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Embracing the Management of Chronic Pain

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Embracing the Management of Chronic Pain

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    1. Embracing the Management of Chronic Pain COL Diane Flynn, MC, USA LTC Mary V. Krueger, MC, USA USAFP Scientific Assembly 7 April 2009

    2. . How many of you take care of patients with chronic pain….how many of you like it? Why/why not?How many of you take care of patients with chronic pain….how many of you like it? Why/why not?

    3. Outline. Chronic pain concepts Initial evaluation of patient with chronic pain Treatment Nonpharmacologic Pharmacologic Helpful tools

    4. Key Distinction. Among the second group, goal is not to “coping” with pain, but teaching pt to cope without pain. 90% respond well to treatment, 10% lead to drugs, compensation.Among the second group, goal is not to “coping” with pain, but teaching pt to cope without pain. 90% respond well to treatment, 10% lead to drugs, compensation.

    5. Red flags for Complexity. Belief that “pain means harm” and “all pain must go before return to work” Passive attitude toward rehabilitation, avoidance of normal ADLs Overprotective spouse Poor work history, frequent job changes

    6. Case. 24 yo active duty specialist, MEB pending Chronic mechanical LBP, fibromyalgia, trochanteric bursitis, trigeminal neuralgia PTSD related to sexual assault Daily life.Daily life.

    7. Bedridden much of time, uses wheelchair outside of home Married, 4 yo daughter Medications: fentanyl, MS contin, MS IR, diazepam, lorazepam, piroxicam, venlafaxine Case. Simplified regimen. Continued benzos. Instructed will never increase dosage – goal is taper down to safer dosages.Simplified regimen. Continued benzos. Instructed will never increase dosage – goal is taper down to safer dosages.

    8. History: Past Medical Specific diagnosis of underlying etiology helps to direct adjunctive therapy Past medical and surgical history Comprehensive pain assessment* Social history: Employment, legal history (pending litigation), social network Evaluation of occupational risks and ability to perform duties A multidimensional tool to assess chronic pain should be utilized, since chronic pain affects a person' s entire being. Evidence rating C: Penny 1999, as cited in the ICSI guideline. Bedridden much of time, uses wheelchair outside of home Married, 4 yo daughter Medications: fentanyl, MS contin, MS IR, diazepam, lorazepam, piroxicam, venlafaxine A multidimensional tool to assess chronic pain should be utilized, since chronic pain affects a person' s entire being. Evidence rating C: Penny 1999, as cited in the ICSI guideline. Bedridden much of time, uses wheelchair outside of home Married, 4 yo daughter Medications: fentanyl, MS contin, MS IR, diazepam, lorazepam, piroxicam, venlafaxine

    9. History: Pain Assessment Pain Related History Prior pain treatment and results of this treatment Adequate trial of non-opioid therapy Pain related fear Interference with function: Impact on work/family life Review prior studies Comprehensive assessment Intensity of pain: 1 - 10* Response to current pain treatments Other attributes of pain Type of pain Nociceptive Neuropathic Function in all domains* Other attributes of pain include: Duration of symptoms Onset and triggers Location Co-morbidity Previous episodes Intensity and impact Patient perception of symptoms Evaluate function related to pain, from the DoD/VA guideline, Quality of evidence: I, Overall quality: Good, Recommendation: A. Evaluate pain intensity using 0-10 scales: from the DoD/VA guideline, Quality of evidence: II-2, Overall quality: Fair, Recommendation: B.Other attributes of pain include: Duration of symptoms Onset and triggers Location Co-morbidity Previous episodes Intensity and impact Patient perception of symptoms Evaluate function related to pain, from the DoD/VA guideline, Quality of evidence: I, Overall quality: Good, Recommendation: A. Evaluate pain intensity using 0-10 scales: from the DoD/VA guideline, Quality of evidence: II-2, Overall quality: Fair, Recommendation: B.

