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Pain Management- It’s Everyone’s Business!

Pain Management- It’s Everyone’s Business!. Dr. Joel Loiselle BSc. MD FRCPC Staff Anesthesiologist SBGH (General OR and OBS.) Director Acute Pain Service (SBGH) Palliative Care Consultant Chronic Pain Consultant Assistant Professor U of M. April 12, 2010.

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Pain Management- It’s Everyone’s Business!

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  1. Pain Management- It’s Everyone’s Business! Dr. Joel Loiselle BSc. MD FRCPC Staff Anesthesiologist SBGH (General OR and OBS.) Director Acute Pain Service (SBGH) Palliative Care Consultant Chronic Pain Consultant Assistant Professor U of M April 12, 2010.

  2. CPG- opioids are only one part of a multi-modal/multi-disciplinary pain approach. H1N1!!! …although I am going to talk about opioids a fair bit today!

  3. Objectives • Discuss some general pain definitions. • Why pain is like an onion! • Some short case vignettes- why pain is important to _______. • Take home pearls- look for the important concept slides.

  4. Definition of Pain “…an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” Merskey H, Bogduk N. 2nd ed Seattle, WA: IASP Press; 1994.

  5. Acute Pain: Adverse Consequences • “Stress hormone response” • Suffering • Neuronal remodeling • Chronic Pain • Peripheral and central sensitization • De-conditioning: excessive bed rest • Associated behaviors Prevention and aggressive treatment of acute pain may help prevent the development of chronic pain

  6. Chronic Pain • Definition: pain that lasts beyond the period of healing or is associated with chronic disease (arbitrarily 2-6 months). • Ceases to serve protective function or adaptive purpose. • Identified pathology may not explain the presence and/or severity of pain. • May be perpetuated by factors unrelated to the cause. • Associated with irritability, social withdrawal, depressed affect and vegetative symptoms. • Symptoms of catecholamine hyperactivity (tachycardia and sweating) less common. Jacobsen L.. Bonica’s Management of Pain, 3rd ed. Baltimore, MD, Lippincott Williams & Wilkins; 2001;241-254.

  7. = Pain =

  8. Injury-induced Pain: Patient Factors Injury Individual variation in response to injury: physiological, behavioural, and cultural Individual variation in response to treatment Context: battlefield orlonely bed Pain improveswith time Complaint of pain McQuay H. BMJ 1997;314:1531.

  9. Three Hierarchical Levels of Pain Sensory-Discriminatory Components Location, intensity, quality Motivational-Affective Component Depression, anxiety Cognitive-Evaluation Component Thoughts concerning the cause and significance of the pain Pain Management: Pathophysiology of Pain and Pain Assessment. AMA, December, 2003

  10. Pain Pathways

  11. PHYSICAL SUFFERING PSYCHOSOCIAL EMOTIONAL SPIRITUAL

  12. A not so pretty picture The steps: -GLU excess -NMDA receptor loses Mg2+ -Ca2+ moves in and stimul. PKC -NO is produced and stimul. guanyl syn. (K+ conduc. decreased) and Sub. P is released -Sub. P stimul. NK-1 receptor which causes c-fos activation -c-fos activation signals pain is entrenched

  13. Chronic pain as a disease? • Pain has outlived its utility. • It is typically much more difficult to identify the source of ongoing pain • The earlier chronic pain is treated, the less likely the physiological changes that occur will become firmly entrenched. • It is no longer the symptom but the disease…

  14. Important concept #1 Pain is not a diagnosis but it may be a disease.

  15. How common is Chronic Pain in our society?

  16. Canadian National Pain Study, 2002Prevalence of Chronic Pain – (>6 Months) (n=2012) Moulin D., PR&M, 2002

  17. Canadian National Pain Study, 2002Condition Causing The Most Pain (n=340) • Those over 55 years of age are significantly more likely to cite arthritis and osteoarthritis particularly Moulin D., PR&M, 2002

  18. Canadian Survey of Post-surgical Pain • 305 Canadian patients – surgery in past 3 years • Both inpatient and day surgery • Severe or extreme pain – 47% inpts; 15% outpts • Still in pain 2 wks afterwards – 79% inpts; 74% outpts • Good relief from pain medications in 54 - 72% Conclusion: improvements could be made Rocchi A. Can J Anaesth, 2002

  19. Canadian Pain SocietyPosition Statement on Pain Relief “Almost all acute and cancer pain can be relieved, and many people with nonmalignant pain can be helped.” Patients have the right to the best pain relief possible. 1. Unrelieved acute pain complicates recovery. 2. Routine assessment is essential for effective management. 3. The best pain management involves patients, families, and health professionals. Canadian Pain Society, Patient Pain Manifesto, 2001

  20. Treatment options for pain Many more options outside of drug choices!!!

  21. Opioids are accepted therapy for…. • Acute Pain • But for how long should you treat? • Cancer Pain • Addiction/diversion is still a concern in this population. • Chronic Non Cancer Pain (CNCP) • Most controversial area!

  22. Case vignette # 1 Why pain is important to the surgeon… • 50 y/o female • Cholecystectomy (Day surgery) for biliary colic. • Healthy. • Previous surgery: ACL repair- was given Acetaminophen/Codeine Tabs and states they did not help to relieve her pain at all. She asks for Oxycodone specifically. Is this a problem?

