CHRONIC PAIN MANAGEMENT Michael Marschke, MD Medical

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CHRONIC PAIN MANAGEMENT

• Michael Marschke, MD
• Medical Director of Horizon Hospice

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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

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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

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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

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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

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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

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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

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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

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Marschkes Modified Pain Escalator
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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

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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

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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

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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

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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

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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

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prn dosing
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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!!!

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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

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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

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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.

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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

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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.

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• 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