    10. History: Psychiatric Depression Frequently co-morbid with chronic pain Presence can complicate chronic pain treatment Inquire about prior suicidal ideation/attempt Anxiety disorders Personality disorders Presence may be associated with manipulation, noncompliance, and impulsiveness - It is essential to elicit history of depression or other psychopathology that may affect perception of pain. Evidence rating B: Carragee, 2005; Schultz 2004, Zautra 2005, as cited in the ICSI guideline. - It is essential to elicit history of depression or other psychopathology that may affect perception of pain. Evidence rating B: Carragee, 2005; Schultz 2004, Zautra 2005, as cited in the ICSI guideline.

    11. History: Substance Abuse At risk for developing addiction to opioids Young age More recent history of abuse Consult with addiction specialist for co-management if history of substance abuse

    12. Physical Thorough physical exam in every patient Etiology of pain Physical signs of substance abuse Mental Status Exam Cognitive function Anxiety Depression Other psychiatric disorders

    13. Selected Studies Review any studies relating to source of pain EMG Radiologic studies: MRI, CT, plain films, etc Renal function Liver function tests Urine drug screen Presence of illicit metabolites Be familiar with local sensitivity and specificity

    14. Treatment Plan. Goal setting Nonpharmacologic treatments Pharmacologic treatment OTC meds Prescription non-opioids Opioids

    15. Patient’s perspective. Example of not going to churchExample of not going to church

    16. Self-management perspective. Goal of therapy is to help pt to acknowledge all of their major problems. Encourage them to let go of pain as an excuse to avoid achieving goalsGoal of therapy is to help pt to acknowledge all of their major problems. Encourage them to let go of pain as an excuse to avoid achieving goals

    17. Goal Setting. Help patients to identify their own goals, should be measurable and realistic Get family members involved Should include many facets of life Exercise Social/family Vocation/avocational Spiritual Ask pts to identify ways for them to be a better person. Ask: what would you being doing if you did not have pain Ask pts what they would be doing if they did not have pain to help them identify goals. Consider short-term goals to be identified by the next visit, and long-term goals. Provide encouragement. Consider changing or tapering medication therapy if pt repeatedly fails to achieve goals or maintains a lack of motivation Ask pts to identify ways for them to be a better person. Ask: what would you being doing if you did not have pain Ask pts what they would be doing if they did not have pain to help them identify goals. Consider short-term goals to be identified by the next visit, and long-term goals. Provide encouragement. Consider changing or tapering medication therapy if pt repeatedly fails to achieve goals or maintains a lack of motivation

    18. Exercise Goals. Avoid telling patients to let pain be their guide. Quota system: Set patient’s exercise baseline Level of increased pain, weakness, fatigue. Include aerobic, general strengthening, low level functional activity Exercise program – six days per week Start with ˝ to ľ of baseline Increase incrementally with each exercise session, ie one repetition, one minute, one flight of stairs per day If patient cannot meet expected exercise on a given day, maintain current level for a few days

    19. Non-pharmacologic interventions. Exercise Osteopathic manipulation Biofeedback Acupuncture Ice/heat Cognitive behavioral approaches

    20. Pharmacologic approaches.

    21. World Health Organization Analgesic Ladder. NSAIDs and acetaminophen Corticosteroids “Muscle relaxants” Neuropathic pain meds Anticonvulsants – for neuropathic pain (DM neuropathy, trigeminal neuralgia) Anti-depressants Corticosteriod – polymyalgia rheumatica Abortive and prophylactic meds for migraine Opioids NSAIDs and acetaminophen Corticosteroids “Muscle relaxants” Neuropathic pain meds Anticonvulsants – for neuropathic pain (DM neuropathy, trigeminal neuralgia) Anti-depressants Corticosteriod – polymyalgia rheumatica Abortive and prophylactic meds for migraine Opioids

    22. Antidepressant use in Chronic Pain. For psychologic disorders >50% of patients with chronic pain have major depression Depression decreases pain tolerance For sleep disturbance 50% of chronic pain patients have sleep disturbance For neuropathic pain Antidepressants with NE uptake are probably best choice for pain relief (Nortrip, buprprion, venlafaxine, mirtazapine) SSRIs, SNRIs do not generally improve sleep continuity.Antidepressants with NE uptake are probably best choice for pain relief (Nortrip, buprprion, venlafaxine, mirtazapine) SSRIs, SNRIs do not generally improve sleep continuity.

