Working with Pain

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Working with Pain

• Lucian Bednarz, M.D.
• Northeastern Rehabilitation Associates, P.C.

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Pain

• An unpleasant sensory and emotional experience
  associated with actual or potential tissue
  damage, or described in terms of such damage.

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Potential Spinal Structures That Can Cause Pain

• Annular Fibers
• Posterior Longitudinal Ligament
• Facet Joint
• SI Joint

• Muscle
• Tendon
• Ligament

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PAIN

• No Direct Relationship Between
• Tissue Damage
• and
• Severity of Pain
• Beecher (1959)

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Define the Pain Generator

• (If you can)

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Pain A Conceptual Approach
Pain Behavior Suffering Pain Perception Nociceptio
n

• Loeser JD, Cousins MJ. Med J Aust.
  1990153208-12, 216.

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Diagnosis

• Use large fancy medical terms to mask our
  ignorance

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Facts and Figures

• 1 in 4 Americans suffers from chronic pain
• 1 in 10 Americans takes prescription pain
  medications
• 2 in 5 Americans unable to work at full capacity

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• 54.6 million Americans suffer from back pain
• 43 million from arthritis
• 40 million from chronic headaches

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• Cost of chronic pain is estimated to be as high
  as 150 billion dollars, including medical
  expenses, lost income and lowered productivity

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• Pain is the most frequent reason why patients
  seek the care of a physician, accounting for an
  estimated 70 million office visits in the United
  States each year.

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• In 1996 the World Health Organization indicated
  that the control of pain remained pervasively
  inadequate.

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• Cancer-related pain, for example, though
  effectively manageable by relatively simple and
  low cost means in up to 90 of patients often
  causes needless suffering because of under
  treatment.

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• The Eastern Cooperative Oncology Group, in the
  Annals of Internal Medicine in 1993, published a
  survey that considered analgesic therapy as
  insufficient in 86 of cancer patients with pain.

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• 75 viewed poor pain assessment as a major
  barrier to analgesic prescribing.

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Causes of Deficient Pain Management

• Improper application of available knowledge
  concerning analgesics.
• Misapprehension concerning risk of addiction
• Poor understanding of the concepts of tolerance
  and physical dependence.
• Regulatory burdens.

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What Are the Goals of Clinical Assessment?

• Achieve diagnosis of pain
• Identify underlying causes of pain
• Identify comorbid conditions
• Evaluate psychosocial factors
• Evaluate functional status (activity levels)
• Set goals
• Develop targeted treatment plan
• Determine when to refer to specialist or
  multidisciplinary team (pain clinic)

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Goals of Treatment

• Optimal relief of pain without unacceptable
  adverse effects.
• Over treatment versus under treatment

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• In October of 2001, the Federal Drug Enforcement
  Administration joined 21 leading pain and health
  organizations in releasing a consensus statement
  calling for balanced policy governing
  prescription pain medications, such as Oxycontin

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• Consensus statement called for an increased focus
  on educating health professionals, law
  enforcement and the public about the use and
  abuse of such medications.

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• Oxycontin 20 mg tablets is the most frequently
  prescribed pharmaceutical in the state of PA.

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Major Sources of Diverted Oxycodone

• Forged prescriptions
• Doctor shopping
• Large scale theft
• Over-prescription
• Diversion by health professionals
• Pharmacy thefts
• Organized drug rings
• Foreign diversion and smuggling in the US

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• National Institute in Drug Abuse (NIDA) indicates
  that almost 47 of physicians reported that it
  was difficult to discuss prescription drug abuse
  with their patients.

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In 1998 the AMA recommended

• Keep a medication record as part of the medical
  record.
• Collaborate with the patient when making
  decisions about treatment plan.
• Provide oral counseling about the medication.
• Provide written information.
• Specifically follow up medication compliance and
  effects during office visits.

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Opioid Contract
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Assumptions of Opioid Contract
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• Terms and consequences for breaching the contract
  are explicitly stated.

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• The doctor and patient have unique
  responsibilities.

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• The doctor/patient relationship is consensual,
  not obligatory.

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• Both physician and patient are willing and able
  to negotiate.

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Typical Opioid Contract Inclusion

• Clear descriptions and expectation of medication
  use and abuse as well as consequences of
  violating the contract and the procedure for
  opioid discontinuation should this become
  necessary.

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Guidelines for the use of opioids in chronic pain
management.
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• Select opioid based on patients report of pain
  intensity and consideration of availability,
  convenience of use and ease of compliance.
• Use long-acting preparation unless
  contraindicated
• Prescribe short-acting analgesic for rescue
  medications to treat break through pain.

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• Individualize dose by titrating to pain relief or
  dose limiting side effect.

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• Treat side effects prophylactically and
  aggressively.

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• Do not confuse the concept of tolerance, physical
  dependence and addiction (psychological
  dependence).

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• Withdraw chronic opioids slowly to avoid
  prescription of abstinence syndrome.

