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Pain Management in Primary Care Kimberly Zoberi, MD Saint Louis University School of Medicine.

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Presentation on theme: "Pain Management in Primary Care Kimberly Zoberi, MD Saint Louis University School of Medicine."— Presentation transcript:

1 Pain Management in Primary Care Kimberly Zoberi, MD Saint Louis University School of Medicine

2 Who treats chronic pain? Chronic pain specialists Acupuncturists Chiropractors PCP’s 2% 7% 40% 52% Bruer B, et al, Southern Medical Journal, 2010; 103: MacFarlane GJ, Rheumatology 2012; 51: Gross AR, Spine 2004; 29: (Cochrane Review – neck pain) Rubinstein SM, Spine 2013; 38:E158-E177 (Systematic rev : Spinal Manipulative Therapy)

3 Ways to classify pain ► Acute vs. chronic ► Nociceptive vs. neuropathic ► Psychogenic vs. somatic

4 Acute vs. Chronic Acute Cause is known Function is protective Increased autonomic activity Short duration, resolves with healing Inflammation, tissue injury Short term upregulation of pain sensitivity Chronic Cause = ? No protective function None Does not resolve with healing None Long term changes including allodynia, hyperalgesia, etc.

5 Nociceptive vs. Neuropathic ► Nociceptive: Appropriate stimulation of nerve endings leads to signaling ► Neuropathic: Dysfunction of nerve

6 Acute, nociceptive pain ► Examples? ► Goals of treatment  Heal the injury  Decrease acute pain  Prevent progression to chronic pain ► Strategies

7 Acute, neuropathic pain ► Migraine, herniated disk

8 Chronic, nociceptive pain ► Arthritis, cancer ► BOTH ongoing damage and upregulation of nerve impulses ► Remodeling centrally and dorsal horn of spinal cord ► Multimodal treatment

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11 Chronic, neuropathic pain ► Fibromyalgia, IBS ► Not much utility to anti-inflammatories ► Neuromodulating agents are key

12 Psychogenic component

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14 ► Musculoskeletal symptoms and non-REM sleep disturbance in patients with "fibrositis syndrome" and healthy subjects. ► Moldofsky, et al, Psychosomatic Medicine, 1975, 37 (4):

15 ► Sleep deprivation patients looked identical to fibromyalgia patients in mood mood somatic complaints somatic complaints sleep architecture sleep architecture

16 ► ► Smith et al. The effects of sleep deprivation on pain inhibition and spontaneous pain in women. Sleep The effects of sleep deprivation on pain inhibition and spontaneous pain in women. ► ► Kundermann et al. The effect of sleep deprivation on pain. Pain Res Manag. 2004The effect of sleep deprivation on pain.

17 Source: Sleep and Pain, Lavigne (ed) 2007.

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19 How patients feel

20 What patients want

21 Physical therapy Psychotherapy Neuromodulators Sleep regulation Mood regulation NSAIDS/Co-analgesics Narcotics Interventions Behavioral activation Family therapy Anxiety management TENS

22 General Treatment Strategy ► Acknowledgement of patient’s pain ► Nonpharmacologic treatments  Physical therapy  Exercise  Heat/ice  Coping mechanisms  CBT

23 Pharmacologic treatment Acetaminophen Adjuvant pain meds NSAIDS +/- mild opioids Short acting Opioids PRN Long Acting Opioids ATC +/- Adjuvant pain meds Continued pain NeuropathicNon-neuropathic ++

24 Facilitation Substance P Glutamate NGF CCK Inhibition NE/Serotonin Dopamine Opioids GABA Cannabinoids Adenosine

25 Adjuvant Pain Meds ► Neuromodulators ► Calcium channel agents  Ca needed for afferent pain fibers to synapse  Gabapentin inhibits this ► Sodium channel agents  Na needed for spinal cord neurons to transmit impulses  Topamax inhibits this ► Serotonin/NE reuptake inhibitors

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27 Adjuvant pain meds ► Side effects? ► Which one has NO weight gain?

28 3 Circumstances to Use Opioids ► Moderate to severe pain ► Patient has already failed other therapies ► Other therapies (NSAIDs) are contraindicated

29 Opioids ► Which patients should NOT use opioids?

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31 Informed Consent for Opioids

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33 Documentation ► How NOT to get in trouble with the DEA

34 Initial Assessment ► Onset, duration ► Location, distribution ► Quality, character ► Intensity ► Aggravating and relieving factors ► Associated factors  Mood and emotional distress  Functional impairment ► Associated features  Neurological deficit, hyperalgesia, allodynia ► Previous treatments

35 Ongoing Assessment (Progress Note) ► 4 A’s ► Analgesia (use a pain scale) ► ADL’s ► Adverse effects ► Aberrant drug related behavior ► Assessment and Plan

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