    23. Suggested Protocol for Opioid Therapy. Once you have completed your evaluation and a trial of non-opioid therapies, you may decide to consider a trial of chronic opioid therapy. Discussion of decussion phase (section 3.c.iii by Mary…) Once you have completed your evaluation and a trial of non-opioid therapies, you may decide to consider a trial of chronic opioid therapy. Discussion of decussion phase (section 3.c.iii by Mary…)

    24. When Pain Remains Opioids Opioids

    25. Indications for Opioid Therapy Failure of relief of moderate to severe pain with non-opioid therapies* Pharmacologic Adjunctive therapies Inability to safely be treated with non-opioids No absolute contraindications to opioids Answers ethical imperative to relieve pain* Both from the DoD/VA guideline; QE: III, Overall quality: PoorBoth from the DoD/VA guideline; QE: III, Overall quality: Poor

    26. Contraindications to Opioids Absolute Allergy to opioid agents Co-administration of contraindicated drug Active diversion of controlled substances Relative Acute psychiatric instability High suicide risk Inability to manage opioid therapy responsibly Unwilling to comply with treatment plan Elderly patients COPD patients Patient with uncontrolled sleep disorders Intolerable adverse effects

    27. Opioid Use for Non-Malignant Pain Tailor use to patient’s circumstances and characteristics of their pain Consider continuing/initiating adjuncts Opioids are rarely the only treatment Therapeutic exercise, biofeedback, CBT Acknowledge trial period of dosing Choose initial dose and taper to effect/goals Establish written plan to monitor progress* A written plan for treating chronic pain should state objectives to determine success, state if further diagnostic tests are indicated, address psycholsocial and physical function, adjust therapy to meet needs of the patient, and use nondrug modalities in addtion to medication. Recommendation as quoted in The American Family Physician, Volume 78, number 10, November 15, 2008, page 1156. Original source was: Federation of State Medical Boards of the United States Inc. Model policy for the use of controlled substance for the treatment of pain. May 2004. Also cited in the DoD/VA guideline under sections G, H, I. A written plan for treating chronic pain should state objectives to determine success, state if further diagnostic tests are indicated, address psycholsocial and physical function, adjust therapy to meet needs of the patient, and use nondrug modalities in addtion to medication. Recommendation as quoted in The American Family Physician, Volume 78, number 10, November 15, 2008, page 1156. Original source was: Federation of State Medical Boards of the United States Inc. Model policy for the use of controlled substance for the treatment of pain. May 2004. Also cited in the DoD/VA guideline under sections G, H, I.

    28. Referrals Medical home key for success Multidisciplinary team often necessary* Development of integrated treatment plan Routine communication between team members Addiction specialist if evidence of substance abuse Pain management specialist Refer to multidisciplinary pain clinic. Becker 2000, Flor 1992, Malone 1988, Guzman, 2001: QE: I, Overall quality: fair, R: B Refer to pain clinic I from DoD/VA Refer to substance abuse specialist C from DoD/VARefer to multidisciplinary pain clinic. Becker 2000, Flor 1992, Malone 1988, Guzman, 2001: QE: I, Overall quality: fair, R: B Refer to pain clinic I from DoD/VA Refer to substance abuse specialist C from DoD/VA

    29. Patient Education Risks Addiction Side effects Benefits Limitations Importance of expectation management Primary goal is restoration of function Important to be realistic / have common ground

    30. Treatment Agreement Defines responsibilities of patient and provider Ensures common goals in objective form Resources on CD: Sample pain agreements from MTFs Sample agreement form www.partnersagainstpain.com

