A B I O P S Y C H O S O C I A L A P P R O A C H T O C A R E

CHRONIC PAIN TREATMENT MANAGING RISK

TREATMENT LEVELS

• Level I treatment encompasses the standard approaches to the treatment of chronic pain including pharmacologic management, intervention management, non-pharmacologic management and complementary medicine management

• Level II treatment includes referral for interdisciplinary pain rehabilitation or surgery for placement of a spinal cord stimulator or intrathecal pump.

• Level II treatments may be effective interventions for patients with chronic pain who have failed more conservative treatment options.

• Level II treatments are designed for the most complex and challenging patients with chronic pain

PAIN ASSESSMENT

• Functional Assessment Including: pain location, intensity, quality, onset/duration/variations/rhythms, manner of expressing pain, pain relief, exacerbation triggers, effects of pain and response to previous treatments.

• General Assessment: history, stressors, support, health beliefs, physical comorbidity, and psychiatric comorbidities.

• Assessment Screeners: Function and Quality of Life and pain scales.

• Assess Biological Mechanism of pain.

• Assess for Comorbid Psych: DIRE Score, PHQ9, PC-PTSD, GAD7, SBIRT, CAGE, AUDIT, MDQ etc. Sleep Disorders.

TYPES OF PAIN - NEUROPATHIC

• Neuropathic Pain: Pain caused by damage to the

somatosensory nervous system e.g. periferal neuropathy,

sciatica, trigeminal neuralgia, post-stroke neuropathic

pain.

• Clinical Indications:

• Neuropathic pain is usually described as burning or

shooting/stabbing.

• neuropathic pain is usually described as burning or

shooting/stabbing.

• Neuropathic pain often follows a specific nerve path e.g.

stocking/glove distribution of peripheral neuropathy.

• numbness in the pain territory, sensitivity to a non-noxious

stimulus like light touch or rubbing (allodynia), or coolness of

the skin in the pain territory (sympathetically mediated pain).

FIBROMYALGIA – A SPECIAL CASE

• Fibromyalgia syndrome: widespread musculoskeletal aching, stiffness and tenderness.

• Current research indicates fibromyalgia is a centrally (brain) mediated neuropathic pain syndrome

• It can be considered a special case within neuropathic pain.

• The 2010 American College of Rheumatology Criteria Diagnostic Criteria for Fibromyalgia:• Presentation of widespread pain and symptoms for three months or

more

• Presentation of widespread pain and symptoms for three months or more

• Symptom Severity Scale that assesses the severity of fatigue, waking unrefreshed and cognitive symptoms, as well as the extent of other somatic symptoms

PHARMACOTHERAPY NEUROPATHIC PAIN

• First goal – Manage or eliminate the underlying causes of pain e.g. better managed diabetes or cancer treatment.

• Gabapentin and pregablin: Growing consensus as first line treatment. 1/3 of patients had significant improvement (multi-site study). • Excretion – 100% Renal (Kidneys) dosage modulation needed in

those with poor renal fxn.

• Mechanism - Modulates alpha2delta subunit of the N-type voltage-gated calcium channels, regulating influx of calcium into the nerve reducing the outflow of excitatory neurotransmitters that transmit pain.

• Indications: Pregabalin is indicated for treatment of diabetic neuropathy, postherpetic neuralgia and fibromyalgia, (possibly for spinal chord inj) as well as for partial onset seizures.

• Indications: Gabapentin has an indication for diabetic neuropathy pain, postherpetic neuralgia, fibromyalgia, and partial onset seizures

PHARMACOTHERAPY NEUROPATHIC PAIN

• ANTICONVULSANTS

• LCarbamazepine: Indicated in idiopathic trigeminal

neuralgia (lack of other evidence).

• topiramate, lamotrigine, oxcarbazepine and tiagabine may

be effective and evidence is still developing.

• Tricyclic Antidepressants

• Tricyclic antidepressants (amitriptyline, nortriptyline,

desipramine, imipramine and others)have a role in pain

treatment.

• Their mechanism of action is believed to involve

potentiation of descending inhibitory pathways, especially at the level of the lower brainstem.

PHARMACOTHERAPY NEUROPATHIC PAIN

• Opioids

• Mechanism: In general opioids are not thought to have an

antineuropathic mechanisms, they are nevertheless potent

analgesics.

• Methadone and tramadol, may be more effective than

others in neuropathic pain.

• Methadone blocks: NMDA receptor is involved in central

sensitization, windup, neurogenic hyperalgesia, and

development of opioid tolerance

• Tramadol: weak opioid analgesic that also causes serotonin

reuptake inhibition like tricyclic's

MUSKOSKELITAL PAIN

• Skeletal muscle pain is a common cause of chronic pain.

• Failure of proper dx can lead to result in poor treatment outcomes, unnecessary surgery etc.

• Myofascial pain is regional muscle pain • Characterized by painful muscle dysfunction with loss of range

of motion; and by tenderness at muscle sites that causes referred pain.

• Treatment:

• Restoring muscle balance and function through physical therapy not medication management.

• Managing factor perpetuating problem e.g. posture, repetitive stress or work place factors.

• Trigger point injections, acupuncture can be effective adjunct.

PHARMACOTHERAPYMUSCULOSKELETAL PAIN

• Screen for serious medical pathology, and for

psychological and social factors that may delay

recover.

• Pain Assessment: Rate location, duration, intensity on

pain scale, screen for medical pathology, social factors

and psychological factors that could impact course.

• Screen for serious medical pathology, and for

psychological and social factors that may delay

recovery.

• A graded exercise program starting within baseline and

gradually increasing in a time-contingent manner works

best.

BIOPSYCHOSOCIAL APPROACHMUSCULOSKELETAL PAIN

• Physical Rehabilitation:• Fitness Program: Graded strength, Cardio, Flexibility, Balance.

• Body Mechanics: Head position, posture etc.

• Modalities: Ice, Heat, Massage, Pacing.

• Aquatic therapy

• Behavioral: • Psychoeducational

• Mood/Emotions: Stress management, relaxation tech, Anger tx

• Biofeedback

• CBT

• Pharmacotherapy Targets• Pain and sleep: Tricyclic's, Anticonvulsants

• Depression and pain: Tricyclic's

• Opioids are rarely indicated

INFLAMMATION PAIN AND COMPRESSION PAIN

• Inflammatory Pain:• Arthritis, tendonitis and chronic infections are common examples• Indications: swelling and warmth of tissue and sometimes redness of

the skin• Mechanism: activation of nociceptors by inflammatory mediators like

prostaglandins or sensitization. • Treatments:

• NSAID (Non-Steroidal Anti-Inflammatory Drugs)

• Corticosteroids

• Compression Pain:• Mechanical/compressive pain refers to tumors or cysts that may

compress pain sensitive structures. • Treatments: Surgical decompression or stabilization, splinting,

strengthening and use of assistive devices can all address mechanical pain

• Medications: Play less of a role and are less effective. Opioids can be used to manage pain during treatment process.

TREATMENT PLAN OVERVIEW

• A plan of care for all patients with chronic pain should address all of the following five major elements:• Set personal goals

• Improve sleep

• Increase physical activity

• Manage stress

• Decrease pain

• Motivation Matters • Connect to values

• Adapt to stage of change

• Role with resistance

• Support intrinsic movement toward change

• Use change talk

PAIN MEDICATIONS

• Opioid Characteristics• Codeine often has dose-limiting GI side effects and is

therefore not a good choice for chronic use. Ultra rapid and no effect patients mediated through CYP2D6 Gene for liver metabolism.

• Transdermal fentanyl patch: Stabilizes levels of medication in body has high risk of lethality particularly in opiate naïve patients.

• Hydrocodone is partial synthetic opioid derived from codine. Takes 20 – 30 min to act and lasts 4-8 hrs.

• Hydromorphone a semi-synthetic μ-opioid agonist.

• Meperidine is metabolized to an active metabolite normeperidine, which has neurotoxic side effects. It is not an appropriate choice for chronic use.

PAIN MEDICATIONS

• Opiate Medications Cont.• Morphine is available in rapid-acting and long-acting oral,

injectable and rectal dosage forms. There are 12-hour sustained-release and 24-hour sustained-release dosage forms of morphine available.

• Methadone has a long half-life, initially 12-16 hours but may be 90-120 hours after one week of therapy. Due to the complexity of dosing and potential for cardiac adverse effects.

• Methadone has a long half-life, initially 12-16 hours but may be 90-120 hours after one week of therapy. Due to the complexity of dosing and potential for cardiac adverse effects,

• Oxymorphine is available in intramuscular (IM) and subcutaneous (SQ) injections, IV use, as well as oral 12 hour extended-release (ER) dosage forms. It is indicated for use in moderate to severe chronic pain.

• Tramadol is a weak mu-opioid agonist and also is a serotonin and norepinephrine reuptake inhibitor. Doses should not exceed 400 mg daily.

PAIN MEDICATIONS

• Buprenorphine acts on the mu opioid receptors.

