1. Pain Medicine Antonio Quidgley-Nevares, MD Associate Professor
Eastern Virginia Medical School
Physical Medicine & Rehabilitation

2. Objectives Define pain
Review pharmacologic management options for chronic pain
The opioid treatment agreement
Documentation and monitoring

3. How much opioids are consumed in the U.S.?

4. Opioid Statistics USA is 4.6% of world population
USA consumes 80% of the world’s opioids
USA consumes 99% of the world’s hydrocodone
This statistic is very interesting
Why? It’s complicated

5. Pain Epidemiology in The United States
1. Pain is the most common reason a person seeks care from a physician. 2. Ninety percent of all Americans regularly experience acute or chronic pain. 3. One third of all Americans will experience chronic pain during their lifetime.

6. Pain Epidemiology in The United States
The economic impact of pain on the healthcare system and society is enormous.
Chronic pain accounts for 90 million physician visits annually, 14% of all prescriptions, and more than 50 million lost workdays per year.
Total annual healthcare costs are estimated in excess of 100 billion dollars.

7. Pain Epidemiology - U.S. Estimates
CHRONIC PAIN
77.3 mil (US)
nociceptive
visceral
neuropathic
25.6 mil (US)
9.1 mil (US)
17.5 mil (US)
Diabetic neuropathy (DN)
post-herpetic neuralgia (PHN)
radiculopathy (RADIC)
Fibromyalgia
Osteoarthritis
rheumatoid arthritis
IBS
Pancreatitis
bladder pain
Non-cardiac chest pain
abdominal pain syndrome
MIXED
neuropathic and nociceptive
25.1 mil (US)
Mixed agents will influence > 68.2 mil patients
Cancer pain
Low Back pain
CRPS

8. What is pain?

9. Pain Definitions
Pain = An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.
International Association for the Study of Pain (IASP) – Committee on Taxonomy 1979

10. Pain Definitions
In reality, pain is whatever the patient says it is. It is always relative and highly subjective.

11. Pain Definitions
Acute pain = Strictly speaking, pain lasting less than 3-6 months.
Or : Pain occurring during a period of known injury.

12. Pain Definitions Chronic pain = Pain lasting more than 3-6 months.
Or : Pain lasting beyond the period of expected recovery from an injury.

13. Should we treat or manage every patient that reports pain?

14. “…the ethical obligation to manage pain and relieve the patient’s suffering is at the core of the health care professional’s commitment”
Carr et al. US Dept of Health and Human Services

15. We ARE obligated to treat pain But…
Not obligated to treat on the first visit
Not obligated to treat in the absence of adequate diagnostic workup (physical/psychological)
Not obligated to treat with opioids
Not obligated to treat as patient specifies
Not obligated to treat using only pharmacology
Not obligated to treat without requiring patient involvement and responsibility

16. Pain Assessment Onset Location/Site Temporal profile Quality
Unpleasantness
Distress
Associated Symptoms
Psychological
Aggravating
Alleviating
Impact on Function
Habits
Coping Skills

17. Pain Assessment
In addition to a complete history, information regarding all prior therapeutic measures attempted is important.
These may include: medication (by class), injections, neurolytics, surgeries, physical/occupational therapy, behavioral approaches, chiropractic care, acupuncture, TENS, herbal remedies.
If something has not worked previously, ask why. Treatment failures occur for a number of reasons, including: failure to stay on a drug due to tolerable side-effects, improper dosing, improperly targeted anatomy, change in the patient’s condition, co-morbid conditions.

