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
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
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
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
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
Marschkes Modified Pain Escalator
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
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
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
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
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%
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
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, IV/SQ OxyIR, 5-10mg PO NEVER USE DEMEROL IN CHRONIC PAIN!!!
MAINTAINING AN OPIOID For constant pain: (MAINTENANCE) 1. Go long (convert 24hr total of short acting directly to long acting) 2. REM breakthru = % of total daily dose, as short-acting, immediate release 3. Re-eval, if 4+ breakthru/d, increase maintainance dose
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
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 % of equivalent dose To taper drug, decrease by 25% a day.
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
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.
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