Presentation is loading. Please wait.

Presentation is loading. Please wait.

When Chronic Pain Comes Knocking Kenneth R. Goldschneider, MD, FAAP Director, Division of Pain Management Cincinnati Children’s Hospital Medical Center.

Similar presentations


Presentation on theme: "When Chronic Pain Comes Knocking Kenneth R. Goldschneider, MD, FAAP Director, Division of Pain Management Cincinnati Children’s Hospital Medical Center."— Presentation transcript:

1 When Chronic Pain Comes Knocking Kenneth R. Goldschneider, MD, FAAP Director, Division of Pain Management Cincinnati Children’s Hospital Medical Center

2 The Chronic Pain Patient Arrives…

3 Disclosure 2006 Pfizer Pain Visiting professorship 2006 Pfizer Pain Visiting professorship No promotional activity No promotional activity

4 Case #1 12y.o. female presents with 3 months of severe, constant abdominal pain, epigastric, sometimes wakes her, interferes with school. Looks a little uncomfortable. VSS, abd diffusely tender, o/w (-) 12y.o. female presents with 3 months of severe, constant abdominal pain, epigastric, sometimes wakes her, interferes with school. Looks a little uncomfortable. VSS, abd diffusely tender, o/w (-) PMHx: headaches 1-2/week, o/w (-) PMHx: headaches 1-2/week, o/w (-) Meds: PPI, MVits; NKA Meds: PPI, MVits; NKA FHx: Aunt with “spastic colon” FHx: Aunt with “spastic colon”

5 Functional Gastrointestinal Disorders (FGIDs) Pain anywhere in abdomen Pain anywhere in abdomen Usually constant or frequent, may waken from sleep. Many descriptors. Usually constant or frequent, may waken from sleep. Many descriptors. Exam non-focal Exam non-focal Often start with infectious or stressful event Often start with infectious or stressful event Stress exacerbates Stress exacerbates

6 Alarm Symptoms Weight loss, vomiting, focal exam or complaint, decelerating growth curve, GI blood loss, dysphagia, fever, arthritis, delayed puberty, perirectal disease; FHx of IBD, Celiac Dz; Eosinophilic Dz Weight loss, vomiting, focal exam or complaint, decelerating growth curve, GI blood loss, dysphagia, fever, arthritis, delayed puberty, perirectal disease; FHx of IBD, Celiac Dz; Eosinophilic Dz

7 Pediatric FGIDs Functional Dyspepsia Functional Dyspepsia Irritable Bowel Syndrome Irritable Bowel Syndrome Abdominal Migraine Abdominal Migraine Childhood Functional Abdominal Pain+/- Syndrome Childhood Functional Abdominal Pain+/- Syndrome Functional Constipation Functional Constipation Nonretentive Fecal Incontinence Nonretentive Fecal Incontinence Gastroenterology 2006; Vol 130:1537 Gastroenterology 2006; Vol 130:1537

8 They’ll fool ya’ Myofascial pain Myofascial pain Intercostal neuralgia Intercostal neuralgia Slipping rib syndrome Slipping rib syndrome Umbilical hernia Umbilical hernia Xyphoidalgia Xyphoidalgia

9 Treatment of FGIDs Behavioral Medicine Behavioral Medicine Biofeedback, coping, lifestyle adaptations, parental coaching Biofeedback, coping, lifestyle adaptations, parental coaching Avoid obvious triggers Avoid obvious triggers Fatty foods, NSAIDs, prolonged NPO Fatty foods, NSAIDs, prolonged NPO Medication Medication TCAs, antispasmodics, PPIs, anticonvulsants, peppermint oil TCAs, antispasmodics, PPIs, anticonvulsants, peppermint oil

10 Case #2 14 y.o. WF presents with a two week history of burning foot pain that started after twisting her ankle playing soccer. The foot is cyanotic, a bit puffy, and she won’t let you near it. Straight-A student, good family. 14 y.o. WF presents with a two week history of burning foot pain that started after twisting her ankle playing soccer. The foot is cyanotic, a bit puffy, and she won’t let you near it. Straight-A student, good family. PMHx (-); Meds (-); NKA; FHx (-) PMHx (-); Meds (-); NKA; FHx (-)

11 CRPS Type I Formerly: Reflex Sympathetic Dystrophy AlgodystrophyAlgoneurodystrophy Sudek’s Atrophy Reflex Neurovascular Dystrophy Osteodystrophy

12 CRPS Type I: Diagnosis 1. Develops after initiating noxious event 2. Spontaneous pain or allodynia occurs not necessarily dermatomal not necessarily dermatomal disproportionate to inciting event disproportionate to inciting event 3. Evidence or history of: edema edema sudomotor abnormality sudomotor abnormality skin blood flow abnormality skin blood flow abnormality 4. Excluded by existence of conditions otherwise accounting for degree of pain and dysfunction

