1. Chronic Pain Management Elaine Wendt, MD

2. Pain is now “Fifth Vital Sign”

3. The best way to perceive the professional burden involved in the care of patients with chronic pain is to pick your most comfortable chronic medical diagnosis to manage and take out that diagnosis and substitute the syndrome, “chronic pain.”

4. For Example My patient with diabetes will have diabetes throughout her lifetime and need medical help to manage the diabetes throughout her lifetime while I am her physician. My patient with diabetes will have diabetes throughout her lifetime and need medical help to manage the diabetes throughout her lifetime while I am her physician. My patient with chronic pain will have chronic pain throughout her lifetime and need medical help to manage the chronic pain throughout her lifetime while I am her physician. My patient with chronic pain will have chronic pain throughout her lifetime and need medical help to manage the chronic pain throughout her lifetime while I am her physician.

5. Pain management: physiologic permanence http://www.ama-assn.org/ama/no-index/about- ama/16408.shtml http://www.ama-assn.org/ama/no-index/about- ama/16408.shtml http://www.ama-assn.org/ama/no-index/about- ama/16408.shtml http://www.ama-assn.org/ama/no-index/about- ama/16408.shtml Somatic pain model Somatic pain model Local inflammation>lowered threshold of c-fiber excitation> eventual Rexed lamina 5 wide dynamic neuronal intracellular protein changes…. Local inflammation>lowered threshold of c-fiber excitation> eventual Rexed lamina 5 wide dynamic neuronal intracellular protein changes…. Neuropathic pain model Neuropathic pain model Nerve injury> changes in location, density, number, and type of ion channels> altered nerve firing> eventual Rexed lamina 5 wide dynamic neuronal intracellular protein changes > altered neurotransmitter dynamics> neuronal death/drop out> altered behavior of glial and other architectural cells (scar) Nerve injury> changes in location, density, number, and type of ion channels> altered nerve firing> eventual Rexed lamina 5 wide dynamic neuronal intracellular protein changes > altered neurotransmitter dynamics> neuronal death/drop out> altered behavior of glial and other architectural cells (scar)

6. Currently no single pain medication exists that will take away more than 30 % of a patient’s chronic pain.

7. Set Appropriate Expectations Early

8. Assess Pain Score and Functionality Wong Baker in EMR Wong Baker in EMR ICSI Functional Ability Questionnaire ICSI Functional Ability Questionnaire

9. Make an Appropriate Differential Diagnosis Determine biological mechanisms of pain Determine biological mechanisms of pain Neuropathic pain Neuropathic pain Muscle pain Muscle pain Inflammatory pain Inflammatory pain Mechanical / Compressive pain Mechanical / Compressive pain

10. Identify and Address Comorbitities Early On

11. Perform a Psychological Assessment, including risk of Addictive Disorders Depression Depression Anxiety Anxiety Substance Abuse and Dependence Substance Abuse and Dependence Sleep disorders Sleep disorders Personality disorders Personality disorders History of abuse History of abuse Coping patterns and resources Coping patterns and resources Spirituality Spirituality Working and disability Issues Working and disability Issues

12. Make Therapy GOAL Oriented, Not PAIN Oriented By Next visit, I will be able to do…

13. Use a Treatment Agreement Plan of care Plan of care Set personal goals Set personal goals Improve sleep Improve sleep Increase physical activity Increase physical activity Manage stress Manage stress Decrease pain Decrease pain