    31. Agreement Content Goals of therapy Requirement for sole provider Limitation on dosage and number of pills Prohibition for use with other substances Need for periodic re-evaluation Prohibition for medication sharing/sales Responsibility for safe keeping of medication Limitation on refills Compliance with overall plan Role of random UDS Acknowledgement of safety issues Consequences for non-adherenece

    32. Suggested Protocol for Opioid Therapy. Once you have completed your evaluation and a trial of non-opioid therapies, you may decide to consider a trial of chronic opioid therapy. Discussion of decussion phase (section 3.c.iii by Mary…) Once you have completed your evaluation and a trial of non-opioid therapies, you may decide to consider a trial of chronic opioid therapy. Discussion of decussion phase (section 3.c.iii by Mary…)

    33. Initiate Therapeutic Trial of Opioid. Opioid selection, initial dosing and titration based on Patient heath status Previous exposure to opioids Low, standard dose for opioid-naďve patients Previous effective dose for those with previous use Strong recommendation, low quality evidence Insufficient evidence to recommend Short-acting vs long-acting opioids As needed vs around-the-clock dosing Caution with COPD, chr constipation IN opioid-naďve, start with low dose short acting, titrate slowlyCaution with COPD, chr constipation IN opioid-naďve, start with low dose short acting, titrate slowly

    34. Choice of Agent. Long-Acting Agents Consider Long acting morphine, ie MS contin – good standby strong recommendation, mod-quality evidence Caution with Methadone – dosing tricky, long and varied half-life. Maximum recommend dosage 30-40 mg daily. Use only if familiar with its use and risks. OxyContin – avoid – high abuse risk, high cost Transderm fentanyl – avoid – high abuse risk, high overdose potential, high cost

    35. Choice of Agent. Short-acting Agents Consider – hydromorphone or oxycodone Avoid prescribing more than 4 doses per day; consider long-acting if 4 doses insufficient Avoid Darvocet – major cause of drug-related deaths Propoxyphene Acetaminophen Demerol – American Pain Society, ISMP recommends against use as analgesic Unique neurotoxicity If used, limit to <48 hrs, <600 mg daily

    36. Choice of Agent Breakthrough Pain. Controversial May consider for patients on around-the-clock opioids with breakthrough pain weak recommendation, low-quality evidence If used, recommend no more than average of 1-2 tabs per day (30-60 tabs per month, in addition to long acting agent)

    37. Ceiling opioid dosage?. No evidence of benefit with opioid dosages >180 morphine-equivalents per day Potential harms of high-dosage opioids: Hormonal effects Immunosuppression Hyperalgesia Expert consensus

    38. Monitoring Progress towards goals Titrate to effect Assess adherence Assess efficacy Address adverse effects Need for referral to specialized services

    39. Progress Toward Goals Ensure identification of medical home Follow-up schedule based on patient risk factors, titration of medication, side effects, pain control Frequency of follow up may change based on clinical course Progress towards goals involves evaluation of: Functioning in ADLs at home and at work Sense of well being/worth Control of pain to tolerable level

    40. Titrate to Effect (1 of 2) Utilize medication with best pain relief and fewest adverse effects at lowest dose Optimal level of analgesia and function obtained in absence of unacceptable side effects Utilize equianalgesic conversion table when switching between preparations

    41. Titrate to Effect (2 of 2) Evaluate breakthrough pain for new etiology Repeated dose escalations may be marker for substance abuse or diversion Consider opioid rotation if inadequate benefit or intolerable adverse effects Incomplete cross tolerance to opioid effects Reduce calculated equianalgesic dose by 20 – 25%

    42. Assess Adherence/Abuse Document adherence with medication Pill counts Urine drug screens Document adherence to treatment plan Compliance with adjunctive therapies Follow-up with referrals Assess patient motivation/barriers to adherence Assess for behaviors predictive of addiction

