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1
Diagnosing & Treating Musculoskeletal
Pain In Working-Aged Adults
The Importance of Identifying The Central Pain
Phenotype3/21/17
Presented By:
Paul C. Coelho, MD
2
Disclosures:Dr. Coelho has no disclosures. He will not be discussing any off-
label uses of medications or devices.
3
Table of Contents
Early Pain Models
Modern Pain Models
FMS, HA, and LBP
The Central Pain Phenotype
Sample Case
Evidence-Based Treatments
4
1980 Model of MSK Pain
Nociceptive Neuropathic
Primarily due to inflammation or
tissue damage in the periphery
Damage or entrapment of
peripheral nerves.
NSAID/Opioid Responsive Responds to both peripheral
and central pharmacotherapy.
Responds to procedures. Does not respond to
procedures.
Behavioral factors minor. Behavioral factors minor.
Examples: Osteoarthritis,
Rheumatoid arthritis, cancer
pain.
Examples: Diabetic peripheral
neuropathy, post-herpetic
neuralgia.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1829161/
5
1990 FMS
https://www.rheumatology.org/Portals/0/Files/1990_Criteria_for_Classification_Fibro.pdf
6
US Overdose Deaths
1980-2014
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1829161/
0
12500
25000
37500
50000
1980 1983 1986 1989 1992 1995 1998 2001 2004 2007 2010 2013
Wolfe ACR FMS
1990
FDA Approves OxyContin
1995
APS Pain as a 5th Vital Sign
1996
Wolfe Recants FMS
2008
IOM 100M In Pain
2011
Peak Incidence of Prescription OD 45-54
Portenoy Portenoy/Foley
1986
Portenoy Recants
2012
7
Variation in Opioid Rx’ing for
FMS 2007-2009
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4346177/
Peak Incidence of Prescription OD 45-54
8
35% of FMS Pt’s Receive
SSDI
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4151179/
Disabled Medicare Beneficiaries Rx’d Opioids
9
FMS Patients Report High Pain
Levels In Spite of High Dosages
https://www.ncbi.nlm.nih.gov/pubmed/24310048
N = 582
10
Opioids In FMS: Once Started
Seldom Stopped
https://www.ncbi.nlm.nih.gov/pubmed/26443495
N = 100K, 60% Received Opioids.
11
Opioids In FMS: Once Started
Seldom Stopped
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5117947/
N = 64K, 44% Received Opioids.
12
30 Day Supply & Risk of COT
https://www.cdc.gov/mmwr/volumes/66/wr/mm6610a1.htm
20% will remain on opioids at 3yrs.
13
FMS Is Not Opioid Responsive
https://www.ncbi.nlm.nih.gov/pubmed/26975749
Organization
American Pain Society
American Academy of Pain Medicine
American Academy of Neurology
European League Against Rheumatism
Canadian Pain Society
Canadian Rheumatology Association
British Pain Society
14
2017 Model of MSK PainNociceptive Neuropathic Central
Primarily due to
inflammation or tissue
damage in the periphery
Damage or entrapment
of peripheral nerves.
Primarily due to a
central disturbance in
pain processing.
NSAID/Opioid
Responsive
Responds to both
peripheral and central
pharmacotherapy.
Tricyclic neuro-active
compounds. Opioid
unresponsive.
Responds to
procedures.
Does not respond to
procedures.
Does not respond to
procedures.
Behavioral factors
minor.
Behavioral factors
minor.
Behavioral Factors
Prominent.
Examples:
Osteoarthritis,
Rheumatoid arthritis,
cancer pain.
Examples: Diabetic
peripheral neuropathy,
post-herpetic neuralgia.
Examples: FMS,
cLBP, cHA, IBS.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1829161/
15
Comorbid Pain in FMS is the
Norm
https://www.ncbi.nlm.nih.gov/pubmed/22364327
Low Back Pain
“Overwhelming evidence reveals that what is
often labeled as a single chronic regional pain
syndrome is, upon closer evaluation, a chronic
illness beginning much earlier in life, where the
pain merely occurs at different points of the body
at different points in time and is given different
labels by subspecialists focusing on “their region”
of the body.”
Daniel Clauw, MD
16
Prevalence of LBP & HA in
FMS
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1829161/
2007 Internet Survey of 2596 FMS Pts
Ave Age = 47
If due to chance alone
LBP .3 x .05 =1.5%
HA: .2 x .05 =1%
17
Prevalence of FMS in cLBP
42%
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1829161/
Chance Alone: .3 x .05 = 1.5%
18
Prevalence of FMS in Migraineurs
56%
Chance Alone:
.2 x .05 += 1%
https://www.ncbi.nlm.nih.gov/pubmed/25994041
N = 1,730
19
Head Ache & LBP Predict FMS
https://www.ncbi.nlm.nih.gov/pubmed/26772544
20
Comorbid Pain in FMS is the
Norm
https://www.ncbi.nlm.nih.gov/pubmed/22364327
Fibromyalgia
Low Back Pain
Fibromyalgia Fibromyalgia
Head AcheLow Back Pain
21
Central Sensitivity Spectrum
Disorders
https://www.ncbi.nlm.nih.gov/pubmed/17350675
22
Overlapping Chronic Pain
Conditions
https://www.ncbi.nlm.nih.gov/pubmed/27586833
23
Prescribers are Poor at
Diagnosing
Central Pain Syndromes
https://www.ncbi.nlm.nih.gov/pubmed/23071343
23% Sensitivity
N = 312, 240 FMS+
24
Prescribers are Poor at
Diagnosing
Central Pain Syndromes
https://www.ncbi.nlm.nih.gov/pubmed/23071343
27% Specificity
N = 4M
25
Prescribers are Poor at
Diagnosing
Central Pain Syndromes
https://www.ncbi.nlm.nih.gov/pubmed/20461781
“You cannot guess at the extent of fatigue,
unrefreshed sleep, cognitive problems, multiplicity
of symptoms, and extent of pain without a detailed
interview. The new criteria obligate you to pay
careful attention to the patient if you want to
diagnose fibromyalgia.”
