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Massage. Acupuncture. Yoga. Topical agents (Ben Gay/Icy Hot

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Title: Massage. Acupuncture. Yoga. Topical agents (Ben Gay/Icy Hot


1
CHRONIC PAIN MANAGEMENT
  • Michael Marschke, MD
  • Medical Director of Horizon Hospice

2
COMMON ETIOLOGIES OF CHRONIC PAIN
  • Episodic pain syndromes
  • Headaches migraine, tension, cluster
  • Ischemic episodes claudication, angina, sickle
    cell disease
  • Visceral pain biliary colic, irritable bowel,
    pre-menstrual syndrome, renal colic
  • Somatic pain - gout

3
COMMON ETIOLOGIES OF CHRONIC PAIN
  • Chronic pain syndromes
  • Somatic degenerative and inflammatory arthitis,
    trauma, vertebral compression fractures, boney
    metastases, fibromyalgia
  • Visceral abdomenal cancers, chronic
    pancreatitis
  • Neuropathic diabetic neuropathy, phantom limb
    pain, spinal stenosis/sciatica, spinal mets, HIV,
    drug induced

4
CHRONIC PAIN IS MULTI-FACTORIAL
  • Psychologic factors depression, anxiety,
    somatization
  • Socioeconomic factors cultural differences,
    urban poor, gender
  • Spiritual factors spiritual suffering, meaning
    of pain
  • Physical factors VERY complex neuroanatomy
    creating the pain sensation, from pain receptors
    to afferent nerves to spinothalamic tract, to
    thalamus to cortex with modulators all along the
    way
  • Therefore best approach is multi-disciplinary

5
EVALUATION OF CHRONIC PAIN
  • GOALS
  • Determine etiology to better treat this pain
  • Determine if correctable, intractable, or
    potentially dangerous causes
  • Determine impact on patients life
  • Take a detailed pain history to aid in
    controlling this pain

6
PAIN HISTORY
  • O Other associated symptoms ( nausea with
    stomach cramps, swelling with somatic pain,
    depression, anxiety)
  • P Palliative/provocative factors (mobility,
    touching, eating)
  • Q Quality
  • R Region/radiation
  • S Severity ( 0 to 10 )
  • T Timing (when started, continuous/intermittent,
    time of day)
  • U Untoward effects on activity or quality of
    life, including psychosocial, spiritual effects

7
HOW DO YOU TELL WHICH PAIN SYNDROME? HISTORY!
  • Somatic focal, ache/throb/sharp, maybe with
    swelling/edema/redness, tender, worse with
    movement, better at rest, maybe from trauma
  • Visceral viscous organ colicky, vague,
    diffuse, worse with meals, liver/spleen/pancreas
    may be more constant, more focal, worse with
    eating, uterine colicky, pelvic, maybe with
    discharge
  • Neuropathic burning, sharp, tingling, either
    dermatomal or stocking-glove, worse with touch,
    maybe with numbness

8
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9
DRUGS IN WHO STEP LADDER
  • Step 1 Acetomenophen, Tramadol (Ultram) plus
    adjuvant
  • Step 2 Tylenol 2/3/4, Vicoden, Darvocet,
    Percocet
  • Step 3 Morphine, Dilaudid, Fentanyl, Demerol,
    Methadone, Oxycodone, Levodromaran

10
Marschkes Modified Pain Escalator
11
ADJUVANTS TO SOMATIC PAIN
  • Non-pharmacologic
  • Ice, heat
  • Physical therapy
  • Chiropractic/osteopathic manipulations
  • Massage
  • Acupuncture
  • Yoga
  • Topical agents (Ben Gay/Icy Hot with menthol,
    salcylates, Capcaicin)
  • Local injections (steroids, lidocaine)
  • Glucosamine shown to help with osteoarthritis
  • Pharmacologic
  • NSAIDs
  • Cox 2 inhibitors
  • Steroids
  • Muscle relaxants

12
SPECIAL SOMATIC PAIN SYNDROMES
  • Boney mets
  • Local RT
  • Pamidronate and other diphosphonates
  • Strontium 89 and other radioactive isotopes,
    taken up by osteoclasts
  • Vertebral compression fractures
  • Calcitonin
  • Pamidronate
  • Vertebroplasty

13
VISCERAL PAIN
  • Anti-cholinergics for colicky pain
  • H2 blockers/PPIs for PUD/GERD
  • Steroids for enlarged organs with capsular
    swelling
  • NSAIDs for uterine pain
  • Nitrates for angina
  • Others celiac/pelvic plexus blocks, RT for
    enlarged organs, massage, herbs, aromatherapy,
    acupuncture, healing touch

14
NEUROPATHIC PAIN
  • Tricyclic antidepressants
  • Anti-epileptics
  • Anti-arrhythmics
  • Topical agents lidocaine, capsiacin
  • Steroids for spinal radiculopathies
  • Others RT for spine mets, TENS/PENS units and
    also spinal electrical stimulators
  • CAM - Acupuncture, massage, PT, yoga, healing
    touch

