4CHRONIC PAIN IS MULTI-FACTORIAL Psychologic factors – depression, anxiety, somatizationSocioeconomic factors – cultural differences, urban poor, genderSpiritual factors – spiritual suffering, meaning of painPhysical 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 wayTherefore best approach is multi-disciplinaryStudies show depression and anxiety create more pain and stronger pain. Pure psychologic pain. Poor under report pain for fear of being a burdn, mistrust of richer docs, addiction running around neighborhood. Subtle cultural diffenences – ex –Eastern European rate pain worse than Asians or African Amer. Gender – females tolerate visceral pain better, males – somatic. Spiritual suffering can increase pain and different religions have different meaning behind physical suffersing – “cruxifixion complex”
5EVALUATION OF CHRONIC PAIN GOALS:Determine etiology to better treat this painDetermine if correctable, intractable, or potentially dangerous causesDetermine impact on patient’s lifeTake a detailed pain history to aid in controlling this painEtiology helpful to correct problems, verify reality of the pain for more aggressive pain control.Correctable – injections, surgery, meds…. Intractable or terminal conditions for prognosis… Dangerous – dissecting aneurysm, DVTs, cerebral bleeds…Impact – affecting ADLs, work, secondary gains – disability, QOL, QODPain history – severity 0-10 (quantifiable per pt), quality, timing, location, exacerbaters, alleviaters, a/w – worst in last 24 hrs, ever go away, what do you want it at – what is tolerable/livable, emotional/spiritual meaning? – help with determining physiologic pain syndrome, how to use meds, how to best treat it and follow it
6PAIN HISTORYO = Other associated symptoms ( nausea with stomach cramps, swelling with somatic pain, depression, anxiety…)P = Palliative/provocative factors (mobility, touching, eating…)Q = QualityR = Region/radiationS = 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
7HOW 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 traumaVisceral – 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 dischargeNeuropathic – burning, sharp, tingling, either dermatomal or stocking-glove, worse with touch, maybe with numbness
8WHEN FIRST TREAT CHRONIC PAIN, created in 1990 when The World Health Organization realized physicians across the globe were ill-prepared to treat chronic pain, so tried to simplify and teach a model
9DRUGS IN WHO STEP LADDER Step 1: Acetomenophen, Tramadol (Ultram) plus adjuvantStep 2: Tylenol #2/3/4, Vicoden, Darvocet, PercocetStep 3: Morphine, Dilaudid, Fentanyl, Demerol, Methadone, Oxycodone, LevodromaranWHO ladder falls short because separate step 2 from step 3 drugs, playing into doctor’s fears about using “stronger” narcotics; when the reality is that even step 3 drugs when used in small amounts can be less potent that Tylenol #3 or Vicoden… In past step 3 drugs needed special presriptions to be able to use – doctors feared scrutiny
11ADJUVANTS TO SOMATIC PAIN Non-pharmacologic:Ice, heatPhysical therapyChiropractic/osteopathic manipulationsMassageAcupunctureYogaTopical agents (Ben Gay/Icy Hot – with menthol, salcylates, Capcaicin)Local injections (steroids, lidocaine)Glucosamine shown to help with osteoarthritisPharmacologic:NSAIDsCox 2 inhibitorsSteroidsMuscle relaxantsCapsaicin (Zostrix) – red hot chili pepper juice – used for centuries in S. America, burns for first few days then wears out substance P in pain receptorsPT/chirpracter/massage/yoga/acupuncture in some studies equally effective in certain conditions like low back painNSAIDs – beware of GI side effects and platelet effects, though the Salcylate class and Diflunisal have less of these effects. NSAIDs in studies shown to decrease narcotic use by up to 40% in things like wide-spread boney metsRelaxants – soma, flexeril, benzodiazepines
12SPECIAL SOMATIC PAIN SYNDROMES Boney mets:Local RTPamidronate and other diphosphonatesStrontium 89 and other radioactive isotopes, taken up by osteoclastsVertebral compression fractures:CalcitoninPamidronateVertebroplastyCalcitonin – 8IU/kg sq, intranasal MIacalcin, 1squirt alt nostrils qdPamidronate 30-90mg IV q2-4wks
13VISCERAL PAIN Anti-cholinergics for colicky pain H2 blockers/PPIs for PUD/GERDSteroids for enlarged organs with capsular swellingNSAIDs for uterine painNitrates for anginaOthers – celiac/pelvic plexus blocks, RT for enlarged organs, massage, herbs, aromatherapy, acupuncture, healing touchHerbs – chamomile, ginger, cola, aromas - peppermint
14NEUROPATHIC PAIN Tricyclic antidepressants Anti-epileptics Anti-arrhythmicsTopical agents – lidocaine, capsiacinSteroids for spinal radiculopathiesOthers – RT for spine mets, TENS/PENS units and also spinal electrical stimulatorsCAM - Acupuncture, massage, PT, yoga, healing touchTricyclics and anti-epileptics work within 4-6 days, but may need to push up to therapeutic drug levels. Most anti-epileptics work 60-70% of time compared to placebo 30%. Tegretol most well used, $10/mo, levels easy to monitor. Neurontin shown only with dosing TID, costs over $300/mo and sedation in elderly/debilitated common and no drug levels. Anti-arrhythmics not used because arrhythmogenic.
