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Pain Management: Conservative Treatments of Painful Conditions

Pain Management: Conservative Treatments of Painful Conditions. Principles Of Pain Management. 1. Reduction of Pain Medications, Nerve Blocks, Surgery 2. Rehabilitation Reconditioning and Prevention 3. Coping

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Pain Management: Conservative Treatments of Painful Conditions

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  1. Pain Management: Conservative Treatments of Painful Conditions

  2. Principles Of Pain Management 1. Reduction of Pain Medications, Nerve Blocks, Surgery 2. Rehabilitation Reconditioning and Prevention 3. Coping Management of residual pain with biofeedback, cognitive therapies

  3. Acute Pain: Treatment • NSAIDs • Opioids • Adjuvant (s) • Other...

  4. Components of Chronic Pain: Stable and “Breakthrough” Pain Breakthrough pain Around-the-clockmedication Persistent pain Time

  5. Musculoskeletal Pain:The Role of Medications • Analgesics are permissive • They allow parallel interventions to succeed • Physical / occupational therapy • Bracing • Psychological counseling • Surgery • Adequate analgesia preserves • Function • Quality of life • Psychological well-being

  6. Opioids Antidepressants Anticonvulsants Local anesthetics Corticosteroids Alpha agonists GABA-ergic NSAIDs / COX-2s Cannabinoids NMDA antagonists Tramadol Analgesics and Adjuvants for Neuropathic Pain

  7. A Place for Opioids? • Documentation • The Four “A’s” • Analgesia • ADLs • Adverse events • Abuse issues* *Passik, SD, Weinreb, HJ. Adv Ther. 2000;17(2):70-83.

  8. Opioid Myths • “I’ll get hooked” or “You’ll get hooked” • Studies show addiction to be problematic only in a small % of patients • Some patients are tolerant to opioids, different than addiction

  9. Opioid Realities • Patients don’t like to take them (if they have an effective alternative) • They cause constipation/mental clouding/nausea (all manageable) • Costs associated with Opioid side effects • Diversion/Bad Behavior • Endocrine suppression

  10. A Place for Opioids? • Dependent upon opioid trial • Diminution of pain intensity • Increase in functioning for ADLs • Minimal adverse events which adversely affect psychological and/or physical functioning • Documented pain / function diary • Documented physical examination • Documented discussion regarding trial, results, and plan

  11. What is the Risk of Addiction? • 7% of population uses/abuses illegal drugs1 • Random surveillance urine toxicology screen 400 patients in Ky pain practice receiving prescription opioids2: • 17% + screen (Comm. Ins) • 10% + screen (Medicare) • 39% + screen (Medicaid) • Lussier D, Pappagallo M. The Neurologist 2004;10:221-4 • Manchakanti L, et al. J Ky Med Assoc 2005;103(2):55-62

  12. Opioid Realities • Many patients don’t like to take them (if they have an effective alternative) • They cause constipation/mental clouding/nausea (all manageable) • Costs associated with opioid side effects • Diversion/bad behavior • Societal/regulatory pressure • Prosecution! (DEA/DPS/Etc.) • Long Term Adverse Outcomes? Endocrine issues

  13. Opioid Analgesics • Mainstay of cancer pain management1 • Guidelines published by • World Health Organization, 1996 • United States Agency for Health Care Policy and Research, 1994 • American Pain Society, 1992 • Adoption into chronic non-cancer pain past decade…not really evidence based… 1Foley KM. Cancer. 1989;63(11 Suppl):2257-2265.

  14. Increasing use of opioids in chronic pain • Consensus APS-AAPM statements;more pain education; meetings;new opioids • 1980-2000 use of strong opioids to Rx chronic musculoskeletal pain 2% to 9% in primary care* • Cause for celebration or alarm? “Flying blind”** *Caudill-Slosberg MA, et al. Pain 2004 **Von Korff M, Deyo RA. Editorial Pain 2004.