18. Pain Assessment
Review prior work-up to assess for accuracy and completeness.
Does anything need to be repeated?
Are prior diagnoses confirmed by the work-up?
Complete as needed:
Imaging
Electrodiagnostic Evaluation
Nuclear Medicine
Chemistries
Consultation – Psych, Surgical, Rheum.
Diagnostic blocks

19. Pain Assessment
Complete prior: medical/surgical/social/family/occupational histories.
Physical Exam should be complete, but targeted to systems of complaint. Usually this means functional musculoskeletal and neurological exams are dominant.
Localization of pain by region and down to point of maximal tenderness.
The exam starts when you first see the patient. All observational information is important.
Watch for inconsistencies

20. Assessment of Pain Visual Analog Scale
Vertical or horizontal line with verbal, facial or numerical continuum
5 years or older
Reliable and valid
Intervals on numerical scales may not be equal from a child’s perspective
Do not compare one patient’s VAS with another patient

21. VAS

22. Treatment of Pain
Many patients come to pain center/clinics with misconceptions and unrealistic expectations. These should be addressed fairly early on, without alienating the patient.
The primary goal of treatment must be based on improving function, not on reducing pain.
Most people will increase their activity level until they are essentially in the same level of pain.

23. Treatment of Pain
Pain Management centers and clinics are not able to “cure” pain – Patients often do not understand this.
Approach pain reduction by setting realistic goals.
50% reduction of daily pain reduction represents a major improvement.

24. Treatment of Pain
Use of a multidisciplinary approach is resource intensive, therefore it must be planned and make sense for a given patient. The plan should evolve as the patient makes gains.
Having said this, patients should not be able to pick and choose their most desired portions of the program. For many this results in only passive participation, which may be why prior attempts to treat them have failed.
Patients must recognize the importance of being invested in their own recovery.

25. Treatment of Pain
Failure to treat co-morbid medical and psychiatric conditions makes the task of the pain center/clinic difficult, if not impossible.
A history of addiction or drug seeking behavior should be investigated and addressed. This type of patient may be more appropriate for a different clinic.
Compliance with the clinic policies is very important.

26. Assess for addiction risk

27. Tools of the Pain Trade Invasive Non invasive Pharmacologic pain meds
Exercise
Cognitive Behavioral Therapy
Physical and Occupational Therapy
Chiropractic
Nutritional Therapy
Massage Therapy
Psychotherapy
Alternative/complementary therapies
Invasive
Pharmacologic pain meds
Anesthetic blocking agents
Neuromodulatory techniques
Surgery
Neuroablation

28. Treatment of Pain 1. Pharmacology – Drug Classes A.Opiates
1. Methadone
2. Morphine, Fentanyl, Demerol, Oxycodone, Hydromorphone
3. Darvon, Ultram
B.Non-Opiates
1. Tricyclics and atypical antidepressants
2. NSAIDS – COX1, COX2
3. Steroids
4. Antiepileptics
5. Muscle relaxants
Alpha agonists
Benzodiazepines

29. Opioid Analgesics Bind to mu, kappa, delta opioid receptors
Inhibit transmission of nociceptive input periphery to spinal cord, activate descending inhibitory pathways, alters limbic system

30. Opioid Analgesics
Most effective are full mu agonist - do not exhibit ceiling effect
Avoid partial and mixed due to possible ceiling
Often cross sensitivity within a subclass but patient may respond differently to another subclass

31. Opioids: Phenanthrenes
Representative drug: Morphine
Similar drugs:
Codeine
Hydrocodone
Oxycodone
Hydromorphone
Levorphanol
Oxymorphone
Heroin
Naloxone
Nalbuphine (Nubaine,m)
Butorphanol (Stadol,m)
Buprenorphine (Bupronex,p)
p=partial agonist
m=mixed

32. Opioids: Benzomorphans
Representative drug: Pentazocine (Talwin, m)
Similar drugs:
Diphenoxylate (lomotil)
Loperamide

33. Opioids: Phenylpiperidines
Representative drug: Meperidine (Demerol)
Similar drugs:
Fentanyl
Sufentanyl
Alfentanyl
Remifentanyl

34. Opioids: Diphenylheptanes
Representing drug: Methadone
Similar drugs:
Propoxyphene (Darvon)

35. Tramadol
Partial mu agonist, serotonin and norepinephrine reuptake inhibitor
Risk for seizures
May be helpful for neuropathic pain due to multiple areas of action.

36. Tapentadol Partial mu agonist, norepinephrine reuptake inhibitor
Schedule II opioid
May be helpful for neuropathic pain due to multiple areas of action.

