confirm the needle location under fluoroscopy and verify entry into the epidural space by using the loss-of-resistance technique. � Introduce a guidewire through the needle into the epidural space to clear a path for the lead, then remove. � Slowly insert the lead through the needle and up the path created by the guidewire, rotating the lead tip to steer it toward the target site. If resistance is encountered, remove the lead and reintroduce the guidewire. � Confirm lead placement in the epidural space using fluoroscopy.� Under fluoroscopic visualization, make a small stab wound and insert a Tuohy needle at the spinal location corresponding to the patient�s pain pattern. Insert the needle at the shallowest angle possible, not to exceed 45 degrees. � Confirm the needle location under fluoroscopy and verify entry into the epidural space by using the loss-of-resistance technique. � Introduce a guidewire through the needle into the epidural space to clear a path for the lead, then remove. � Slowly insert the lead through the needle and up the path created by the guidewire, rotating the lead tip to steer it toward the target site. If resistance is encountered, remove the lead and reintroduce the guidewire. � Confirm lead placement in the epidural space using fluoroscopy.

15. 15 Dual Lead Placement Insert second needle one level below/contralateral to first Place lead tips at same level or staggered � If a patient has a broad pain pattern, it may be appropriate to consider implanting dual leads for the test stimulation. This can provide greater flexibility in superimposing the area of paresthesia over the patient�s pain pattern. � Should the clinician opt to use a second lead for test stimulation, then a second Tuohy needle should be inserted one vertebral level below and contralateral to the first needle. This positioning reduces the likelihood of inadvertently nicking or cutting the first lead. � Introduce a second guidewire and steer the second lead parallel and a few millimeters from the first lead. The two lead tips may be at the same vertebral level or staggered. � If a patient has a broad pain pattern, it may be appropriate to consider implanting dual leads for the test stimulation. This can provide greater flexibility in superimposing the area of paresthesia over the patient�s pain pattern. � Should the clinician opt to use a second lead for test stimulation, then a second Tuohy needle should be inserted one vertebral level below and contralateral to the first needle. This positioning reduces the likelihood of inadvertently nicking or cutting the first lead. � Introduce a second guidewire and steer the second lead parallel and a few millimeters from the first lead. The two lead tips may be at the same vertebral level or staggered.

16. 16 Intraoperative Screening Connect lead and screener Goal of matching stimulation to pain pattern Test by trying different electrode combinations and polarities � Insert the lead stylet handle into the twist-lok connector of the screening cable and lock it in place. Then connect the screening cable to the handheld screener. When testing with a dual lead system, connect lead 1 to the CH1 receptacle and connect lead 2 to the CH2 receptacle. � Conduct the test stimulation with the goal of matching the stimulation (or paresthesia) pattern to the patient�s pain distribution. � Test different electrode combinations and polarities by changing the appropriate controls on the screener. Reposition the lead or leads, if needed. Keep in mind that patients will feel stimulation under the cathode (-) rather than the anode (+). � Insert the lead stylet handle into the twist-lok connector of the screening cable and lock it in place. Then connect the screening cable to the handheld screener. When testing with a dual lead system, connect lead 1 to the CH1 receptacle and connect lead 2 to the CH2 receptacle. � Conduct the test stimulation with the goal of matching the stimulation (or paresthesia) pattern to the patient�s pain distribution. � Test different electrode combinations and polarities by changing the appropriate controls on the screener. Reposition the lead or leads, if needed. Keep in mind that patients will feel stimulation under the cathode (-) rather than the anode (+).

17. 17 Test Stimulation: Partial Percutaneous Lead Implant Least invasive initial approach Preferred test stimulation for surgical leads Lead secured to skin Allows for test stimulation of several days � Some physicians prefer to partially implant a percutaneous lead, and then explant it at the end of the test stimulation period. � The least invasive approach, this is the screening technique of choice when the physician intends to eventually implant a surgical lead. � At the end of the procedure the lead is secured to the skin with medical tape in a four-point configuration. The lead is then connected to a percutaneous extension, which is also taped tothe skin. Some physicians implant a longer lead and do not use the extension. � The patient uses the test stimulation system for several days. � Some physicians prefer to partially implant a percutaneous lead, and then explant it at the end of the test stimulation period. � The least invasive approach, this is the screening technique of choice when the physician intends to eventually implant a surgical lead. � At the end of the procedure the lead is secured to the skin with medical tape in a four-point configuration. The lead is then connected to a percutaneous extension, which is also taped tothe skin. Some physicians implant a longer lead and do not use the extension. � The patient uses the test stimulation system for several days.

18. SCS Controls Pain Masks pain signals by delivering tiny electrical signals to the spinal cord Stimulation reduces pain by creating paresthesia over the pain area.