14. Use of Controlled Substances is Sometimes Appropriate. However, there are Associated Risks.

15. DEA Practitioner’s manual “The Drug Enforcement Administration is pleased to provide this updated edition of the 1990 Practitioner’s Manual to assist you in understanding your responsibilities under the Controlled Substances Act (CSA) and its implementing regulations. This manual will help answer questions that you may encounter in your practice and provide guidance in complying with federal requirements. “The Drug Enforcement Administration is pleased to provide this updated edition of the 1990 Practitioner’s Manual to assist you in understanding your responsibilities under the Controlled Substances Act (CSA) and its implementing regulations. This manual will help answer questions that you may encounter in your practice and provide guidance in complying with federal requirements. DEA remains committed to the 2001 Balanced Policy of promoting pain relief and preventing abuse of pain medications. In enforcing the CSA, it is DEA’s responsibility to ensure drugs are not diverted for illicit purposes. Unfortunately, this country is now experiencing an alarming prescription drug abuse problem: DEA remains committed to the 2001 Balanced Policy of promoting pain relief and preventing abuse of pain medications. In enforcing the CSA, it is DEA’s responsibility to ensure drugs are not diverted for illicit purposes. Unfortunately, this country is now experiencing an alarming prescription drug abuse problem: Today, more than 6 million Americans are abusing prescription drugs—that is more than the number of Americans abusing cocaine, heroin, hallucinogens, and inhalants, combined. Today, more than 6 million Americans are abusing prescription drugs—that is more than the number of Americans abusing cocaine, heroin, hallucinogens, and inhalants, combined. Researchers from the Centers for Disease Control and Prevention report that opioid prescription painkillers now cause more drug overdose deaths than cocaine and heroin combined. Researchers from the Centers for Disease Control and Prevention report that opioid prescription painkillers now cause more drug overdose deaths than cocaine and heroin combined. Today more new drug users have begun abusing pain relievers (2.4 million) than marijuana (2.1 million) or cocaine (1.0 million). Today more new drug users have begun abusing pain relievers (2.4 million) than marijuana (2.1 million) or cocaine (1.0 million). It is more important now than ever to be vigilant in preventing the diversion and abuse of controlled substances. This manual will help you do that by listing some safeguards you can take to prevent such diversion. It also explains registration, recordkeeping, and valid prescription requirements. It is more important now than ever to be vigilant in preventing the diversion and abuse of controlled substances. This manual will help you do that by listing some safeguards you can take to prevent such diversion. It also explains registration, recordkeeping, and valid prescription requirements. As a practitioner, your role in the proper prescribing, administering, and dispensing of controlled substances is critical to patients’ health and to safeguarding society against the diversion of controlled substances. DEA is committed to working jointly with the medical community to ensure that those in need are cared for and that legitimate controlled substances are not being diverted for illegal use.” As a practitioner, your role in the proper prescribing, administering, and dispensing of controlled substances is critical to patients’ health and to safeguarding society against the diversion of controlled substances. DEA is committed to working jointly with the medical community to ensure that those in need are cared for and that legitimate controlled substances are not being diverted for illegal use.”

16. Document Informed Consent Informed consent for chronic opioid therapy (HCHD has bilingual forms) Informed consent for chronic opioid therapy (HCHD has bilingual forms) Side effects of medication Side effects of medication Monitoring of medication use Monitoring of medication use Refill policy Refill policy

17. Assess Pain Level and Function before and during Therapy Wong Baker Scores Wong Baker Scores Attainment of Goals Attainment of Goals

18. Regularly Assess the 4 “A’s” Analgesia Analgesia Activity Activity Adverse effects Adverse effects Aberrant behavior Aberrant behavior

19. Document all Assessments and Care Plans Texas Medical Board Rules, Ch.170 Texas Medical Board Rules, Ch.170 http://www.tmb.state.tx.us/rules/docs/CurrentR ulesRevised09-20-07.pdf http://www.tmb.state.tx.us/rules/docs/CurrentR ulesRevised09-20-07.pdf http://www.tmb.state.tx.us/rules/docs/CurrentR ulesRevised09-20-07.pdf http://www.tmb.state.tx.us/rules/docs/CurrentR ulesRevised09-20-07.pdf

20. Texas Medical Board Rules, Ch.170 The Shalls: The Shalls: “the medical record shall document the medical history and a physical examination that includes a problem- focused exam specific to the chief presenting complaint of the patient.” “the medical record shall document the medical history and a physical examination that includes a problem- focused exam specific to the chief presenting complaint of the patient.” “The medical record shall document the physician’s rationale for the treatment plan and the prescription of drugs for the chief complaint of chronic pain and show that the physician has followed these guidelines” “The medical record shall document the physician’s rationale for the treatment plan and the prescription of drugs for the chief complaint of chronic pain and show that the physician has followed these guidelines” “Each periodic review shall be documented in the medical record” “Each periodic review shall be documented in the medical record”

21. Summary Chronic pain is a chronic illness Chronic pain is a chronic illness Assess comorbidities early on Assess comorbidities early on Create goals for therapy Create goals for therapy Use formal contracts for controlled substances Use formal contracts for controlled substances Reassess and document Reassess and document