Fredrick Wolfe
26
Diagnosing Central Sensitivity
Spectrum Disorders
https://www.ncbi.nlm.nih.gov/pubmed/26266995
1. Pain in many body regions.
2. Higher current and lifetime history of chronic pain in several
body regions.
3. Multiple somatic symptoms (e.g., fatigue, memory difficulties,
sleep problems, mood disturbance)
4. Negative Affect, dispositional pessimism, pain catastrophizing.
5. More sensitive to other sensory stimuli (e.g., bright light, loud noises,
odors, other sensations in internal organs)
6. 1.5 to 2x more common in women.
7. Strong family history of chronic pain.
8. High self-reported pain & distress (VAS/NPS/PSD/PCS)
9. Pain triggered or exacerbated by stressors.
10. Peak prevalence of FMS age 30-59 (working-age).*
11. Essentially normal physical examination +/- diffuse tenderness.
27
2016 FMS Survey Questionnaire96% Sensitivity, 92% Specificity
28
Pain Catastrophizing ScaleModerate Risk 20-29
High Risk > 30
29
Elevated PCS Predicts Abuse
https://www.ncbi.nlm.nih.gov/pubmed/23618767
30
Elevated PCS Predicts Abuse
https://www.ncbi.nlm.nih.gov/pubmed/24612286
31
Elevated PCS Predicts Abuse
https://www.ncbi.nlm.nih.gov/pubmed/23809983
32
Why Is Dx’ing FMS/CSS
Important?
https://www.ncbi.nlm.nih.gov/pubmed/26266995
1. It is opioid unresponsive.
2. Prognosis: It does not improve with time.
3. When present amid other CNP conditions – HA,
LBP, etc. – it is likely to be the primary source of
morbidity.
33
FMS Is Opioid Unresponsive
https://www.ncbi.nlm.nih.gov/pubmed/26975749
34
Natural Hx of FMS
https://www.ncbi.nlm.nih.gov/pubmed/21765102
N = 1,555
11yr f/u
35
Natural Hx of FMS
https://www.ncbi.nlm.nih.gov/pubmed/28077978
N = 76
2yr f/u
36
FMS is the Primary Source of
Morbidity in Mixed Pain States
https://www.ncbi.nlm.nih.gov/pubmed/27049402
N = 383, 76 FMS+
37
FMS is the Primary Source of
Morbidity in Mixed-Pain States
https://www.ncbi.nlm.nih.gov/pubmed/28182837
N = 156, 25 FMS+
38
FMS is the Primary Source of
Morbidity in Mixed Pain States
https://www.ncbi.nlm.nih.gov/pubmed/28229811
N = 172
38 + FMS
39
Sample Case
40
Joyce
Joyce is a 45y/o woman who recently moved from
CA to Douglas, County to retire. Her past medical
history is significant for a work related back injury
for which she was medically retired. She now
receives SSD and seeks to establish care with you
for primary care needs as well as pain
management. Her medication regimen consists of
Lisinopril for HTN. She is requesting “Percocet” for
pain.
41
>13 = FMS
7
10
17
Joyce
>13 = FMS
42
Joyce
>30 Abnl
443
44
3
43
344
44
48/52
43
Evidence-Based Treatments of
FMS
https://www.ncbi.nlm.nih.gov/pubmed/28077978
Treatment Evidence Level
Patient Education 1A
Graded Exercise 1A
CBT 1A
Tricyclics 1A
SNRI’s 1A
Gabapentenoids 1A
NSAIDS 5D
Opioids 5D
44
Centralized Pain Pt Handout
https://www.painscience.com/articles/central-sensitization.php
45
Evidence-Based Treatments for
FMS
https://www.youtube.com/watch?v=pgCfkA9RLrM
46
Evidence-Based Treatments for
FMS
https://fibroguide.med.umich.edu/
47
Evidence-Based Treatments for
Pain Catastrophizing
48
Resources
Fibromyalgia Screening Questionnaire
http://www.slideshare.net/101N/pcp-pain-screening-tool
Evidence-Based Treatments for FMS, Dr. Clauw JAMA
http://www.slideshare.net/101N/fibromyalgia-clinical-review
Daniel Clauw, MD Youtube Video for patients
https://www.youtube.com/watch?v=pgCfkA9RLrM&t=6s
Sample Centralized Pain Patient Handout
http://www.slideshare.net/101N/central-sensitization-70569194
List of non-opioid alternatives for chronic non-cancer pain
http://www.slideshare.net/101N/nonopioid-alternatives-for-chronic-
noncancer-pain