13 RSD: Stages (?) 1. Acute: weeks to months warm, dry, most responsive to treatment warm, dry, most responsive to treatment 2. Dystrophic: months cool, cyanosis/mottling, sudomotor changes cool, cyanosis/mottling, sudomotor changes 3. Atrophic: years cool, white, atrophy of muscle/skin cool, white, atrophy of muscle/skin Traditional sequential stages may not exist May be subtypes: − Limited vasomotor predominant − Limited neuropathic pain/sensorimotor abnormalities predominant − Florid presentation “Classic RSD” Bruehle, et al 2002

14 Presentation Age range: 3 years and up Female:Males = 5:1 Lower:Upper extremity ~5:1 Sports-related injury: ~50% ~85% involved in sports or dance Spontaneous pain Mechanical allodynia, edema, cold extremity, cyanosis

15 CRPS

16 Ancillary Findings CRPS Bone scan: mixed results, not useful Radiography: non-specific demineralization Psychological profile: stress seems to exacerbate Wilder, et al, 1992

17 Recommendations Central theme : functional restoration Objective and Reachable rehab goals essential PT is key Psychological treatment essential Neuropathic meds and occasional block All components subserve the central theme Self-management is emphasized

18 Outcome Younger patients have milder course less pain, higher function, fewer remaining autonomic signs on follow-up, shorter duration, more likely to return to sports less pain, higher function, fewer remaining autonomic signs on follow-up, shorter duration, more likely to return to sports School days missed in first year after injury in first year after injury No effect: Duration of symptoms Gender Relation to sports Immobilization Number of SNS Wilder, et al, 1992

19 Figure from Reg Anes 23(3)

20 Case #2 again Your CRPS patient returns a couple weeks later complaining of sleepiness, dizziness, dry mouth, and (per her mom) significant mood swings. Her pain is a little better. HR: 115; mucous membranes dry, cerebellar signs OK; no SI. Your CRPS patient returns a couple weeks later complaining of sleepiness, dizziness, dry mouth, and (per her mom) significant mood swings. Her pain is a little better. HR: 115; mucous membranes dry, cerebellar signs OK; no SI. Rx: PT; Bmed; gabapentin; amitriptyline; TENS unit Rx: PT; Bmed; gabapentin; amitriptyline; TENS unit

21 Pain Meds? Anticonvulsants Anticonvulsants Neuropathic, abdominal pain, headache Neuropathic, abdominal pain, headache Antidepressants Antidepressants Neuopathic, headache, abdominal pain Neuopathic, headache, abdominal pain Antihypertensives Antihypertensives Neuropathic pain, headache Neuropathic pain, headache Local Anesthetics Local Anesthetics Neuropathic, back pain Neuropathic, back pain

22 AnaesthesiaUK

23 Adjunct Meds

24 Anticonvulsant Side Effects Minor: Minor: Sedation, dizziness, trouble with memory or concentration, extremity swelling Sedation, dizziness, trouble with memory or concentration, extremity swelling Major: Major: Renal stones (Topiramate) Renal stones (Topiramate) Rash, Stevens-Johnson Syndrome (any) Rash, Stevens-Johnson Syndrome (any) Liver dysfunction (valproate, carbamazepine) Liver dysfunction (valproate, carbamazepine) Pancreatitis (valproate) Pancreatitis (valproate) Mood swings (gabapentin) Mood swings (gabapentin)

25 Antidepressant Side effects Minor: Minor: Sedation, mood swings, weight gain/loss, insomnia, dry mouth Sedation, mood swings, weight gain/loss, insomnia, dry mouth Major: Major: Suicidal ideation (any, more prominent in SSRIs) Suicidal ideation (any, more prominent in SSRIs) Prolonged QT, Torsades de Pointe (tricyclics) Prolonged QT, Torsades de Pointe (tricyclics) SSRI interactions (CYP 2D6) SSRI interactions (CYP 2D6)

26 Topical Treatments Lidocaine patch (Lidoderm) Lidocaine patch (Lidoderm) Approved for PHN Approved for PHN Used for back pain, localized neuropathic pain Used for back pain, localized neuropathic pain Systemic toxicity unlikely Systemic toxicity unlikely Clonidine patch Clonidine patch Capsaicin Capsaicin

27 TENS Transcutaneous Electrical Nerve Stimulation

28 Descending Inhibition Small Fibers Large Fibers SG Cognitive Control Action

29 Herbs Not your Parents’ Nuts and Berries

30 Dietary Supplement and Health Education Act, 1994 Created the dietary supplement category Herbs may claim effect but not promise cure No standard for quality No proof needed of efficacy or safety