  23. Case vignette #2Why pain is important to the nurse/ward staff… • 38 y/o female • Post op TAH for menorrhagia (endometriosis) • Chronic Pelvic Pain (HMC 6mg tid). • Refuses Epidural. • PCA HM instituted: 0.2 mg/h with a bolus of 0.4- 0.6 mg LO of 5 min (usual adjuvants of Acetaminophen and NSAID’s given) Thirty min. after getting to the ward (1730), the pt received dimenhydrinate 25 mg iv. Three hours later (2030) got an additional 50 mg of dimenhydrinate po. Pt transferred to stepdown unit at 0100 b/c of somnolence.

  24. Important concept #2 • Caution with other sedating drugs- common examples include BZD’s and dimenhydrinate. Analgesia is important but safety is paramount!

  25. Case vignette # 3Why pain is important to the surgeon (again)… • Urology slate; • Pt #1: 68 y/o male for a lap. nephrectomy • Pt #2: 42 y/o male for a lap. nephrectomy Pt #1- requires a total of 10 mg iv Morphine in PARR. (PCA morphine use was as expected). Pt #2- requires a total of 30 mg iv Morphine in PARR. (Used 100 mg of iv HM in the first 24h!) What is going on???

  26. Chronic Post surgical Pain (CPSP) • Risk factors: • Genetic susceptibility? • Preceding pain? • Psychosocial factors? • Age and sex? • Type of procedure? Strategies to decrease CPSP: -Multi-modal analgesia? -NMDA antagonist? -Analgesia for a longer period of time? -Surgical technique?

  27. Important concept # 3 • Individualize therapy and recognize early chronic post surgical pain syndromes (NeP).

  28. Case vignette # 4Why pain is important to the family physician/geriatrician… • 72 y/o female with post polio syndrome and transverse myelitis (recovered). Also suspected to suffer from fibromyalgia (rheumatology opinion). Consult reads: “Patient has chronic pain and is also insane. Continuously returning for opioid prescriptions (Codeine). Suggestions please.” Assesment: Consistent with NeP pain syn. and FM. Pt settled very nicely with TCA and MSC (no aberrant behavior over 5 yrs of care).

  29. Guidelines from AGS: http://www.americangeriatrics.org/education/pharm_management.shtml

  30. …”the longevity revolution” or “..the silver tsunami…” - Over 50% of pts in nursing home patients suffer from pain and 80% could benefit from palliative care.

  31. Case vignette # 5Why pain is important to the family physician… • 81 y/o male with a RC Tear and Spinal Stenosis. • Minimal activity b/c of pain. • Fragile- numerous co-morbid conditions. Tx: Lumbar ED steroid. Surgical consult- disability minimal with RC. Tramadol XL 200 mg OD and Tramacet 1-2 tabs per day. Function re-established- stable for 2 yrs.

  32. Treatment Goals in Patients with Chronic Pain  Decrease pain  Function • ADL • Sleep • Socialization Minimize adverse effects Importan concept # 4!

  33. Quotes from this paper: - CNCP 15-25% at any given time. - …increases to 50% in pt’s older than 65. - 18% of American respondents did not seek care as they felt their complaints would be ignored. - Worldwide 10 million new cases CA/yr. - 80% of pts with CA experience pain (may be more with advanced disease). -By 2020- figure will double with 70% occurring in third world countries. - 60-80% of pts suffering from HIV will have pain.

  34. Why pain is important to health advocates, policy makers and world leaders….

  35. Case vignette # 6Why pain is important to personal care home staff (including pharmacy)… • 85 y/o female with IHD and PVD. Neither issue is amenable to surgical correction. Pt also suffers from extreme anxiety. Many medications have been tried without success (somnolence). Pt is frustrated and chooses a “palliative care approach”. Ischemic pain is both nociceptive and NeP (many times difficult to treat). Pain stabilized on methadone and increased dose of oxycodone for B/T. Using clonazepam for anxiety- reasonably stable symptoms but more titration has and will be required.

  36. Palliative Care Pain control -Courtesy of Dr. Mike Harlos -Medical Director -Palliative Care Program, Wpg., Mb.

  37. Case vignette # 7- Why pain is important to the ER staff… 35 y/o female- 6 mo. Hx of vague abd pain. Previous gastric bypass procedure- remains moderately obese. Admits to excess ETOH. Pt has numerous tattoos covering her body. Presents several times to ER over months to have abd pain assessed. Presents Friday nt with abd pain - thought to be drug seeking- therefore sent home. Presents Saturday with perf’ed viscus. Laparotomy reveals widespread gastric cancer. Pt declines further tx and PC is consulted. Symptoms controlled- pts dies 3d after transfer to PC ward.

  38. The Seven Stages of Opioid Prescribing Credit for idea: Dr.Allan Gordon MD Neurologist and Director Wasser Pain Management Centre Mount Sinai Hospital Stage 1- Opioid Naive Stage 2- Opiophobic Stage 3- Opioiphillic Stage 4- Opioid Expert Stage 5- Opioid Disaster Stage 6- Acquired Opioiphobia Stage 7- Opioid Balance

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