Kirsten Y. Day, MD Associate Professor Department of Family and Community Medicine UCSF/SFGH FHC

1. Nuts & Bolts of OutpatientPain Management Spring NP/PA/CNM PPG Conference4.18.13 Carr Auditorium Kirsten Y. Day, MD Associate Professor Department of Family and Community Medicine UCSF/SFGH FHC

2. Nuts & Bolts of OutpatientPain ManagementObjectives • Pain Physiology • Evaluation of Pain • History and Physical • Factors that Influence Pain • Management of Pain • Physical Modalities • Psychological Modalities • Pharmacologic Modalities • Meds commonly Used • How to Evaluate Effectiveness • Insurance Issues • Tolerance, Dependence, Addiction and Pseudo-Addiction • Chronic Narcotic Use in Substance Use Disorders

3. Nuts & Bolts of OutpatientPain Management Physiology of Pain Who, except the gods, can live time through forever without any pain? - Aeschylus

4. Acute Pain is an Early Warning System Nuts & Bolts of OutpatientPain Management Physiology of Pain

5. Nuts & Bolts of OutpatientPain Management Physiology of Pain • Nociceptive Pain • Somatic • Tissue Damage - Temperature, Trauma, Chemical • Once Stimulated, become hyperactive • Localized, constant, throbbing, aching • Visceral • Stretching or Pressure • Referred pain • Generalized, less constant or colicky, cramping • Neuropathic Pain • Damage directly to neurons cause abnormal neural activity • Constant, frequently burning or electrical with periods of marked increases in pain

6. Nuts & Bolts of OutpatientPain Management Physiology of Pain • Stress Analgesia Short-term intense pain controlled with short-term nervous system changes • Hyperalgesia Lowered pain threshold produces pain with less stimulation • Allodynia Previously non-painful stimuli are now painful

7. Nuts & Bolts of OutpatientPain Management Physiology of Pain Normal Hyperalgesia Allodynia Pain Tolerance Response Pain Threshold Stimulus Intensity

8. Nuts & Bolts of OutpatientPain Management Evaluation of Pain • Pain is real when you get other people to believe in it. If no one believes in it but you, your pain is madness or hysteria. - Naomi Wolf

9. Nuts & Bolts of OutpatientPain Management Evaluation of Pain • Subjective - NOT a vital sign • History is the foundation for evaluation • PQRST - Provocation, Quality, Radiation, Severity, Time • Location QuEST - Location, Quality, Exacerbating/relieving, Severity, Temporal profile • Functionality

10. Nuts & Bolts of OutpatientPain Management Evaluation of Pain • Physical Examination • General • Movement • Gait • Positioning • Affect • Vital Signs in acute setting

11. Nuts & Bolts of OutpatientPain Management Evaluationof Pain • Physical Examination • Focused System Exam • Musculoskeletal • Palpation • Range of Motion • Strength and Laxity • Neurologic • Determine distribution of symptoms • Sources of Referred Pain

12. Nuts & Bolts of OutpatientPain Management Evaluation of Pain • Diagnosis • Chronic Pain is not a diagnosis • LBP is a symptom, not a diagnosis DJD Radiculopathy Disk Disease Spinal StenosisMyofascial dysfunction Sacroiliac dysfunction • Fibromyalgia - Tender points in specific patterns • Myofascial Pain - Trigger points with twitch response and specific referred pain patterns

13. Nuts & Bolts of OutpatientPain Management Evaluation of Pain Factors that Influence Pain • Cognitive, Emotional factors • Environmental Factors • repeated injury • lack of healing • Timing - duration of pain experience

14. Nuts & Bolts of OutpatientPain Management Management of Pain • Physical Modalities • Psychological Modalities • Pharmacologic Modalities • Insurance Issues

15. Nuts & Bolts of OutpatientPain Management Management of Pain • Physical Modalities • Exercise • Thermal Therapy • Manual Medicine Disciplines • Physical Therapy • Chiropractic • Osteopathy • Acupuncture • Trigger Point Injection • The only treatments that can “Cure” • Myofascial Pain • Joint dysfunction

16. Nuts & Bolts of OutpatientPain Management Management of Pain • Psychological Modalities • Cognitive Behavioral Therapy • Biofeedback • Stress Reduction Techniques

17. Nuts & Bolts of OutpatientPain Management Management of Pain • Pharmacologic Modalities • Step Therapy • Mild pain - Acetaminophen and NSAIDs • Moderate Pain - Combination Analgesics • APAP/Codeine (Tylenol #3), APAP/Hydrocodone (Vicodin), APAP-Oxycodone (Percocet) • Severe or Refractory Pain - Opiates • Morphine • Methadone • Oxycodone • Fentanyl