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• Drug Oral Opioid in Mg
• Codeine 0.15
• Hydrocodone (Vicodin) 0.9
• Hydromorphone (Dilaudid) 4
• Meperidine (Demerol) 0.1
• Methadone (Dolophine) 1.5
• Morphine 0.5
• Oxycodone (Oxycontin Percocet) 1

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Evaluation of Patient

• Nature and intensity of pain
• Underlying or co-existing disease
• Effective pain on physical and psychologic
  function
• History of substance abuse

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• One or more recognized medical indications for
  the use of controlled substance.

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Treatment Plan

• Objectives that will be used to determine
  treatment success such as pain relief, improve
  physical and psychosocial function and whether or
  not further diagnostic evaluations or other
  treatments are planned, listing other treatment
  modalities or rehabilitation program necessary.

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Informed Consent and Agreement for Treatment

• Risk and benefits of the use of controlled
  substance
• One physician
• One pharmacy
• Written agreement which can include
• Urine serum medication levels when requested.

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• Number and frequency of all prescription refills
• Reason for which drug therapy may be discontinued

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Periodic Review

• Review the course of opioid treatment and any new
  information about the etiology of pain should be
  based on improvement in patients pain intensity,
  improved physical and/or psychosocial function
  such as ability to work, need of health care
  resources, activities of daily living, quality of
  social life.

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Consultation

• Physician should be willing to refer as necessary
  for additional evaluation and treatment in order
  to achieve treatment objectives.

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Medical Record

• History and physical
• Diagnostic therapeutic laboratory results
• Evaluations and consultations
• Treatment objectives
• Discussion of risks and benefits

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Proposed Guidelines for the Management of Opioid
Therapy for Non-Malignant Pain
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• Should be considered only after all other
  reasonable attempts at analgesia have failed.

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Freedom from Cancer Pain
Opioid for Moderate to Severe Pain /-
Non-opioid /- Adjuvant
3
Pain Persisting or Increasing
Opioid for Mild to Moderate Pain Non-opioid /-
Adjuvant
2
Pain Persisting or Increasing
Non-opioid /- Adjuvant
1
PAIN
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• A history of substance abuse, severe character
  pathology and chaotic home environment should be
  viewed as a relative contraindication.

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• A single practitioner should take primary
  responsibility for treatment.

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• Informed Consent
• Risk of true addiction
• Potential for cognitive impairment with a drug
  alone or in combination with sedative, hypnotics
• Likelihood that physical dependence will occur

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• Around the clock dosaging with an initial dose
  titration over several weeks and at least partial
  analgesia is an appropriate goal of therapy.

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• Failure to achieve at least partial analgesia at
  relatively low initial dosages should prompt
  re-assessment.

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• Emphasis should be given to attempts to
  capitalize on improved analgesia by gains in
  physical and social function.

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• Each visit assessment should
  specifically address
• Comfort
• Opioid related side effects
• Functional status, physical and psychosocial
• Existence of aberrant drug related behaviors

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• Joint Commission of Accreditation of Health Care
  Organizations (JCAHO) in 1999 developed
  guidelines and consensus statements for improving
  pain management.

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• The JCHAO goal is to provide individualized care
  in a setting responsive to specific patient
  needs, educate patients that pain management is
  part of treatment and emphasize the importance of
  a team approach to implementing the standards of
  pain management.

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• Pain is considered Fifth Vital Sign

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Addiction

• Psychologic dependence for the psychic effects of
  the medication characterized by compulsive use
  despite harm

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Tolerance

• Physiologic state resulting from regular use of a
  drug in which an increased dosage is needed to
  produce the same effect or a reduced effect is
  observed with a constant dose.

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Pseudo-addiction

• Pattern of drug seeking behavior of pain patients
  who are receiving inadequate pain management that
  can be mistaken for addiction.

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Physical Dependence

• Physiologic state where by withdrawal may be seen
  if a drug is stopped or decreased abruptly if an
  antagonist is administered.

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Opioid Adverse Events

• Constipation
• Nausea
• Vomiting
• Sedation
• Somnolence

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General Pain Management Principles

• Respect and accept the complaint of pain as real
• Treat pain
• Treat underlying disorder(s)
• Address psychosocial components
• Utilize multidisciplinary approach

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Multi-disciplinary Rehab Team
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Therapeutic Strategies for Pain and Disability

• Interventional approaches
• Injections
• Neurostimulatory
• Neuraxial infusion
• Neuroablative

• Pharmacotherapy
• Opioid analgesics
• Nonopioid analgesics
• Adjuvant analgesics

• Rehabilitative approaches
• Psychological approaches

• Complementary and alternative approaches
• Lifestyle changes

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Spinal Disorders
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To Inject or Not to Inject

• Is that the question?

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What is Out There?

• Epidural Steroids
• Facet Injections
• SI Blocks
• IDET

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• Neucleoplasty
• Rhizotomy
• Selective Nerve Root Block
• Radioablation Therapy

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• Trigger Points
• Botox
• Prolotherapy
• Acupuncture

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Pain Syndromes

• CRPS (RSD)
• MPS
• FM
• H/A
• GOMER

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Conclusion