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Chronic Pain Management A Structured Approach

Chronic Pain Management A Structured Approach. Dr Gordon Irving Medical Director , Swedish Pain Center . Clinical Associate Professor, University of Washington Medical School. Disclosures. Lecturer Acorda , Xenoport Pain doc. 29 years and counting. Structured Approach. For Providers

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Chronic Pain Management A Structured Approach

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  1. Chronic Pain Management A Structured Approach Dr Gordon IrvingMedical Director , Swedish Pain Center. Clinical Associate Professor, University of Washington Medical School.

  2. Disclosures Lecturer Acorda, Xenoport Pain doc. 29 years and counting

  3. Structured Approach For Providers • www.swedish.org/pain • “for referring physicians” • Videos • Opioid prescribing, naïve and tolerant • Adjuvants and antidepressants for chronic pain • Brain changes in chronic pain • Spinal cord stimulators, intra-thecal pumps • Acupuncture • Ultrasound injections for pain

  4. Stages of Change • Pre contemplative • Passive, angry anxious victim, “fix me” • Contemplative • I know there must be something seriously wrong to have this much pain but the medications and injections are not helping. • Is there something else you could do?

  5. Stages of Change • Action • I am doing more • I have made goals and am achieving them • I do not need as many medications • Maintenance • I am in a good program of self care. • I know what to do if I flare up and how to avoid it • I am doing more now than I have done in years

  6. Structured Approach • For Patients • www.swedish.org/pain • “education and resources” • Videos • CAM • Fibromyalgia • Opioids • www.swedish.org/stomp

  7. General Layout of STOMP • Introduction to the problem eg Anxiety and Depression • Practical ways to improve “Steps to Get There” • Resources: active hyperlinks • Recommended reading • Recommended web sites: e.g.PTSD

  8. Jane: Background 42-yr-old female with pain following MVA 5 years ago Seen multiple doctors , tried acupuncture and chiropractic She is disabled, irritable You review her hand carried records, extensive work up including Xrays and MRI of C and LS spine Multiple failed drug trials; only oxycodone helps a little “No one is doing anything to help me”

  9. Jane: Current Symptoms • Sleep disturbance • “Pain all over” • Fatigue • Persistent diarrhea • Morning stiffness • Dry, itchy eyes • Muscle tenderness • Joint pain • Tension headaches • Depression and irritability

  10. Initial Evaluation(Janet and Husband) Almost any activity makes her pain worse; now inactive Does not sleep well, does not feel rested upon awakening Gained 40 lb since accident. BMI 35 Feels frustrated with herself for not coping better Appears depressed Doses of opioids have been escalating (numerous side effects) Wants to be “fixed”

  11. Jane’s Pain Behaviors Walks in a stiff posture with limited movement of neck Rubs neck frequently Walks in a guarded fashion Sighs Facial grimacing when gets in and out of chair Husband rolls his eyes when he observes her “pain behaviors”

  12. Jane’s Physical Examination • What would this consist of? • What if any laboratory test would you order? • Fibromyalgia tender points 14/18 positive

  13. THE PRINCIPLES AND PRACTICE OF MEDICINE DESIGNED FOR THE USE OF PRACTITIONERS AND STUDENTS OF MEDICINE BY WILLIAM OSLER, M. D. FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS, LONDON PROFESSOR OF MEDICINE IN THE JOHNS HOPKINS UNIVERSITY AND PHYSICIAN-IN-CHIEF TO THE JOHNS HOPKINS HOSPITAL, BALTIMORE, FORMERLY PROFESSOR OF THE INSTITUTES OF MEDICINE, McGILL UNIVERSITY, MONTREAL, AND PROFESSOR OF CLINICAL MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA, PHILADELPHIA NEW YORK D. APPLETON AND COMPANY 1892 William Osler 1849 - 1919

  14. The Principles and Practice of Medicine (1869) Neurasthenia appears to be the expression of a morbid, unhealthy reaction to stimuli acting on the nervous system • Sleeplessness is frequently concomitant • The majority are moody or depressed • The aching pain in the back of the neck is the most constant complaint • There are spots of local tenderness in the spine

  15. fMRI Evidence for Pain Augmentation in Fibromyalgia Patients 14 12 10 8 Pain Intensity 6 Fibromyalgia 4 Control 2 0 1.5 2.5 3.5 4.5 Stimulus Intensity (kg/cm2) Gracely et al. Arthritis Rheum. 2002;46:1333-1343.

