1. Kirsten Y. Day, MD Associate Professor Department of Family and Community Medicine UCSF/SFGH FHC

2. Objectives Nuts & Bolts of Outpatient Pain Management Objectives Pain Physiology Evaluation of Pain History and Physical Factors that Influence Pain Management of Pain Physical Modalities Psychological Modalities Pharmacologic Modalities Meds commonly Used How to Evaluate Effectiveness Insurance Issues Tolerance, Dependence, Addiction and Pseudo-Addiction Chronic Narcotic Use in Substance Use Disorders

3. Physiology of Pain Nuts & Bolts of Outpatient Pain Management Physiology of Pain Who, except the gods, can live time through forever without any pain? - Aeschylus

4. Physiology of Pain Nuts & Bolts of Outpatient Pain Management Physiology of Pain Acute Pain is an Early Warning System

5. Physiology of Pain Nuts & Bolts of Outpatient Pain Management Physiology of Pain o Nociceptive Pain o Somatic o Tissue Damage - Temperature, Trauma, Chemical o Once Stimulated, become hyperactive o Localized, constant, throbbing, aching o Visceral o Stretching or Pressure o Referred pain o Generalized, less constant or colicky, cramping o Neuropathic Pain o Damage directly to neurons cause abnormal neural activity o Constant, frequently burning or electrical with periods of marked increases in pain

6. Physiology of Pain Nuts & Bolts of Outpatient Pain Management Physiology of Pain o Stress Analgesia Short-term intense pain controlled with short-term nervous system changes o Hyperalgesia Lowered pain threshold produces pain with less stimulation o Allodynia Previously non-painful stimuli are now painful

7. Physiology of Pain Nuts & Bolts of Outpatient Pain Management Physiology of Pain Response Stimulus Intensity Pain Threshold Pain Tolerance NormalHyperalgesiaAllodynia

8. Evaluation of Pain Nuts & Bolts of Outpatient Pain Management Evaluation of Pain o Pain is real when you get other people to believe in it. If no one believes in it but you, your pain is madness or hysteria. - Naomi Wolf

9. Evaluation of Pain Nuts & Bolts of Outpatient Pain Management Evaluation of Pain o Subjective - NOT a vital sign o History is the foundation for evaluation o PQRST - Provocation, Quality, Radiation, Severity, Time o Location QuEST - Location, Quality, Exacerbating/relieving, Severity, Temporal profile o Functionality

10. Evaluation of Pain Nuts & Bolts of Outpatient Pain Management Evaluation of Pain o Physical Examination o General o Movement o Gait o Positioning o Affect o Vital Signs in acute setting

11. Evaluationof Pain Nuts & Bolts of Outpatient Pain Management Evaluation of Pain o Physical Examination o Focused System Exam o Musculoskeletal o Palpation o Range of Motion o Strength and Laxity o Neurologic o Determine distribution of symptoms o Sources of Referred Pain

12. Evaluation of Pain Nuts & Bolts of Outpatient Pain Management Evaluation of Pain o Diagnosis o Chronic Pain is not a diagnosis o LBP is a symptom, not a diagnosis DJD Radiculopathy Disk Disease Spinal Stenosis Myofascial dysfunction Sacroiliac dysfunction o Fibromyalgia - Tender points in specific patterns o Myofascial Pain - Trigger points with twitch response and specific referred pain patterns

13. Evaluation of Pain Nuts & Bolts of Outpatient Pain Management Evaluation of Pain Factors that Influence Pain o Cognitive, Emotional factors o Environmental Factors o repeated injury o lack of healing o Timing - duration of pain experience

14. Management of Pain Nuts & Bolts of Outpatient Pain Management Management of Pain o Physical Modalities o Psychological Modalities o Pharmacologic Modalities o Insurance Issues

15. Management of Pain Nuts & Bolts of Outpatient Pain Management Management of Pain o Physical Modalities o Exercise o Thermal Therapy o Manual Medicine Disciplines o Physical Therapy o Chiropractic o Osteopathy o Acupuncture o Trigger Point Injection o The only treatments that can “Cure” o Myofascial Pain o Joint dysfunction

16. Management of Pain Nuts & Bolts of Outpatient Pain Management Management of Pain o Psychological Modalities o Cognitive Behavioral Therapy o Biofeedback o Stress Reduction Techniques

17. Management of Pain Nuts & Bolts of Outpatient Pain Management Management of Pain o Pharmacologic Modalities o Step Therapy 1. Mild pain - Acetaminophen and NSAIDs 2. Moderate Pain - Combination Analgesics o APAP/Codeine (Tylenol #3), APAP/Hydrocodone (Vicodin), APAP-Oxycodone (Percocet) 3. Severe or Refractory Pain - Opiates o Morphine o Methadone o Oxycodone o Fentanyl

