1. Chronic Pain Management Harald Lausen, DO, MA FCM Clerkship SIU School of Medicine

2. Objectives Introduce common definitions Review pharmacologic approaches Review management essentials – FSMB Model Policy – Pain Management Agreements – 4 A’s of Pain Management

3. Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.

4. Acute Pain The normal, predicted physiologic response to a noxious chemical, thermal, or mechanical stimulus and typically is associated with invasive procedures, trauma, and disease. (Generally time-limited.)

5. Chronic Pain A state in which pain persists beyond the usual course of an acute disease or healing of an injury or that may or may not be associated with an acute or chronic pathologic process that causes continuous or intermittent pain over months or years.

6. Physical Dependence A state of adaptation manifested by drug class-specific signs and symptoms that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. (Does not equate with addiction)

7. Addiction A primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include the following: impaired control over drug use, craving, compulsive use and continued use despite harm.

8. Substance Abuse The use of any substance(s) for non- therapeutic purposes or use of medication for purposes other than those for which it is prescribed

9. Pseudoaddiction The iatrogenic syndrome resulting from the misinterpretation of relief seeking behaviors as though they are drug-seeking behaviors that are commonly seen with addiction. The relief seeking behaviors resolve upon institution of effective analgesic therapy

10. Tolerance A physiologic state resulting from regular use of a drug in which an increased dosage is needed to produce a specific effect, or a reduced effect is observed with a constant dose over time. Tolerance may or may not be evident during opioid treatment and does not equate with addiction

11. World Health Organization Pain Pyramid Strong Opioid – Schedule 2 Mild to Moderate Opioid – Schedule 3 Non-Opioid Analgesics – Schedule 4 or less

12. Pharmacologic Approaches Strong Opioid – Oxycodone, Hydromorphone, Fentanyl, Morphine, Oxymorphone, Methadone, Meperidine Mild to Moderate Opioid – Codeine, Propoxyphene, Hydrocodone, Tramadol Non-Opioid Analgesics – Acetaminophen, Ibuprofen, Naproxen

13. Pharmacologic Approaches Long – acting Opioids – Chronic pain management – Specific acute pain management – May be crushed, sniffed, injected for abuse Short – acting Opioids – Acute pain management – Breakthrough pain in chronic pain management – Dose titration

14. Pharmacologic Approaches Adjuvant Therapy for Opioids – Non-opioid analgesics – Muscle relaxants – Anti-emetics – Anti-seizure medications – Anti-depressants – Sleep agents / Anxiolytics

15. Pharmacologic Approaches Managing adverse effects – Constipation – Sedation – Nausea – Pruritis – Dizziness – Dry mouth

16. Pharmacologic Approaches Serious adverse effects – Anaphylaxis – Respiratory depression – Confusion – Urinary retention – Hallucination – Persistent mild adverse effects

17. Clinical Management Patient Evaluation Treatment Plan Informed Consent Periodic Review Consultation Medical Records Compliance with Laws and Regulations

18. Patient Evaluation Complete history and physical exam Thoroughly assess pain Assess risk and history of abuse Identify coexisting conditions Obtain records for all previous treatments, studies, exams, interventions, visits, etc

19. Treatment Plan Document treatment goals Include any further diagnostic evaluation Document medication adjustments Consider other treatment plans such as physical therapy or counseling.

20. Informed Consent Discuss risks and benefits of treatment Rules of informed consent apply No treatment is an option Review Pain Management Agreement in Detail

21. Informed Consent Pain Management Agreement Not a contract Risks, benefits, alternatives – Misuse, abuse, dependence, addiction – Serious and common adverse effects Expectations – specific – Illegal drugs, sell, trade, share – Refills, early, stolen, lost, times, place, directions – Random drug screening – Disclosure of additional information – Violations, discharge, exit strategy

22. Periodic Review Treatment goals Treatment course Etiology of pain 4 A’s of Pain management – Analgesia – Activities of daily living – Adverse effects – Aberrant behavior

23. Periodic Review Aberrant Behavior Less Indicative – Drug hoarding – Acquiring similar meds form other medical sources – Aggressive complaining for higher doses – Unapproved use for another symptom – Unapproved dose increase 1 or 2 times – Requesting specific drugs – Reporting psychic effects More indicative – Prescription forgery – Concurrent abuse of related drugs – Recurrent prescription loss – Selling prescription drugs – Multiple unapproved dose increases – Stealing or borrowing another patient’s drugs – Acquiring similar meds from non-medical sources

24. Consultation Refer the patient as necessary Identify high risk patients Confirmation of appropriate treatment

25. Medical Records Complete and Accurate Records – History and physical – Diagnostic, therapeutic, lab results – Evaluations and consultations – Treatment goals – Informed consent with management agreement – Medications – Periodic reviews

26. Compliance with Laws and Regulations State license Federal and State DEA Appropriate treatment Comply with regulations Must offer an exit strategy for patients