37. Opioid side effects Constipation* Respiratory depression Drowsiness
Itching
Confusion
*most common, mu binding in GI track, no tolerance

38. Non-opioids: Acetaminophen
No platelet activity, no gastric mucosa, no anti-inflammatory effects
Similar analgesic and anti-pyretic to NSAIDs
Dose limited to 4000 mg/day – often not noticed in combo meds
Careful with Liver and warfarin

39. NSAIDs
Inhibition of cycloxygenase inhibiting formation of prostaglandin / leukotrienes -> sensitize peripheral nerves and central sensory neurons
Have ceiling dose (increase in side effects without additional analgesia)
Antipyretic
No physical or psychological dependence

40. Adjuvants
TCA, SSRI and SNRI– neuropathic pain and concomitant depression
Block reuptake of monoaminergic neurotransmitters (i.e. serotonin...) in CNS.
Descending pain modulatory pathways use these neurotransmitters.
Anticonvulsants – decrease ectopic spontaneous firing of sensory neurons associated with neuropathic pain

41. Adjuvants Muscle relaxants – for relief of acute muscle injury
Soma – high potential of addiction
BNZ – acute anxiety or spasms, not analgesics
Lidoderm – neuropathic pain
Calcitonin – pain of osteosporotic fracture
Baclofen – spasm / spasticity
Capsaicin – Depletes Substance P

42. Mechanistic Approach to Pain Treatment
Descending inhibition
Brain
NE/5HT GABA Opioid receptors
Peripheral sensitization
Terminal
PNS
Central sensitization
Spinal
cord
Ca++ :
NMDA: PGE:
Subs P
Na+ TTXr
TTXs
PGEr
Na+ TTXr
NK-1
VR-1
NGF
Opioid r
NEr
Agents used in the treatment of neuropathic pain can be stratified according to their major putative antineuralgic mechanisms of action. They are divided into 3 groups: drugs that modulate peripheral sensitization by way of their effects on the sodium channels; drugs that enhance the descending inhibitory pathways from the brain stem to the spinal cord; and drugs that modulate central sensitization. The other drugs are listed under a category entitled “others.”
Many drugs used for treating neuropathic pain are sodium channel modulators, including carbamazepine, oxcarbazepine, phenytoin, topiramate, lamotrigine, mexiletine, and lidocaine.
Drugs that modulate the descending inhibitory pathways by inhibiting the reuptake of biogenic amines or by interacting with the opiate receptors include TCAs, selective serotonin reuptake inhibitors (SSRIs), selective norepinephrine reuptake inhibitors (SNRIs), selective serotonin norepinephrine reuptake inhibitors (SSNRIs), tramadol, and opiates.
Agents with central mechanisms of action that modulate central sensitization include NMDA antagonists such as ketamine, dextromethorphan, methadone, and topiramate. Drugs that affect the calcium channels include gabapentin and oxcarbazepine.
Within the “others” category are capsaicin, which works by depleting substance P from the peripheral C nociceptors; nonsteroidal anti-inflammatory drugs (NSAIDs) and cyclooxygenase 2 (COX-2) inhibitors, which partially exert their effect by inhibiting COX; and levodopa.