  15. Opioid Precriptions USJan ’04-Dec ‘04 • 200+ m prescriptions 129m NSAIDs 185m 25m C II

  16. Opioids: Cochrane Review Efficacy/Evidence Based Medicine Kalso E, Edwards JE, Moore RA, McQuay HJ. Opioids in chronic non-cancer pain: Systemic review of efficacy and safety. Pain 2004;112:372-80. • 15 randomized placebo controlled trials • 11/15 po meds, 1-8 weeks trial, 6-24 mos. Open label f/u; Mean reduction pain 30% Conclusions: • Short-term efficacy good for musculoskeletal and neuropathic pain • Cannot make conclusions about long term efficacy, tolerance, addiction

  17. Opioid Titration and Maintenance • No analgesic “ceiling” dose • Drug titration until satisfactory pain relief or unmanageable side effects occur • Maintenance doses vary considerably according to individual factors and nature of pain

  18. When given at stable doses for long-term therapy, opioids do not significantly impair cognition, attention, mood, driving ability, or general functioning Therapeutic Use of Opioids Portenoy RK. Ann Acad Med Singapore. 1994;23(2):160-170; Vainio A, et al. Lancet. 1995;346(8976):667-670; Haythornthwaite JA, et al. J Pain Symptom Manage. 1998;15(3):185-194.

  19. Management of Common Opioid Side Effects • Constipation • Prophylactic use of laxatives and stool softeners • Nausea and vomiting • Neuroleptics, metoclopramide, cisapride, antivertigenous drugs • Sedation • Discontinue other CNS depressants • Add psychostimulants • Respiratory depression • Extremely rare. Monitor if not severe; carefully titrate naloxone if severe CNS: Central nervous system

  20. Opioid Conclusions • Opioids are broad spectrum analgesics which act at multiple points in the pain pathway • Safety and short term efficacy are established • Appropriate use of opioids should be established with a controlled opioid trial • Safeguards against diversion/abuse

  21. Chronic Opioids: The downside • DAWN network reporting noted increased abuse of prescription opioids ’94-’00 123%* • Some, albeit small percentage of prescription opioids diverted into abuse** • Trace methadone increase prescribing p oxycodone-CR scare, ’02-’03 methadone prescriptions 1m to 2.6m with 5 fold increase in abuse cases*** *Zacny J 2003; **Hurwitz W Pain Med 2005; ***Cicero TJ JAMA 2005

  22. Long-Term Opioid Side Effects • Opioid induced hypogonadism • Immune suppression • Hyperalgesia • Hearing Loss • All probably seen at higher doses over long term (years) administration Rajagopal A, et al, JCO 2003. Roy S, et al. Neurochem Res 1996; Mao J Pain 2002; Ballantyne J, NEJM 2003; Vrabec J, Burton AW in press

  23. How to safely prescribe chronic opioids Gourlay DL, Heit HA, Almahrezi A, Universal precautions in Pain Medicine: A rational approach to the treatment of chronic pain. Pain Med 2005;6:107-12. • Make a Dx • Psychological assessment including addictive disorders • Informed consent • Treatment agreement • Pre- Post- interventional assessment of pain level and functioning • Trial of “rational polypharmacy” • Regular reassessment • Reassess 4 “A’s”: Analgesia, activity, adverse events, aberrant behavior • Review Dx and comorbidities periodically • Documentation

  24. Chronic Pain Treatment Strategy • Multidisciplinary Care • Primary care, pain specialist, physical medicine, surgeon, psychologist, physical therapist • Multimodal Care • Adjuvant medications • Opioids • Topicals • Holistic Approaches • Massage, meditation, etc.

  25. Principles Of Pain Management 1. Reduction of Pain Medications, Nerve Blocks, Surgery 2. Rehabilitation Reconditioning and Prevention 3. Coping Management of residual pain with biofeedback, cognitive therapies

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