15OTHER CAM ADJUVANTSHerbals/supplements – glucosamine shown to be useful in osteoarthritis, certain herbs like chamomile useful for colicky painHomeopathies/flower essences – for relaxation, visceral painHealing touch/Reiki – using energy techniques, useful with emotional componentsNeuro Emotional Technique – A chiropractic technique also useful with emotional componentsMind – focusing therapies:Meditation, yoga, guided-imagery, hypnosis, biofeedbackArt/music/humor therapy, pet therapyBy distraction, found to lower HR/RR and decrease pain up to 10-20%
16ADDING AN OPIOID To achieve quick pain relief: (LOAD) 1. Start low dose, short-acting2. Dose q peak3. P.C.A. not “prn” (Patient controls it)4. Re-eval in 4 hrs. to figure out what dose is needed
17“prn” dosingStudies show the average time it takes patients in hospitals to get a prn drug is 2 hrs! (to have enough pain to want to get to the call light, get the secretary to find the nurse who 9 times out of 10 is busy, then RN needs to evaluate pt, then needs narcotic key and second RN to get the drug, not even including the time it takes the drug to kick in), Most nursing homes are NOT staffed to be able to give any prn drugs.
18Low-dose, short-acting opioids Tylenol #3, 1-2 tabsVicoden, Norco, Lortab 1-2 tabsDarvocet N-100, 1-2 tabsPercocet, 1-2 tabsVicuprofen, 1-2 tabsDOSING LIMITED BY ATTACHED DRUG (max Tylenol a day is 4000mg)MSIR/Roxanol,5-10mg PO, 1-3MG IV/SQDilaudid, 1-2mg PO, IV/SQOxyIR, 5-10mg PONEVER USE DEMEROL IN CHRONIC PAIN!!!
19MAINTAINING 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 release3. Re-eval, if 4+ breakthru/d, increase maintainance doseUse 24 hrs of a dose of short acting that works, add up total, tell patient to take as soon as pain starts to keep ahead of the pain, don’t wait til pain peaks
20LONG-ACTING OPIOIDSMS Contin, Oramorph, q12hr, in 15,30,60, 100, and 200mg tabsKadian, 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 tabsDuragesic (Fentanyl) patches in 25,50,75, and 100 ug/hr q48-72hrs.Palladone (Dilaudid) q24hr, in time released capsules
21CAVEATS 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 opioidsMethadone – 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 accumulationDemerol – neurotoxic metabolite can build up in 1 wk, in 1 day with renal failureOral, 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 % of equivalent doseTo taper drug, decrease by 25% a day.
22OPIOID SIDE EFFECTSConstipation is a given, no tolerance develops, use stimulants (Senokot, Bisocodyl, Pericolace)Nausea/vomiting – tolerance can occur in 2-5 days, compazine/reglan can helpSedation – tolerance can occur in 2-3 days, changing drug or Ritalin can help if persistsClonic jerks – usually hi doses, can change drug or benzodiazepam can helpRespiratory suppression in toxic doses, never see it if have pain or use the drugs the right way
23PHYSICAL vs. PSYCHOLOGIC DEPENDENCE PHYSICAL DEPENDENCE:Tolerance (20-40%) – up-regulate opioid receptors to need higher dose for sustained effectWithdrawal (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.
24PSEUDO-ADDICTION:Physical dependence confused with psychologic dependencePain-relief seeking, not drug-seekingWhen right dose used, patient functions better in life, whereas opposite true with the true addictTo help diffentiate: one MD controls the drug under a specific contract with pt., one pharmacy, frequent visits, pill counts