Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current

Reducing the Risk of Chronic Pain and Opioid Use Disorders

Dr. Maureen Allen CCFP-EM(PC) FCFP

Chronic pain and Palliative care

October 2019

Promoting a SAFE-ED Approach to ACUTE pain

No Disclosures

What do we know

• Pain is the most common condition we see in clinical practice

• It’s also the only condition that we can say with certainty, we’ve been there

• Yet…

• Very little training

Fact checking: Oct 2019

• We know how to reduce the risk of chronic pain and opioid use disorders

• WE understand the forces that are driving it

• The factors that increase the risk

• How to approach it

Evidence is possibility.

It only has power if we use it.Kwick, 2017

What I hope you learn

• What is Pain chronification ?

• What Factors increase it ?

• What forces drive it ?

• What to do when it happens?

• How to minimize it (SAFE-ED)

2015-2016 8

Melissa

• 22 yo female• ORIF forearm Aug 2019 (altercation)• Surgeon: “Healing perfect”• No CRPS/No Infection/No C-spine• Pain 15/10 along incision “distressed”• Arm/incision look OK • Hyperalgesia• PMedHx: Anxiety, depression• Medications:• Seroquel 100mg qhs, Cannabis 4-5gm

How Does Pain Communication Work?

2015-2016 10

Brain Interpretation:• How big is the threat?• What is the appropriate

response?

Higher-Learning Circuitry

NociceptiveCircuitry

• Injury• Illness• Surgery• Unknown

Lets dig deeper

PAIN is triggered“Threat”

INFLAMMATORY RESPONSE

MAINTAIN HOMEOSTATIC BALANCE

(Survival and protection)

GLIAL cell activation

Neurobiology and ACUTE PAIN:Here’s what we know

How cells communicate in the nervous system“All aboard"

MONTREAL

Neuronal

Chemokines, cytokines

GLIAL CELLS:Non-NeuronalGLIAL CELLS:PASSENGERS

GLIAL CELL DYSREGULATION

(persistent neuroinflammation)

INFLAMMATORY RESPONSE

SENSITIZATION(synaptic plasticity)

LOSS OF NOCICEPTIVE

CIRCUIT REGULATION

HIGHER-LEARNING CIRCUITS

TAKEOVER

Pain Chronification

On going pain

“The fundamental problem regarding inflammation is not how often it starts, but how often it fails to subside”.

(Nathan and Ding 2008)

Trigger

Glial cell Activation

Pain resolves

Homeostasismaintained

Chronic pain is a GLIOPATHY not a NEUROPATHY

When pain becomes chronic the peripheral neuroanatomy becomes less important and central mechanisms such as

central sensitization, neuroinflammation and psychological factors (fear, anxiety, pain avoidance) gradually take over necessitating a shift in management directed

more at the CNS .

Take Home MESSAGE

CHALLENGE

WHAT IS THEIR “READINESS” TO MOVE FROM A “FIX IT” TO “I NEED TO MANAGE IT”?

HEALTH CARE PROVIDERS NEED TO WORK TOGETHER WITH THE PATIENT

ACUTE PAIN TREADMILL

When do goals of care shift from ACUTE to CHRONIC?

2 weeks

ANY ACUTELY Painful Condition Can lead to chronic pain

ACUTEPAIN

CHRONICPAIN

Pain Chronification

Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current Medical Research and Opinion. 34:7,1169-1178. (2018) DOI: 10.1080/03007995.2018.1449738.

“The normal, predicted physiological response to an adverse chemical, thermal, or mechanical stimulus” IASP

“Pain without biological value that has persisted beyond the normal tissue healing time” IASP

Pain Chronification: What force matters most ?

Fiebich BL, Akter S, Akundi RS. The Two-hit hypothesis for neuroinflammation: Role of exogenous ATP in modulating inflammation in the brain. Front. Cell Neurosurgery. 2014; 260. Online access. DOI:10.3389/fncel.2014.00260.