18. Nuts & Bolts of OutpatientPain Management Management of Pain

19. Nuts & Bolts of OutpatientPain Management Management of Pain • Pharmacologic Modalities • Targeted Treatment • NSAIDS - Inflammatory and Prostaglandin mediated processes • Lidocaine - Myofascial Pain by Trigger Point Injection or Topical Patches • Antiepileptics - Neuropathic pain • Tegretol • Depakote • Gabapentin • Tricyclic Antidepressants - Neuropathic pain

20. Nuts & Bolts of OutpatientPain Management Management of Pain • Clonidine - augmentative pain relief • SSRI’s - somatic symptoms with or without depressed mood • “Muscle Relaxants” • Centrally acting • Only helpful in Acute injury or Exacerbations

21. Nuts & Bolts of OutpatientPain Management Management of Pain • Pharmacokinetics of Opiates • Duration of Action - • 4-6 hrs for almost all orals (fentanyl 1-2 hrs.) • Controlled Release (CR) or Sustained Release (SR) 8-12 hours • Onset of Action - • Accelerated with IV dosing versus PO or IM (max effect at 10-20 min for morphine IV) • CR or SR have delayed onset and maximum effect • Steady state • 12-24 hrs with short acting • 48-72 hrs with long acting. • Metabolism and drug interactions.

22. Nuts & Bolts of OutpatientPain Management Management of Pain • Titrating doses • Choose medications based on type and severity of pain • Give initial doses in short acting agents, assess and titrate at 12 hrs. • With mild to mod pain increase by 25-50% of dose • With mod to severe increase by 50-100% of dose • Convert to long acting agents • Inpatients - within 24 hrs. • Outpatients - Once dosing is stable • Provide short acting agents of 10-15% of long acting dose for breakthrough pain.

23. Nuts & Bolts of OutpatientPain Management Management of Pain Evaluation • Function • Activities • What • How Long • How Often • Sleep • Mood • Side Effects of Opiates • Constipation, nausea, histamine release, urinary urgency/retention • Evaluate promptly and frequently for side effects and treat as indicated

24. Nuts & Bolts of OutpatientPain Management Management of Pain • Insurance Issues • Psychological - CBT, Chronic Pain Groups • Physical Modalities • Medicare - Chiropractic and Physical Therapy • Medicaid and SFHP/Slid Scale - Physical Therapy • Pharmacologic Treatments • Formulary Restrictions • Medicare D • Medicaid • SFHP/Slid Scale, HSF • Formulary Overrides • TAR, PAR, PA • Diagnosis and failure of formulary options or medical reason formulary options are contraindicated

25. Nuts & Bolts of OutpatientPain Management Tolerance, Dependence, Addiction and Pseudo-Addiction • Tolerance • Normal Physiologic Response to be expected with long-term use. • Expect to have to adjust doses over time. • Physical Dependence • Normal Physiologic Response to be expected with long-term use. • Physical withdrawal with abrupt cessation or reduction • Addiction • Neurobiological disorder • Compulsive use despite harm, impaired control. • Pseudo-Addiction • Patient behaviors that mimic addiction, caused by provider’s failure to treat pain either adequately or timely • Some patients are drug-seeking because they're in pain. . .

26. Nuts & Bolts of OutpatientPain Management Chronic Pain and Substance Use Disorders • Prevalence of Chronic Pain high amongst Substance Abusing Patients • 37-61% of patients on Methadone Maintenance • HMO patients entering drug/alcohol treatment OR 2-3 versus controls for HA, LBP, and arthritis • Other Considerations • Stimulant and opiate abuse result in increased pain sensitivity • Relapse • 30% in recovery relapse on Rx opiates • Untreated pain is a frequent trigger for relapse

27. Nuts & Bolts of OutpatientPain Management Chronic Pain and Substance Use Disorders • When to use Opioids for patients with Addictive Disorders • Pain is moderate to severe • Pain has a significant impact on function and quality of life • Non-opioids have been tried and failed • The patient agrees to have opioid use closely monitored

28. Nuts & Bolts of OutpatientPain Management Objectives • Pain Physiology • Evaluation of Pain • History and Physical • Factors that Influence Pain • Management of Pain • Physical Modalities • Psychological Modalities • Pharmacologic Modalities • Meds commonly Used • How to Evaluate Effectiveness • Insurance Issues • Tolerance, Dependence, Addiction and Pseudo-Addiction • Chronic Narcotic Use in Substance Use Disorders

29. Nuts & Bolts of OutpatientPain Management Remember. . . • Pain is Subjective • Evaluate and determine a Diagnosis • Aim treatment at Diagnosis • Provide timely follow-up, evaluation and treatment • Communication with Pharmacist and know your formulary

30. Nuts & Bolts of OutpatientPain Management Spring NP/PA/CNM PPG Conference4.18.13 Carr Auditorium Kirsten Y. Day, MD Associate Professor Department of Family and Community Medicine UCSF/SFGH FHC