1. Supported in part by Arkansas Blue Cross and Blue Shield
and the Office of the Arkansas Drug Director and in partnership with the Arkansas Academy of Family Physicians (AAFP), the Arkansas Medical Society (AMS), the Arkansas State Medical Board (ASMB), the Arkansas Department of Health (ADH) and its Division of Substance Misuse and Injury Prevention (Prescription Drug Monitoring Program—PDMP)
Continuing Education Credit: TEXT:
Event ID:

2. The Transition Johnathan Goree, MD Director of Chronic Pain Division
Assistant Professor
Department of Anesthesiology
University of Arkansas for Medical Sciences

3. Poll Everywhere Phone Computer
Text JOHNATHANGOR491 to to respond
Computer
Respond at Pollev.com/johnathangor491

4. Disclosures
I have no financial interests to disclose related to this presentation
I will present some non-FDA approved uses of medications which include steroids (dexamethasone) for lumbar epidural steroid injections and anti-convulsants/anti-depressants for the treatment of neuroinflammatory chronic pain. Both of these medications have been used for these indications for over 20 years.

5. Definition of Pain International Association for the Study of Pain
An unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage
Sensory, emotional, cognitive, and behavioral components that are interrelated with environmental, developmental, socio-cultural, and contextual factors

6. Classification of Pain
Nocioceptive
Somatic
Bone, joint, muscle, skin, or connective tissue
Well localized
Aching & throbbing
Visceral
Visceral organs such as GI tract
Poorly localized
Cramping
Neuropathic
Central
Injury to peripheral or central nervous system causing phantom pain
Dysregulation of the autonomic nervous system (e.g. Complex regional pain syndrome)
Peripheral
Peripheral neuropathy due to nerve injury
Pain along nerve fibers

9. Chronic Pain
“…the use of opioids in treating chronic pain (pain lasting longer than 3 months or past the time or normal tissue healing)”
CDC Guidelines for Prescribing of Opioids for Chronic Pain

10. Question?
If Chronic Pain is purely determined by time (3 months)… why do opioids work well for ACUTE pain but poorly for CHRONIC pain?
Laceration?
Broken Leg?
Wisdom Tooth Surgery?
Back Pain?

11. The Transition
Spinal Cord
Periphery
Brain

12. At the Spinal Cord

13. Acute v. Chronic Pain AMPA receptor Primary Excitatory receptor
Glutamate is primary agonist
Permeable to Na
Causes basic membrane depolarization
Propagation of action potential

14. Acute v. Chronic Pain NMDA receptor Glutamate is primary agonist
Blocked by Mg at resting state
Mg is expelled with repeated depolarization or high levels of Glutamate
NMDA is permeable to Na AND Ca
Calcium sets off cascade of events which include
It makes AMPA receptors more permeable
Adds more AMPA receptors to the synapse

15. At the Periphery

16. Chronic Inflammation
Prolonged inflammation causes continued release of inflammatory mediators
Through various intracellular mechanisms
Pain threshold in presynaptic neuron decreases
Increased Substance P release
Causes neurogenic inflammation
May affect mood, cause stress
From: Transition from acute to chronic pain
Contin Educ Anaesth Crit Care Pain. 2014;15(2): doi: /bjaceaccp/mku044

17. At the Brain

18. Mind Changes in ability to cope with pain
Increased rates of anxiety and depression
Higher rates of substance misuse and addiction

19. How fast does this happen?
Maybe faster than we think

20. Remifentanil 3 minute half life Dream for anesthesiology
Can use for severe pain of surgery
Will be out of system by the time the patient wakes up
Decreased use of long term opioids!

21. Remifentanil
Patients who received remifentanil in the operating room have:
increased peak POD1 pain scores
Increased rates of opioid induced hyperalgesia
Lower satisfaction

22. What does this mean clinically?
Poorly treated ACUTE pain leads to CHRONIC pain.
Recognize who is at risk

25. Maybe opioids don’t work for chronic pain because the mechanisms are different?

26. Questions?
Cases?

27. Discussion
Patient is a 54 y/o male with severe axial back pain for 1 month after lifting a bag of mulch from his trunk. Patient has taken ibuprofen and tramadol without much relief. Patient said that this pain has gotten worse over the past 2 weeks and it is limiting his mobility.
Is this poorly treated acute pain or chronic pain?

28. Supported in part by Arkansas Blue Cross and Blue Shield
and the Office of the Arkansas Drug Director and in partnership with the Arkansas Academy of Family Physicians (AAFP), the Arkansas Medical Society (AMS), the Arkansas State Medical Board (ASMB), the Arkansas Department of Health (ADH) and its Division of Substance Misuse and Injury Prevention (Prescription Drug Monitoring Program—PDMP)
Continuing Education Credit: TEXT:
Event ID: