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CHRONIC PAIN MANAGEMENT
Michael Marschke, MD
Medical Director of Horizon Hospice
COMMON ETIOLOGIES OF CHRONIC PAIN
Episodic pain syndromes: Headaches – migraine, tension, cluster… Ischemic episodes – claudication,
angina, sickle cell disease Visceral pain – biliary colic, irritable
bowel, pre-menstrual syndrome, renal colic
Somatic pain - gout
COMMON ETIOLOGIES OF CHRONIC PAIN
Chronic pain syndromes: Somatic – degenerative and inflammatory
arthitis, trauma, vertebral compression fractures, boney metastases, fibromyalgia
Visceral – abdomenal cancers, chronic pancreatitis
Neuropathic – diabetic neuropathy, phantom limb pain, spinal stenosis/sciatica, spinal mets, HIV, drug induced
CHRONIC PAIN IS MULTI-FACTORIAL Psychologic factors – depression, anxiety,
somatization Socioeconomic factors – cultural differences,
urban poor, gender Spiritual factors – spiritual suffering,
meaning of pain Physical factors – VERY complex
neuroanatomy creating the pain sensation, from pain receptors to afferent nerves to spinothalamic tract, to thalamus to cortex with modulators all along the way
Therefore best approach is multi-disciplinary
EVALUATION OF CHRONIC PAIN
GOALS: Determine etiology to better treat
this pain Determine if correctable, intractable,
or potentially dangerous causes Determine impact on patient’s life Take a detailed pain history to aid in
controlling this pain
PAIN HISTORY
O = Other associated symptoms ( nausea with stomach cramps, swelling with somatic pain, depression, anxiety…)
P = Palliative/provocative factors (mobility, touching, eating…)
Q = QualityR = Region/radiationS = Severity ( 0 to 10 )T = Timing (when started,
continuous/intermittent, time of day…)U = Untoward effects on activity or quality of
life, including psychosocial, spiritual effects
HOW DO YOU TELL WHICH PAIN SYNDROME? – HISTORY!
Somatic – focal, ache/throb/sharp, maybe with swelling/edema/redness, tender, worse with movement, better at rest, maybe from trauma
Visceral – viscous organ – colicky, vague, diffuse, worse with meals, liver/spleen/pancreas – may be more constant, more focal, worse with eating, uterine – colicky, pelvic, maybe with discharge
Neuropathic – burning, sharp, tingling, either dermatomal or stocking-glove, worse with touch, maybe with numbness
DRUGS IN WHO STEP LADDER
Step 1: Acetomenophen, Tramadol (Ultram) plus adjuvant
Step 2: Tylenol #2/3/4, Vicoden, Darvocet, Percocet
Step 3: Morphine, Dilaudid, Fentanyl, Demerol, Methadone, Oxycodone, Levodromaran
Marschke’s Modified Pain Escalator
ADJUVANTS TO SOMATIC PAINNon-pharmacologic: Ice, heat Physical therapy Chiropractic/osteopathic
manipulations Massage Acupuncture Yoga Topical agents (Ben
Gay/Icy Hot – with menthol, salcylates, Capcaicin)
Local injections (steroids, lidocaine)
Glucosamine shown to help with osteoarthritis
Pharmacologic: NSAIDs Cox 2 inhibitors Steroids Muscle relaxants
SPECIAL SOMATIC PAIN SYNDROMES
Boney mets: Local RT Pamidronate and
other diphosphonates
Strontium 89 and other radioactive isotopes, taken up by osteoclasts
Vertebral compression fractures:
Calcitonin Pamidronate Vertebroplasty
VISCERAL PAIN Anti-cholinergics for colicky pain H2 blockers/PPIs for PUD/GERD Steroids for enlarged organs with
capsular swelling NSAIDs for uterine pain Nitrates for angina Others – celiac/pelvic plexus blocks, RT
for enlarged organs, massage, herbs, aromatherapy, acupuncture, healing touch
NEUROPATHIC PAIN Tricyclic antidepressants Anti-epileptics Anti-arrhythmics Topical agents – lidocaine, capsiacin Steroids for spinal radiculopathies Others – RT for spine mets, TENS/PENS units
and also spinal electrical stimulators CAM - Acupuncture, massage, PT, yoga,
healing touch
OTHER CAM ADJUVANTS Herbals/supplements – glucosamine shown to be
useful in osteoarthritis, certain herbs like chamomile useful for colicky pain
Homeopathies/flower essences – for relaxation, visceral pain
Healing touch/Reiki – using energy techniques, useful with emotional components
Neuro Emotional Technique – A chiropractic technique also useful with emotional components
Mind – focusing therapies:• Meditation, yoga, guided-imagery, hypnosis, biofeedback• Art/music/humor therapy, pet therapy• By distraction, found to lower HR/RR and decrease pain up
to 10-20%
ADDING AN OPIOID
To achieve quick pain relief: (LOAD)1. Start low dose, short-acting2. Dose q peak3. P.C.A. not “prn” (Patient controls it)4. Re-eval in 4 hrs. to figure out what dose is needed
“prn” dosing
Low-dose, short-acting opioids Tylenol #3, 1-2 tabs Vicoden, Norco,
Lortab 1-2 tabs Darvocet N-100, 1-2
tabs Percocet, 1-2 tabs Vicuprofen, 1-2 tabs
DOSING LIMITED BY ATTACHED DRUG (max Tylenol a day is 4000mg)
MSIR/Roxanol,5-10mg PO, 1-3MG IV/SQ
Dilaudid, 1-2mg PO, 0.25-0.5 IV/SQ
OxyIR, 5-10mg PO
NEVER USE DEMEROL IN CHRONIC PAIN!!!
MAINTAINING AN OPIOIDFor constant pain:
(MAINTENANCE)1. Go long (convert 24hr total of short acting directly to long acting)2. REM breakthru = 10-20% of total daily dose, as short-acting, immediate release3. Re-eval, if 4+ breakthru/d, increase maintainance dose
LONG-ACTING OPIOIDS MS Contin, Oramorph, q12hr, in 15,30,60,
100, and 200mg tabs Kadian, Avinza, q24hr, in 20,50, 100mg
time-release capsules (can be opened to ease swallowing or put thru gastric tubes)
OxyContin, q12hrs, in 10,20,40,80, and 100mg tabs
Duragesic (Fentanyl) patches in 25,50,75, and 100 ug/hr q48-72hrs.
Palladone (Dilaudid) q24hr, in time released capsules
CAVEATS IN OPIOID USE With pure agonists, the sky is the limit 80% of the time dose needs to be increased because the
disease is advancing; 20% because of tolerance. Mixed or partial agonists (Stadol, Talacen, Talwin) have a
ceiling, neurotoxicity, and can induce withdrawal if on other opioids
Methadone – q8-24hr drug, may be better with neuropathies & addiction because inhibits the NMDA receptor in the brain, though half-life 6-100hrs so watch for accumulation
Demerol – neurotoxic metabolite can build up in 1 wk, in 1 day with renal failure
Oral, sublingual, rectal short acting meds peak within 1 hr., IV/SQ peak within 10 minutes. Choose oral if they can do it.
Use conversion tables to switch narcotics, start at 50-100% of equivalent dose
To taper drug, decrease by 25% a day.
OPIOID SIDE EFFECTS Constipation is a given, no tolerance develops,
use stimulants (Senokot, Bisocodyl, Pericolace) Nausea/vomiting – tolerance can occur in 2-5
days, compazine/reglan can help Sedation – tolerance can occur in 2-3 days,
changing drug or Ritalin can help if persists Clonic jerks – usually hi doses, can change drug
or benzodiazepam can help Respiratory suppression in toxic doses, never
see it if have pain or use the drugs the right way
PHYSICAL vs. PSYCHOLOGIC DEPENDENCEPHYSICAL DEPENDENCE: Tolerance (20-40%) – up-regulate opioid receptors
to need higher dose for sustained effect Withdrawal (20-40%) – after 2 wks, withdrawing
drug leads to adrenaline response (sweating, tachycardia, tachypnea, cramps, diarrhea, hypertension); avoid by decreasing drug 25% a day.
PSYCHOLOGIC DEPENDENCE: Addiction (0.1% in CA pain) – a need to get “high”
where drug controls your life, compulsive uncontrolled behavior to get the drug; lie, cheat, steal.
PSEUDO-ADDICTION: Physical dependence confused with
psychologic dependence Pain-relief seeking, not drug-seeking When right dose used, patient
functions better in life, whereas opposite true with the true addict
To help diffentiate: one MD controls the drug under a specific contract with pt., one pharmacy, frequent visits, pill counts