    43. Predictors of Misuse Illegal or criminal behavior Dangerous behavior: MVA, suicide attempt Behavior suggestive of addiction Multiple episodes of prescription “loss” Refusal to perform UDS Deterioration of home or work functioning Aberrant behavior Requesting more of the drug Requesting specific drugs Missing appointments

    44. Adverse Effects (1 of 2) Constipation Initiate bowel regimen for those at risk Increase fluid/fiber, consider stool softeners Nausea and vomiting Tends to diminish over initial weeks Sedation or clouded mentation Decreases over time Patient must take precautions driving/operating machinery until this resolves

    45. Adverse Effects (2 of 2) Hypogonadism Fatigue, decreased libido, sexual dysfunction Test for hormonal deficiencies if symptoms present Itching Tends to diminish over initial weeks Due to histamine release with morphine Respiratory depression Worse when doses titrated too quickly Caution in patients with sleep apnea, COPD

    46. Suggested Protocol for Opioid Therapy. Once you have completed your evaluation and a trial of non-opioid therapies, you may decide to consider a trial of chronic opioid therapy. Discussion of decussion phase (section 3.c.iii by Mary…) Once you have completed your evaluation and a trial of non-opioid therapies, you may decide to consider a trial of chronic opioid therapy. Discussion of decussion phase (section 3.c.iii by Mary…)

    47. Stable Phase. Maintain stable moderate dosage Monthly refills Assess and document pain score and side effects of opioid Treat side effects Recommend patient for comprehensive follow up if indicated Comprehensive follow up Require at least every year and optimally every 3 months Assess pain relief, well being, achievement of treatment goals, functioning and quality of life Toxicology screening, if indicated Low-quality evidence

    48. Suggested Protocol for Opioid Therapy.

    49. Indications to Stop Opioids. Pain is resolved No progress toward therapeutic goals Inability to tolerate side effects Serious or repeated aberrant behaviors Request for early renewals – does not usually require discontinuation Doctor/pharmacy shopping Positive urine tox screen Strong recommendation, low-quality evidence

    50. Periodic requests for escalation of opioids Periodic threats to find another doctor Little sustained progress toward goals Did not follow through on multiple referrals for mental health counseling Clinical Course.

    51. Clinical Course. Required mental health referral as condition of continued opioids Social worker helped with goal setting Required pain specialist referral Suspected opioid associated hyperalgesia and recommended taper off opioids for 3+ months prior to evaluation for other treatment Started slow taper late December 08 Much support given, declined ASAP referral Reached crisis off opioids – ASAP evaluation – inpatient program of detox and treatment of sexual trauma

    52. Conclusion Family physicians are well qualified to manage chronic pain in most patients Medical home with team approach is key in chronic pain management Emphasis on function and well-being, rather than pain level will increase chance of success Use caution with opioid dosages over 120 morphine equivalents per day

    53. Resources VA/DoD CPG summary for the management of opioid therapy for chronic pain; March 2003 Sample MTF pain agreements Side effect tables for pain medications Internet links to: Clinical Guidelines for Use of Chronic Opioid Therapy in Chronic Noncancer Pain: Feb 2009 AAFP online: Assessment and Management of Chronic Pain: June 2008; link to podcasts Partners against pain website Va/DoD Guideline http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=4812 Clinical Guidelines for Use of Chronic Opioid Therapy in Chronic Noncancer Pain: Feb 2009 http://www.jpain.org/article/PIIS1526590008008316/fulltext AAFP online: Assessment and Management of Chronic Pain: June 2008; link to podcasts http://www.aafp.org/online/en/home/cme/selfstudy/learninglink/pain1/paintract.html www.partersagainstpain.comVa/DoD Guideline http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=4812 Clinical Guidelines for Use of Chronic Opioid Therapy in Chronic Noncancer Pain: Feb 2009 http://www.jpain.org/article/PIIS1526590008008316/fulltext AAFP online: Assessment and Management of Chronic Pain: June 2008; link to podcasts http://www.aafp.org/online/en/home/cme/selfstudy/learninglink/pain1/paintract.html www.partersagainstpain.com

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