15
OTHER CAM ADJUVANTS
  • Herbals/supplements glucosamine shown to be
    useful in osteoarthritis, certain herbs like
    chamomile useful for colicky pain
  • Homeopathies/flower essences for relaxation,
    visceral pain
  • Healing touch/Reiki using energy techniques,
    useful with emotional components
  • Neuro Emotional Technique A chiropractic
    technique also useful with emotional components
  • Mind focusing therapies
  • Meditation, yoga, guided-imagery, hypnosis,
    biofeedback
  • Art/music/humor therapy, pet therapy
  • By distraction, found to lower HR/RR and decrease
    pain up to 10-20

16
ADDING AN OPIOID
  • To achieve quick pain relief (LOAD)
  • 1. Start low dose, short-acting
  • 2. Dose q peak
  • 3. P.C.A. not prn (Patient controls it)
  • 4. Re-eval in 4 hrs. to figure out what dose is
    needed

17
prn dosing
18
Low-dose, short-acting opioids
  • Tylenol 3, 1-2 tabs
  • Vicoden, Norco, Lortab 1-2 tabs
  • Darvocet N-100, 1-2 tabs
  • Percocet, 1-2 tabs
  • Vicuprofen, 1-2 tabs
  • DOSING LIMITED BY ATTACHED DRUG (max Tylenol a
    day is 4000mg)
  • MSIR/Roxanol,5-10mg PO, 1-3MG IV/SQ
  • Dilaudid, 1-2mg PO, 0.25-0.5 IV/SQ
  • OxyIR, 5-10mg PO
  • NEVER USE DEMEROL IN CHRONIC PAIN!!!

19
MAINTAINING AN OPIOID
  • For constant pain (MAINTENANCE)
  • 1. Go long (convert 24hr total of short acting
    directly to long acting)
  • 2. REM breakthru 10-20 of total daily dose,
    as short-acting, immediate release
  • 3. Re-eval, if 4 breakthru/d, increase
    maintainance dose

20
LONG-ACTING OPIOIDS
  • MS Contin, Oramorph, q12hr, in 15,30,60, 100,
    and 200mg tabs
  • Kadian, Avinza, q24hr, in 20,50, 100mg
    time-release capsules (can be opened to ease
    swallowing or put thru gastric tubes)
  • OxyContin, q12hrs, in 10,20,40,80, and 100mg tabs
  • Duragesic (Fentanyl) patches in 25,50,75, and 100
    ug/hr q48-72hrs.
  • Palladone (Dilaudid) q24hr, in time released
    capsules

21
CAVEATS IN OPIOID USE
  • With pure agonists, the sky is the limit
  • 80 of the time dose needs to be increased
    because the disease is advancing 20 because of
    tolerance.
  • Mixed or partial agonists (Stadol, Talacen,
    Talwin) have a ceiling, neurotoxicity, and can
    induce withdrawal if on other opioids
  • Methadone q8-24hr drug, may be better with
    neuropathies addiction because inhibits the
    NMDA receptor in the brain, though half-life
    6-100hrs so watch for accumulation
  • Demerol neurotoxic metabolite can build up in 1
    wk, in 1 day with renal failure
  • Oral, sublingual, rectal short acting meds peak
    within 1 hr., IV/SQ peak within 10 minutes.
    Choose oral if they can do it.
  • Use conversion tables to switch narcotics, start
    at 50-100 of equivalent dose
  • To taper drug, decrease by 25 a day.

22
OPIOID SIDE EFFECTS
  • Constipation is a given, no tolerance develops,
    use stimulants (Senokot, Bisocodyl, Pericolace)
  • Nausea/vomiting tolerance can occur in 2-5
    days, compazine/reglan can help
  • Sedation tolerance can occur in 2-3 days,
    changing drug or Ritalin can help if persists
  • Clonic jerks usually hi doses, can change drug
    or benzodiazepam can help
  • Respiratory suppression in toxic doses, never see
    it if have pain or use the drugs the right way

23
PHYSICAL vs. PSYCHOLOGIC DEPENDENCE
  • PHYSICAL DEPENDENCE
  • Tolerance (20-40) up-regulate opioid receptors
    to need higher dose for sustained effect
  • Withdrawal (20-40) after 2 wks, withdrawing
    drug leads to adrenaline response (sweating,
    tachycardia, tachypnea, cramps, diarrhea,
    hypertension) avoid by decreasing drug 25 a
    day.
  • PSYCHOLOGIC DEPENDENCE
  • Addiction (0.1 in CA pain) a need to get
    high where drug controls your life, compulsive
    uncontrolled behavior to get the drug lie,
    cheat, steal.

24
  • PSEUDO-ADDICTION
  • Physical dependence confused with psychologic
    dependence
  • Pain-relief seeking, not drug-seeking
  • When right dose used, patient functions better in
    life, whereas opposite true with the true addict
  • To help diffentiate one MD controls the drug
    under a specific contract with pt., one pharmacy,
    frequent visits, pill counts
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