43. Mechanistic Approach to Pain Treatment
Descending inhibition
Brain
TCAs
SNRIs
Opioids
Tramadol
Clonidine
Baclofen
Clonazepam
NE/5HT GABA Opioid receptors
Peripheral sensitization
Terminal
PNS
Central sensitization
Spinal
cord
Ca++ : GBP; OXC Conotoxin
NMDA: Ketamine, TPM
Dextromethorphan Methadone PGE: NSAIDs / COX-2
Na+ TTXr
TTXs
PGEr
Na+ TTXr
NK-1
VR-1
NGF
Opioid r
NEr
Agents used in the treatment of neuropathic pain can be stratified according to their major putative antineuralgic mechanisms of action. They are divided into 3 groups: drugs that modulate peripheral sensitization by way of their effects on the sodium channels; drugs that enhance the descending inhibitory pathways from the brain stem to the spinal cord; and drugs that modulate central sensitization. The other drugs are listed under a category entitled “others.”
Many drugs used for treating neuropathic pain are sodium channel modulators, including carbamazepine, oxcarbazepine, phenytoin, topiramate, lamotrigine, mexiletine, and lidocaine.
Drugs that modulate the descending inhibitory pathways by inhibiting the reuptake of biogenic amines or by interacting with the opiate receptors include TCAs, selective serotonin reuptake inhibitors (SSRIs), selective norepinephrine reuptake inhibitors (SNRIs), selective serotonin norepinephrine reuptake inhibitors (SSNRIs), tramadol, and opiates.
Agents with central mechanisms of action that modulate central sensitization include NMDA antagonists such as ketamine, dextromethorphan, methadone, and topiramate. Drugs that affect the calcium channels include gabapentin and oxcarbazepine.
Within the “others” category are capsaicin, which works by depleting substance P from the peripheral C nociceptors; nonsteroidal anti-inflammatory drugs (NSAIDs) and cyclooxygenase 2 (COX-2) inhibitors, which partially exert their effect by inhibiting COX; and levodopa.
NSAIDs
COX-2i
Opioids
Capsaicin
Clonidine
TCA
CBZ OXC
TPM LTG
Mexiletine
Lidocaine

44. Mechanistic Approach to Pain Treatment
Descending inhibition
Disease
Modifiers
Brain
TCAs
SNRIs
Opioids
Tramadol
Clonidine
Baclofen
Clonazepam
NE/5HT GABA Opioid receptors
Peripheral sensitization
Terminal
PNS
Central sensitization
Spinal
cord
Ca++ : GBP; OXC Conotoxin
NMDA: Ketamine, TPM
Dextromethorphan Methadone PGE: NSAIDs / COX-2
Na+ TTXr
TTXs
PGEr
Na+ TTXr
NK-1
VR-1
NGF
Opioid r
NEr
Agents used in the treatment of neuropathic pain can be stratified according to their major putative antineuralgic mechanisms of action. They are divided into 3 groups: drugs that modulate peripheral sensitization by way of their effects on the sodium channels; drugs that enhance the descending inhibitory pathways from the brain stem to the spinal cord; and drugs that modulate central sensitization. The other drugs are listed under a category entitled “others.”
Many drugs used for treating neuropathic pain are sodium channel modulators, including carbamazepine, oxcarbazepine, phenytoin, topiramate, lamotrigine, mexiletine, and lidocaine.
Drugs that modulate the descending inhibitory pathways by inhibiting the reuptake of biogenic amines or by interacting with the opiate receptors include TCAs, selective serotonin reuptake inhibitors (SSRIs), selective norepinephrine reuptake inhibitors (SNRIs), selective serotonin norepinephrine reuptake inhibitors (SSNRIs), tramadol, and opiates.
Agents with central mechanisms of action that modulate central sensitization include NMDA antagonists such as ketamine, dextromethorphan, methadone, and topiramate. Drugs that affect the calcium channels include gabapentin and oxcarbazepine.
Within the “others” category are capsaicin, which works by depleting substance P from the peripheral C nociceptors; nonsteroidal anti-inflammatory drugs (NSAIDs) and cyclooxygenase 2 (COX-2) inhibitors, which partially exert their effect by inhibiting COX; and levodopa.
NSAIDs
COX-2i
Opioids
Capsaicin
Clonidine
TCA CBZ
OXC TPM
LTG
Mexiletine
Lidocaine

45. Treatment of Pain
2. Physical/Occupational Therapy (Outpatient/Inpatient/Home Health)
Bracing, orthoses
Modalities
TENS
Stabilization – active and passive
Strengthening
Biomechanical re-education
Aquatics
Home exercises

46. Treatment of Pain 3. Interventions 1. Epidural Steroid Injection
2. Neurolytic Procedures
3. Radio frequency vs Chemical
4. Peripheral Nerve Blocks
5. Therapeutic vs Diagnostic
6. Autonomic vs. somatic

47. Treatment of Pain
4. Implanted Therapeutics a. Spinal Cord Stimulators Indicated for chronic pain of the limb or trunk Electrical stimulation of the dorsal columns b. Intrathecal Pumps Intrathecal delivery of medications Indicated for chronic pain and spasticity not controlled with PO meds IT opioids are 1/300 of the PO dose

