Taking the Pain Out of Treating Chronic Pain

1. Taking the Pain Out of Treating Chronic Pain Rhonda Feldman, MHS, MSS, PA-C Associate Academic Coordinator University of New England Physician Assistant Program

2. Essentials of Treating Pain – and Keeping Your Sanity Provider Responsibility Patient Responsibility Willingness to approach pain management from a multi-focal plan Compliance with agreed upon treatment plan Consequence of non-compliance Honest communication • Stay up to date on pain research • Understand treatment strategy • If you don’t have time to do it right – refer • If your only response to chronic pain is to write a RX – refer • Honest communication

3. Partner With Your Patient • Research indicates provider-patient relationship cornerstone of effective treatment • Duel responsibility removes some on the pressure from the provider • The patient feels as though they are empowered

4. What Type of Pain Are You Treating? • Pain from known pathology – it’s easier for you and the patient to treat something you can see • Pain from unknown, unidentified source – much more difficult to manage pain that just doesn’t make sense.

5. Let’s Make Some Sense of It • Is there a history of trauma/injury/surgery? • Is there a history of intense emotional stress? • Is there a family history of similar issues with chronic pain?

6. Central Pain • “Central Pain” refers to pain that, although may originate from peripheral injury or disease, becomes a CNS phenomena • Research indicates a hypersensitivity reaction – some type of “uptake” resulting in a malfunction of the pain system • Results in a “false” report of pain – there is no peripheral impetus, the CNS “creates” pain

7. In a nutshell…. • “the CNS can change, distort or amplify pain, increasing its degree, duration, and spatial extent in a manner that no longer directly reflects the specific qualities of peripheral noxious stimuli, but rather the particular functional circuits in the CNS” Woolf, Clifford J., Pain, March 2011; 152(3 suppl)

8. Central Sensitization • CNS “winds up” into a persistent state of hyperactivity • Becomes regulated – leading to persistent pain after injury has long healed • 2 Main Characteristics – Allodynia (perception of pain with simple insult) and hyperalgesia (increased pain level to an actual painful stimulus)

9. Other factors… • Cognitive deficits – poor concentration, poor short-term memory • Increased levels of emotional distress, especially anxiety • Associated with sick role behaviors – resting and malaise and pain behaviors

10. Predisposing Factors • Sensitivity to pain – genetic predisposition • Stress-response – research supports relationship between stress and lowering of pain thresholds • Pre-existing anxiety about pain consistently relates to higher pain sensitivities • A prior history of anxiety, physical and psychological trauma and depression is significantly predictive of onset of chronic pain

11. Antecedent Factors • Onset of pain often associated with fear-avoidance, anxiety, depression, general stress – all may drive up reactivity in the CNS • Sleep deprivation known to increase pain sensitivities • Operant learning – patient experience reinforcement within their environment

12. Treatments • Anticonvulsants • Antidepressants • Cognitive Behavior Therapy • Non-steroidal medications (inflammation theory) • Requires interdisciplinary treatment plans

13. Red Flags Indicating Possible Central Component • Localized treatment ineffective (the OA knee pain that doesn’t respond to inter-articular injection) • Pain report greatly exceeds what would be expected or observed in majority of patients • Emotional buy-in by patient • Impact on family dynamics – does the family revolve around the patient’s pain?

14. The Biopsychosocial Model • Disease – “an objective biological event” • Illness – “subjective experience or self-attribution” – “how a sick person and members of his or her family live with, and respond to, symptoms of disability ‘ (Gatchel, et. al.)

15. Provides A Multilayered Plan • Effective regardless of etiology of pain • Works well with emphasis on inter-professional healthcare team models • Ensures monitoring across parameters • Ensures responsible prescribing • Decreases time consumption in regards to PCP management

16. Trifurcated Plan • Physical Pain (BIO) • Emotional Pain (Psycho) • Impact on Life (Social)

17. What kind of Pain? Peripheral Central Is there a past trauma, injury? Does the amount of pain reported exceed what could reasonably be expected? Hypersensitivity? Exaggerated response? • Identifiable pathology • Poorly healed wound • Structural compromise

18. Treatment Options? Peripheral Central Specific use of opioids – refer to pain clinic – often best managed via pump directly to spine Anticonvulsants Antidepressants • Opioid • NSAID • Massage • Therapy • Exercise

19. American Academy of Pain Medicine Position Statement • Opioids should be prescribed only after a thorough evaluation of the patient, considerations of the alternatives, development of a treatment plan tailored to the needs of the patient and minimization of adverse effects, and on-going monitoring and documentation.