  16. What Do You Tell the Patient? That she has fibromyalgia, a disease that has no cure; suggest a handout, book, or Web site That she has generalized pain syndrome of unclear etiology and will have to learn to live with it; and have her come back at your next routine check-up (3 mo) That she has fibromyalgia syndrome (FMS); suggest further investigation and symptom management

  17. Labeling the Patient Population studies have showed that providing the FMS label did not increase illness behavior, disability, or office visits White KP, et al. Arthritis Rheum. 2002;47:260–265. [Evidence Level B]; Moldofsky H, et al. J Rheumatol. 1993;20:1935–1940. [Evidence Level B]

  18. Appropriate Laboratory Workup CBC, TSH, CRP, ?ANA Vitamin D Possibly a sleep study Avoid over investigating CBC = complete blood count; ESR = erythrocyte sedimentation rate; TSH = thyroid-stimulating hormone; CRP = C-reactive protein; ANA = antinuclear antibody; LP = lipoprotein; MRI C = cardiac magnetic resonance imaging; LS = lumbosacral.

  19. Suggested Structured Approach • Education • www.swedish.org.pain • Video on fibromyalgia • www.swedish.org/stomp • Look for comorbidities • Anxiety • PTSD • Depression

  20. Fibromyalgia: Treatment • Few proven treatments in randomized controlled trials • Amitriptyline1, Tramadol2, Cyclobenzaprine3 Duloxetine, Pregabalin • Exercise4 • Cognitive-behavioral interventions5 • Most prescribed—anti-inflammatories • Patient preference—opioids 1. O’Malley PG, et al. J Gen Intern Med. 2000;15:659–666 [Evidence Level A]; 2. Furlan AD, et al. CMAJ. 2006;174:1589–1594 [Evidence Level A]; 3. Tofferi JK, et al. Arthritis Rheum. 2004;51:9–13 [Evidence Level A]; 4. Busch A, et al. Cochrane Database Syst Rev. 2002;3:CD003786 [Evidence Level A]; 5. Goldenberg DL, et al. JAMA. 2004;292:2388–2395. [Evidence Level A]

  21. Fibromyalgia: Treatment (cont) • Education • Biofeedback • Pacing • Treat mood disturbance • Avoid opioids • Avoid benzodiazepines • Exclusion diets • Cognitive restructuring • Group support • Medications • Exercise • Low dose naltrexone • Vitamin D

  22. Changes in Brain Gray Matter with Chronic Low Back Pain (CLBP) • Age related losses in gray matter = 0.5%/year • Chronic low back pain patients = 5.4% decrease • Reduced in bilateral prefrontal cortex and right thalamus • Impact of chronic low back pain is an additional 10 years of brain atrophy • Duration of chronic low back pain is a strong predictor of gray matter changes Apkarian et al. J Neuroscience 2004

  23. Achieving Goals • Change the way you think about your vices. • Resisting temptation: more successful if participants said “I don’t” eg I don’t eat sugar instead of “I can’t” • “I don’t” makes one feel empowered and better able to resist temptation • J of Consumer Research Aug 2012

  24. Steps to Help Patients WithFibromyalgia • Accept pain as real • Protect from excessive invasive testing/procedures • Get patient to set SMART goals • S= Specific: M=Measurable: A=Achievable: R=Realistic: T=Timely • Expect to treat, but not to cure • Evaluate in terms of what they do, not what they say • Avoid opioids and benzodiazepines

  25. Life Satisfaction Wheel and SMART goals

  26. Get the patient “involved” Exclusion diets 2 Weeks off dairy gluten Reintroduce foodstuff “super sensitized

  27. Jim: Background • 64 year old male • BMI 42 • Type 2 diabetes • Painful peripheral neuropathy • OA bilateral knees • Co-morbidities • Smoking one pack a day • Sleep Apnea • Depression

  28. Jim Recommendations: Stop smoking Stop smoking: Why? One hour post cigarette CO causes decreased O2 to poorly perfused tissues “discs, tight muscles” Interferes with metabolism of opioids You have a choice to smoke “I have a choice to prescribe opioids and I elect not to for patients who are not taking an active role in their own health care” Opioid lack, unlike insulin, is NOT life threatening