19. Optimizing SCS Therapy Patients can test SCS Therapy prior to permanent implantation Trial SCS Incision is made to place a lead in the epidural space near the spinal cord External trial stimulator is connected, producing the paresthesia Patient is awake while a computer to guides the pain-masking signals to provide optimal pain relief Patient wears the remote-controllable system on a belt for 5-14 days

20. Optimizing SCS Therapy (cont) Implanting a permanent device If the SCS Trial goes well, the permanent SCS device will be implanted Programming the SCS Doctor steers the signal as patient says where it feels best For people with complex pain, or pain in multiple locations, the Precision system offers the ability to deliver pain-masking signals to up to four locations at the same time

21. Importance of Effective Pain Management Poorly managed pain can result in: Chronic debilitated state Chronic medication with increasing doses Deconditioning of muscle groups Repetitive testing Psychological deterioration Quick Reversal Important Get pain under control within 5-7 days Start rehabilitation after pain is under control

22. Referral to a Pain Specialist Sooner is better Will the pain reverse quickly without intervention? Is a procedure needed to quickly reverse the process? Is this a chronic issue that will require ongoing care? �The longer that you wait to get to a pain management specialist, the more likely that you're going to fall into these pitfalls..... If the usual -- the nonsteroidals, the muscle relaxants -- aren't working very quickly, they're not going to work. If they don't work in 3 days, they're not going to work in a month. So there's no reason not to get to a specialist and get the patient controlled as quickly as possible.� � Dr. John Stamatos

23. Some Common Pain Conditions

24. Lower Back Pain $20B annually in direct health care costs1 5th most common reason for MD visit1

25. Complex Regional Pain Syndrome Approximately 10% of patients referred to pain clinics have CRPS Includes reflex sympathetic dystrophy (CRPS 1) and causalgia (CRPS 2) includes burning pain, hypersensitivity, allodynia, edema, and, sometimes, muscle spasms and dystonias Sympathetically maintained pain - The pain is accompanied by signs of autonomic dysfunction, and sympathetic blockade generally relieves pain. Sympathetically independent pain - the pain state that occurs most often in treatment-resistant cases of CRPS, in which sympathetic blockade or sympathectomy yields no clinical reduction in pain.

26. CRPS - Continued CRPS 1 An initiating noxious event, however trivial, Ongoing pain, allodynia, or hyperalgesia that is not limited to the distribution of a single peripheral nerve and is disproportionate to the inciting event, and Evidence of edema, blood-flow abnormalities (such as mottled skin), or abnormal sudomotor activity in the region of pain (such as sweaty skin). CRPS 2 Development after a nerve injury, Ongoing pain, allodynia, or hyperalgesia that usually exceed the distribution of the injured nerve, and Evidence of edema (figure 1), skin blood-flow abnormalities, or abnormal sudomotor activity in the region of pain (as in CRPS 1).

27. CRPS - Continued Studies have shown the value of SCS, particularly when all other therapeutic modalities have failed In a randomised controlled trial in type I CRPS patients, SCS therapy lead to a reduction in pain intensity at 24 months of follow-up (mean change in VAS score -2.0), whereas pain was unchanged in the control group (mean change in VAS score 0.0) (p<0.001). Economic analysis based on the randomised controlled trial showed a lifetime cost saving of approximately 58,470 (60,800 US dollars) with SCS plus physical therapy compared with physical therapy alone. The mean cost per quality-adjusted life-year at 12-month follow-up was 22,580 (23,480 US dollars).

28. Neuropathic Pain 4M People in the US/year suffer from Neuropathic pain (NP), caused by a primary lesion or dysfunction in the nervous system1 Associated with diabetic peripheral neuropathy, postherpetic neuralgia, human immunodeficiency virus-related disorders, and chronic radiculopathy. Treatment often fails because2: inadequate diagnosis and a lack of appreciation of the mechanisms involved insufficient management of comorbid conditions incorrect understanding or selection of treatment options the use of inappropriate outcomes measures

29. Pain Facts Chronic pain is continuous pain that persists for more than 3 months, and beyond the time of normal healing. It ranges from mild to severe and can last weeks, months, or years to a lifetime. (http://www.niams.nih.gov) 20% of the population in developed countries is afflicted with chronic pain 30-40% due to musculoskeletal and joint disorders 30% neck and back pain Headache and migraines < 10%

30. Pain as the 5th Vital Sign Consider pain the fifth vital sign and assess patients for pain every time you check for pulse, blood pressure, core temperature, and respiration. Urge your colleagues to take their patients' complaints of pain seriously. Remind them not to put patients in the position of asking for a favor when they want pain relief. Inform patients that they deserve to have their pain evaluated and treated. Work to implement the APS Quality Improvement Guidelines for the Treatement of Acute Pain and Cancer Pain in your own practice setting. (JAMA, 274, 1874-1880) Wear your Fifth Vital SignTM button and make opportunities to explain the importance of pain evaluation and treatment to other healthcare professionals and to the public.