• It elicits two specific dose dependent therapeutic

responses. within the brain cells, depending on the dose.

• At low doses buprenorphine has effects like methadone, b

• At high doses it behaves like naltrexone, blocking the

receptors so strongly that it can precipitate withdrawal.

PAIN MEDICATIONS

• SSRI’s Have some efficacy but not as effective as TCA. They have less cardiac events.

• Tricyclic antidepressants have a role in the treatment of neuropathic pain, especially if the patient has co-existing insomnia, anxiety or depression• Analgesic effects of TCAs are independent of their

antidepressant effect, and analgesia may be seen with lower doses.

• Start low and increase doses gradually over several weeks to months. Maximum analgesic effect may takes several weeks or longer to be seen.

• Baseline ECG is indicated in patients at risk for cardiac adverse effects.

PAIN MEDICATIONS

• Anticonvulsant or Antiepileptic Drugs• Carbamazepine is approved for the treatment of trigeminal

neuralgia, and benefits are well established.

• Pregabalin is indicated for treatment of diabetic neuropathy, postherpetic neuralgia and fibromyalgia.

• Oxcarbazepine is chemically similar to carbamazepine and may have benefits in the treatment of neuropathic pain, including trigeminal neuralgia and diabetic neuropathy.

• Gabapentin is approved for the treatment of postherpetic neuralgia but has been shown to have analgesic effects in many cases of neuropathic pain syndromes (titrate dose up slowly to reduce side effects).

• Lamotrigene has efficacy in trigeminal neuralgia, neuropathies associated with human immunodeficiency virus infection, and poststroke pain.

PAIN MEDICATIONS

• Topical Applications

• NSAIDs can provide acceptable levels of pain relief in knee

and hand osteoarthritis, and are available through a

diclofenac 0.3% topical patch and 1% topical gel.

• Topical lidocaine 5% patches are FDA approved for

postherpetic neuralgia and have shown efficacy in other neuropathic pain syndromes.

• Capsaicin, the active ingredient in the herbal product

cayenne, is used topically to deplete the pain mediator

substance-P from afferent nociceptive neurons.

PAIN MEDICATIONS

• Muscle Relaxants

• Cyclobenzaprine, which is structurally a tricyclic muscle

relaxant, has shown benefits in the treatment of

fibromyalgia at doses of 10 to 40 mg daily.

• Tizanidine is a muscle relaxant that may be used for longer

periods of time due to its mechanism of action (alpha-2 sympathomimetic), so it may cause hypotension. It may

provide benefits as an adjunct in the treatment of

fibromyalgia.

• Baclofen may have benefits in the treatment of lancinating,

paroxysmal neuropathic pain.

PAIN MEDICATIONS

• Anxiolytics

• Buspirone is an anxiolytic that is relatively low sedating. It

may take several weeks to see maximum benefits.

• SSRIs or SNRIs are generally the drugs of choice for

treatment of anxiety. Onset of effect is slow and may take

several weeks for maximum benefits.

• Benzodiazepines are beneficial for treatment of acute

anxiety and muscle spasms associated with acute pain but

have minimal benefits in treating chronic pain.

Benzodiazepine side effects of sedation and respiratory

depression may limit the amount of opioids that can be used safely. They also result in physical dependence when

used long term

PAIN MEDICATIONS

• Insomnia Management

• Tricyclic antidepressants are a good choice in the

treatment of insomnia, especially if the patient has anxiety

or depression

• Tricyclic antidepressants are a good choice in the

treatment of insomnia, especially if the patient has anxiety or depression

• The sedative antidepressant trazodone may be effective in

treating insomnia associated with chronic pain.

• Benzodiazepines generally should be limited to short-term

management of insomnia.

ADDICTION OPIATES

• Tolerance occurred in all use of opioids.

• Withdrawal occurs in all opioid use.

• Addiction is a complex set of behaviors that includes tolerance, withdrawal, drug seeking and lack of regard for consequences.

• Psuedoaddictive Behaviors: Behaviors that appear addictive due to under treatment of pain. In one dual clinic there were 25% of individuals under medicated for pain.

WITHDRAWAL AND OPIOIDS

Early symptoms of withdrawal include:

• Agitation

• Anxiety

• Muscle aches

• Increased tearing

• Insomnia

• Runny nose

• Sweating

• Yawning

Late symptoms of withdrawal include:

• Abdominal cramping

• Diarrhea

• Dilated pupils

• Goose bumps

• Nausea

• Vomiting

C A S E D I S C U S S I O N

THANK YOU!