18. Management of Pain Nuts & Bolts of Outpatient Pain Management Management of Pain

19. o Pharmacologic Modalities o Targeted Treatment o NSAIDS - Inflammatory and Prostaglandin mediated processes o Lidocaine - Myofascial Pain by Trigger Point Injection or Topical Patches o Antiepileptics - Neuropathic pain o Tegretol o Depakote o Gabapentin o Tricyclic Antidepressants - Neuropathic pain

20. Management of Pain Nuts & Bolts of Outpatient Pain Management Management of Pain o Clonidine - augmentative pain relief o SSRI’s - somatic symptoms with or without depressed mood o “Muscle Relaxants” o Centrally acting o Only helpful in Acute injury or Exacerbations

21. Management of Pain Nuts & Bolts of Outpatient Pain Management Management of Pain o Pharmacokinetics of Opiates o Duration of Action - o 4-6 hrs for almost all orals (fentanyl 1-2 hrs.) o Controlled Release (CR) or Sustained Release (SR) 8-12 hours o Onset of Action - o Accelerated with IV dosing versus PO or IM (max effect at 10-20 min for morphine IV) o CR or SR have delayed onset and maximum effect o Steady state o 12-24 hrs with short acting o 48-72 hrs with long acting. o Metabolism and drug interactions.

22. Management of Pain Nuts & Bolts of Outpatient Pain Management Management of Pain o Titrating doses o Choose medications based on type and severity of pain o Give initial doses in short acting agents, assess and titrate at 12 hrs. o With mild to mod pain increase by 25-50% of dose o With mod to severe increase by 50-100% of dose o Convert to long acting agents o Inpatients - within 24 hrs. o Outpatients - Once dosing is stable o Provide short acting agents of 10-15% of long acting dose for breakthrough pain.

23. Management of Pain Nuts & Bolts of Outpatient Pain Management Management of Pain Evaluation o Function o Activities o What o How Long o How Often o Sleep o Mood o Side Effects of Opiates o Constipation, nausea, histamine release, urinary urgency/retention o Evaluate promptly and frequently for side effects and treat as indicated

24. Management of Pain Nuts & Bolts of Outpatient Pain Management Management of Pain o Insurance Issues o Psychological - CBT, Chronic Pain Groups o Physical Modalities o Medicare - Chiropractic and Physical Therapy o Medicaid and SFHP/Slid Scale - Physical Therapy o Pharmacologic Treatments o Formulary Restrictions o Medicare D o Medicaid o SFHP/Slid Scale, HSF o Formulary Overrides o TAR, PAR, PA o Diagnosis and failure of formulary options or medical reason formulary options are contraindicated

25. Tolerance, Dependence, Addiction and Pseudo-Addiction Nuts & Bolts of Outpatient Pain Management Tolerance, Dependence, Addiction and Pseudo-Addiction o Tolerance o Normal Physiologic Response to be expected with long-term use. o Expect to have to adjust doses over time. o Physical Dependence o Normal Physiologic Response to be expected with long-term use. o Physical withdrawal with abrupt cessation or reduction o Addiction o Neurobiological disorder o Compulsive use despite harm, impaired control. o Pseudo-Addiction o Patient behaviors that mimic addiction, caused by provider’s failure to treat pain either adequately or timely o Some patients are drug-seeking because they're in pain...

26. Chronic Pain and Substance Use Disorders Nuts & Bolts of Outpatient Pain Management Chronic Pain and Substance Use Disorders o Prevalence of Chronic Pain high amongst Substance Abusing Patients o 37-61% of patients on Methadone Maintenance o HMO patients entering drug/alcohol treatment OR 2-3 versus controls for HA, LBP, and arthritis o Other Considerations o Stimulant and opiate abuse result in increased pain sensitivity o Relapse o 30% in recovery relapse on Rx opiates o Untreated pain is a frequent trigger for relapse

27. Chronic Pain and Substance Use Disorders Nuts & Bolts of Outpatient Pain Management Chronic Pain and Substance Use Disorders o When to use Opioids for patients with Addictive Disorders o Pain is moderate to severe o Pain has a significant impact on function and quality of life o Non-opioids have been tried and failed o The patient agrees to have opioid use closely monitored

28. Objectives Nuts & Bolts of Outpatient Pain Management Objectives Pain Physiology Evaluation of Pain History and Physical Factors that Influence Pain Management of Pain Physical Modalities Psychological Modalities Pharmacologic Modalities Meds commonly Used How to Evaluate Effectiveness Insurance Issues Tolerance, Dependence, Addiction and Pseudo-Addiction Chronic Narcotic Use in Substance Use Disorders

29. Remember... Nuts & Bolts of Outpatient Pain Management Remember... o Pain is Subjective o Evaluate and determine a Diagnosis o Aim treatment at Diagnosis o Provide timely follow-up, evaluation and treatment o Communication with Pharmacist and know your formulary

30. Kirsten Y. Day, MD Associate Professor Department of Family and Community Medicine UCSF/SFGH FHC