  29. Jim: Stopping Smoking How? Make a SMART goal • Set a quit date • www.swedish.org/stomp “smoking chapter” • Follow up 2 weeks • Nicotine gum; lozenge, nasal spray, inhaler, patch • Buproprion SR 150mg • Varenicline • Chandler MA, Chest. 2010;137(2) • Cysteine (Tabex) • Weight Gain Average 11lb end first year 6-7 more pounds next 4 years US Dept Health Human Serv. 1990

  30. Jim Recommendations: Weight loss • “I need pain killers to exercise, then I can lose weight” • Physical exercise by itself leads to <3% weight loss • Answer: Decrease calories • Mediterranean diet • “Paleo Diet” “New Atkins Diet” • www.swedish.org/stomp • Combined exercise and decreased calories is best • 10 mins 2-4 times a day better than single longer session Burke L et al J Nursing Scholarship 2011.43(4):368-75

  31. Hooked on food Foods dense in fat and sugar prompt striatum to produce endorphins “feel good” chemicals Dopamine released goes to prefrontal cortex (decision making) Feedback loops spur people to seek more and more Get tolerance to the reward effect so have to eat more Decreased reward system causes depression

  32. Hooked on food Morphine injected into striatum of brain in mice triggers binge like over eating. Opioids work on the same pathways as fat and sugar Opioid blockers can cause withdrawal type symptoms in obese mice Congenital low dopamine D2 receptors increase risk of addiction to opioids and obesity

  33. Jim: Weight loss Behavioral therapy Self monitoring Only take enough cash to the supermarket Small meals frequently Learn other clues to over eating “Smart aids” Pedometer Fitbitactivity and sleep Smart phone app Smart provider encouragement

  34. Changing the Brain • Participation in mindfulness based stress reduction for 8 weeks increases in grey matter concentration: hippocampus, post cingulate cortex, temporo-parietal junction and cerebellum • Hotzel BJ, Psychiatry research: Neuroimmaging 2011;191:36-43

  35. Sam: Background 44 year old male Low back and bilateral leg pain Status post 3 back surgeries. Last one fusion L4-S1 On 150 Morphine Equivalents a Day (MED) opioid Clonazepam 1mg tid. Poor sleep Temazepam 20 mg hs Pain 9/10 Smoking BMI 28

  36. Benzodiazepines and Pain • Opioids and benzodiazepines are commonly prescribed together- • Lifetime prevalence non-medical sedative use among adults is 7% (according to NCS in US) • Most patients using BZs do not escalate dose, but long-term use is common and associated with adverse health effects, esp. older adults • MVA, falls, fractures, dementia, global mortality, poor driving reflexes.

  37. Sam: Suggested Structured Approach • Review the patient on the Washington Prescription Monitoring Program. • Do a urine toxicology screen • Ask “what drugs do you expect we will find in your urine?” • Have the significant other there whilst you are explaining the “plan”

  38. Patients w/ 2 or more Prescribers

  39. Sam: Suggested Structured Approach • HB 2876: Washington State Opioid Prescribing law • Refer to a “specialist” for an opinion as to the appropriateness of therapy and what other treatments • Pain management specialist, rheumatologist, anesthesiologist, physical medicine rehab, neurologist • Or 18 hours CME pain management, within the last two years 2 hours on long acting opioids

  40. Sam: Suggested Structured Approach • SMART goals • Patient decides: www.swedish.org/stomp • Physician decides • Stopping smoking: have a stop date next visit • Not stopping, or no goals identified and planned, start decreasing opioids • Encourage patient to buy a pain management book • “Managing pain before it manages you” Caudill $9-15 on Amazon • “The pain survival guide” Turk $6.50-15 • Consider sleep study • Obstructive or central sleep apnea or both

  41. Sam: Suggested Structured Approach • Have significant other at initial visits to assess • Physical function level • Adherence to “the program” • Support “too much or too little”

  42. A Structured Approach Logical Evidence based Safe Gets patient involved “patient centered health care” Gets the best results Least extra time for the provider

  43. Structured Approach Be compassionate Be knowledgeable and have a “hook” Patient directed SMART goals

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