48. Treatment of Pain
5. Pain Psychology Pain is not equivalent to just nociception

49. Treatment of Pain

50. Mood and Pain Develop a trusting treatment relationship
Educate the patient and family
Monitor for treatment adherence
Multiple meds can be used
Cognitive Behavioral Therapy

51. Treatment of Pain 6. Homeopathic/Adjunctive Acupuncture
Chiropractic/Osteopathic manip.
7. Weight Control and Activity
8. Education

52. Educate the Patient
Educate the patient and the family on the nature and prognosis of their condition.
On the treatment
On the importance of function
On the possibility of acute exacerbations and how to address them
Not just by popping a pill
On the importance of their active participation in their recovery

53. Documentation Proper diagnosis Goals of treatment 4 As
Increase function
Palliative care
Increase social interactions
Proper use of medications
4 As
Activity
Analgesia
Adverse reactions
Falls? Problems driving?
Aberrant behavior

54. Documentation Monitoring Compliance of diagnostic and treatment plans
Opioid treatment agreement and consent
Outside records
Preferably from the source and not the patient
Make a copy of valid state issued ID with current address

55. Monitoring Random pill counts Prescription monitoring programs
Urine drug screens
“I know my patients” has been disproven as a way of monitoring

56. Pain Management Protocol
Familiarize with the management options
Decide what you are comfortable with
Write down the protocol
Do not deviate from the protocol
Do not wait until you are uncomfortable or reached the limits of the protocol before referring out

57. Special populations
There are special populations you may feel the need to deviate from the protocol
You must document why you are making a therapeutic exception
Cancer pain
Hospice/Palliative care

58. Opioid treatment agreement and consent form
Some patients feel they are being treated like criminals due to the opioid treatment agreement
“The purpose of this agreement is to give you information about the medications you will be taking for pain management and to assure that you and your physician/health care provider comply with all state and federal regulations concerning the prescribing of controlled substances.”

59. Brief points and examples
I am responsible for my pain medications.  
I will not request or accept controlled substance medication from any other physician or individual
 There are side effects with opioid therapy
 It is my responsibility to notify my physician for any side effects that continue or are severe (i.e., sedation, confusion).
I am also responsible for notifying my pain physician immediately if I need to visit another physician or need to visit an emergency room due to pain, or if I become pregnant.

60. Brief points and examples
Strictly for my own use. Never be given or sold to others because it may endanger that person’s health and is against the law.
I should inform my physician of all medications I am taking, including herbal remedies.  
I understand that opioid prescriptions will not be mailed
Any evidence of drug hoarding, acquisition of any opioid medication or adjunctive analgesia from other physicians (which includes emergency rooms), uncontrolled dose escalation or reduction, loss of prescriptions, or failure to follow the agreement may result in termination of the doctor/patient relationship.

61. Brief points and examples
Not use any illicit substances, such as cocaine, marijuana
Not use alcohol
While physical dependence is to be expected after long-term use of opioids, signs of addiction, abuse, or misuse shall prompt the need for substance dependence treatment as well as weaning and detoxification from the opioids.
there is no improvement in my daily function or quality of life from the controlled substance, my opioids may be discontinued.

62. Brief points and examples
perform random or unannounced urine drug testing.
I agree to allow my physician to contact any health care professional, family member, pharmacy, legal authority, or regulatory agency to obtain or provide information about your care or actions if the physician feels it is necessary.

63. Brief points and examples
responsible for keeping my pain medications in a safe and secure place
Refills will not be made as an “emergency”, such as on Friday afternoon because I suddenly realize I will “run out tomorrow”

64. Brief points and examples
I understand that non-compliance with the above conditions may result in a re-evaluation of my treatment plan and discontinuation of opioid therapy. I may be gradually taken off these medications, or even discharged from the clinic.

65. There are several good examples of opioid treatment agreements to be found on the internet.

66. Thank You ! Rich the treasure, Sweet the pleasure
Sweet is pleasure after pain
For all the happiness man can gain
Is not in pleasure, but in rest from pain.
John Dryden ( )