20. CYP2D6 • A patient’s CYP2D6 determines both analgesic effectiveness AND addiction potential • Too little of the enzyme = diminished pain relief • Too much of the enzyme = rapid burst of analgesia and ALL side effects – euphoria, respiratory depression

21. Opioid • Don’t be hesitant to prescribe • Often cost-effective • Side effects are predictable, many options available – consider CYP2D6 screening • Requires complete evaluation and plan • Requires monitoring • Should never be the ONLY treatment documented for chronic pain

22. Non-opioid Analgesics • Should be tried if appropriate for patient in regards to health, co-morbid risk • Side effect profile may be more dire than opioids • Are effective – the patient should report some relief. No relief? Be wary of statements such as “I didn’t feel anything at all” and “none of this stuff works for me”

23. Negative Patient Statements re: non-opioid Medications • An exaggerated response to the suggestion of these medications may indicate a significant emotional component • By “not feeling” anything – the patient is not telling you pain is not impacted by the medication – they may be disclosing their belief that “strong” pain medicine must cause objective side effects; drowsiness, euphoria, etc.

24. Emotional Pain • Evidence does not exist as to whether mood disorders predispose to chronic pain, or if chronic pain results in mood disorder • Evidence does support the high prevalence of mood disorder (predominately depression and anxiety) among chronic pain sufferers. • 3 most common emotions displayed by chronic pain patients – anger, depression mood, anxiety

25. Anger • Predominate emotion in patients with chronic pain • May express anger at healthcare provider, family, friends, the world • Overriding focus of anger is inward

26. Psychological Mediators • Perceived injustice and catastrophizing result in increased chronicity • Perceived injustice “I didn’t do anything to deserve this!” • Catastrophizing “I will be in awful pain, this will not get better”

27. What does this mean to the PCP? • Testing instruments available to predict outcomes around recovery to injury or disease • PCP’s should acknowledge these mediators in the patient through discussion, identification of anger traits, etc., should be part of the over-all assessment of the patient • Document this in your treatment plan – what are risks specific to this patient? What increases that risk in THIS patient?

28. Benefits of Approach • Offers opportunity for more complete treatment • The provider may identify patients with predispositions which indicate a possible extended recovery time; initiate earlier referral to specialty care, provide pre-surgical counseling to mediate effects, etc.

29. Social Factors • What is the patient’s perception of pain? • What is the impact on activities of daily living? • How do significant others (social group) respond to the patient being in pain? • What is the patient’s perceived loss? • What do they feel their future will be in regards to pain?

30. Treatment Plan • Attempt to identify what type of pain you are treating – if you suspect central pain – refer to pain management • Develop a template addressing management across all three parameters – bio, psycho, social • Refer for services not offered in your practice • Make participation in the psychosocial aspects of plan mandatory

31. Pain Management Template • Medications: • Counseling: • Physical/Occupational Therapy: • Personal Goals: • Participation in physical activity: What type: Frequency: x/week **Compliance statement (with consequences for failure)

32. Outcomes • Works well in inter-professional team model • Offers several areas where patients may improve – takes the focus off of the prescription • Leads to increased insight – among patients and providers • Templates built into EMR improve monitoring across the three parameters

33. Take Home Points • Pain is multi-factorial and requires multi-factorial treatment • Recognition of possible CNS pain component is essential to effective treatment strategy • An effective pain treatment plan is reliant on a team-based approach

34. References • Phillips, K. & Clauw, D.J. (2011). Central pain mechanisms in chronic pain states – maybe it is all in their head. Best Practice Research in Clinical Rheumatology, 25, 141-154 • Gatchel, R. et al, (2007). The Biopsychosocial Approach to Chronic Pain: Scientific Advances and Future Directions. APA Psychological Bulletin, Vol. 133, No. 4, 581-624

35. Questions?