31 DSHEA: Implications Potency can vary Contaminants may exist Additives can be used No mention needed on the label No mention needed on the label Active ingredient need not be contained Active ingredient need not be contained One preparation may be vastly more or less potent than another One preparation may be vastly more or less potent than another

32 Herbs May apple (podophyllum): recommended for pediatric constipation relief Library of Health, 1920 VP-16 (etoposide) Foxglove As a poultice over the kidneys to induce urination, over the joints for inflammation, and as a tea, for heart failureDigitalis

33 Herbs Nicotinaea tabacum: touted for medicinal purposes Tobacco Indian Hemp: “used with benefit in neuralgia” “for medicinal purposes cannabis is used to quiet spasms and produce mental quietude” Library of Health, 1920

34 So, what’s popular at the herb shops?

35 Herbs Chamomile (Chamaemelum nobile) Mild sedative effect, antispasmodic Works Cross-allergenic with ragweed Contains coumarin Garlic (Allium sativum) Treatment of familial hyperlipidemia in children (8-18 years) Garlic oil or placebo TID x 8 weeks No effect May increase bleeding risk (PT/INR/platelet effects)

36 Herbs Ginger (Zingiber officinale) Anti-nauseant and antispasmodic Effective May inhibit platelet function May be mutagenic Echinacea (Echinacea purpurea) Immuno-stimulant Appears to work Hepatotoxic in long term use? Tachyphylaxis may develop 3 different species, effect?

37 Herbs St. John’s Wort (Hyperecium perforatum) Uses: depression, anxiety, sleep disorders Adverse effects: Photosensitivity, dry mouth, fatigue, dizziness, nausea, constipation Drug interactions: Other photo- sensitizers, SSRIs, pseudoephedrine, MAOIs Feverfew (Tanecetum parthenium) Uses: migraine headaches Adverse effects: apthous ulcers, rebound headaches, GI irritability, increased bleeding risk Drug interactions: NSAIDs, heparin, warfarin, inhibits Fe +++ uptake

38 Herb: risks and interactions BleedingChamomileFeverfewGarlicGinkgoGinsengSedationValerian Kava kava GE Reflux Peppermint

39 Case #3 17 y.o. with spondylolysis-based back pain presents with increased pain, sweating, tachycardia. He is noted to be unpleasant to the RNs. He says he ran out of methadone a few days ago, and ran out of Percocet yesterday. 17 y.o. with spondylolysis-based back pain presents with increased pain, sweating, tachycardia. He is noted to be unpleasant to the RNs. He says he ran out of methadone a few days ago, and ran out of Percocet yesterday.

40 Opioids in Pediatric Chronic Pain Few patients Few patients Organic diagnoses Organic diagnoses Stable regimens, once titrated Stable regimens, once titrated Dx: Cancer, Ehlers-Danlos, JRA, EBD, CF, Sickle Cell, Dx: Cancer, Ehlers-Danlos, JRA, EBD, CF, Sickle Cell,

41 Withdrawal Usually a “red flag” Usually a “red flag” Lost/stolen Rx, misuse, not following directions, Lost/stolen Rx, misuse, not following directions, Sx: same as for adults Sx: same as for adults Increased pain, tremors, sweating, tachycardia, irritability, yawning, diarrhea Increased pain, tremors, sweating, tachycardia, irritability, yawning, diarrhea

42 Withdrawal Need to contact Pain Clinic Need to contact Pain Clinic Usually, a bolus dose, then a few days of the prior dosing until they can get to clinic Usually, a bolus dose, then a few days of the prior dosing until they can get to clinic If history of abuse is known, referral to detox is appropriate If history of abuse is known, referral to detox is appropriate 3 day grace period 3 day grace period

43 Opioid Contracts Between Chronic doc and patient/family Between Chronic doc and patient/family Defines rules of engagement Defines rules of engagement All opioids to come from Pain Clinic All opioids to come from Pain Clinic Usually requires pt to contact Clinic of need to go to ED/Urgent Care Clinic Usually requires pt to contact Clinic of need to go to ED/Urgent Care Clinic

44

45 Interacting with Pain Teams Referrals Referrals Pt should return to PMD for referral to Clinic Pt should return to PMD for referral to Clinic Feedback Feedback Note or call to Pain Clinic helpful Note or call to Pain Clinic helpful Admissions Admissions Should not be done for a chronic pain condition without consultation with Clinic (for established patients) Should not be done for a chronic pain condition without consultation with Clinic (for established patients)

46 Thank You


Download ppt "When Chronic Pain Comes Knocking Kenneth R. Goldschneider, MD, FAAP Director, Division of Pain Management Cincinnati Children’s Hospital Medical Center."

Similar presentations


Ads by Google