MEANING NOT MECHANISM

2-Hit Hypothesis

FIRST HIT“PRIMES”

SECOND HIT“Disruptive

pain experience”

Recover Chronic pain


ACUTEPAIN

CHRONICPAIN

#1What the patient brings

#2How they experience

Acute Pain

Factors that Increase the Risk of Pain Chronification

• Life story/experiences• “Habits and Behaviours”

Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current Medical Research and Opinion. 34:7,1169-1178. (2018) DOI: 10.1080/03007995.2018.1449738.

#3Our approach

Resolution0/10

2-Hit Hypothesis

FIRST HIT“PRIMES”

SECOND HIT“Disruptive

pain experience”

Recover Chronic pain


5 FORCES that DRIVE the “CHRONICITY” of chronic pain

(Protection and Survival)

1. Neuroinflammation (Glial cell dysregulation)

2. Central sensitization (pain amplification)

3. The messenger : Higher learning circuits (brain based) take over from the nociceptive regulation circuits

4. Brain/Pain Memory

5. Pain Protective Behaviours (Muscle memory, Movement memory)

Resiliency and Vulnerability Factors

Patient DEMOGRAPHICS

GENETICS/BIOLOGY

ENVIRONMENTEpigenetics

(environmental cues)

CHRONIC PAIN

• Genetics• Age (older)• Poor health status• Gender (female)

Acute Pain Characteristics

• Chaotic home • Adverse childhood experiences• Social support• Work satisfaction• Communication with HCP• Stress litigation• Level of education

PSYCHOSOCIAL FACTORS

DRUG FACTORSOpioids

PaclitaxelHIV meds

Immunotherapies

BRAIN FACTORSNeuroinflammationCentral sensitization

#3: How we MANAGE ACUTE PAIN MATTERS!!!

• Do we stop and listen?

• Do we validate or dismiss?

• Poor management can contribute to significant morbidity

• Overuse of high risk medications can also contribute to morbidity and death (opioids, BZD, sedative-hypnotics)

Oyler DR, et al. Non Opioid Management of Acute Pain Associated with Trauma: Focus on Pharmacological Options. J Trauma Acute Care Surg.

79(3):475, September 2015

We have a responsibility to……

• Manage risk • Manage expectations• Be more mindful of the “habits

and behaviours” we give patient’s to manage their suffering

• Help them address pain protective behaviours that could be driving pain

PharmacotherapyPharmacotherapy:

TREATMENT GOALS

ACUTE PAIN

80-90% Pain reduction

MINIMIZE Sedation

Improve Function

CHRONIC PAIN AND

CHRONIC PAIN FLARE-UP


AVOID Sedation

Improve Function

CANCER PAIN OR PAIN AT THE END

OF LIFE


May Cause Sedation

May Compromise Function

• Lynch, Mary MD. Drugs and Therapeutics for Maritime Practitioners. Pharmacology of Chronic Pain. Vol 20, No 5/6 October/November, 1997.• National Opioid Use Guidelines for the safe and Effective Use of Opioids for Chronic Non-Cancer Pain. Hamilton: National Opioid Use Guideline Group; 2010.• Allen MA, Jewers H, McDonald JS. A Framework for the treatment of pain and addiction in the emergency department. J Emerg Nurs. Vol 40, Issue 6, pages 552-59. November 2014.

Pain Protective Behaviours

• Muscle work

• Pain Tuck

• Pain avoidance (protection)

General Approach to “all” pain

• Talking points (CBT: Re-framing)

• Interventions

• Alternative therapies

• Pharmacotherapy

• Risk Stratification

Pharmacotherapy

• Elia N, Lysakowski C, Tramer MR. Does multimodal analgesia with acetaminophen, nonsteroidal anti-inflammatory drugs, or selective cyclooxygenase-2inhibitors and patient-controlledanalgesia morphine offer advantages over morphine alone? Meta-analyses of randomized trials. Anesthesiology. 2005;103(6):1296-304.

• Allen MA, Jewers H, McDonald JS. A Framework for the treatment of pain and addiction in the emergency department. J Emerg Nurs. Vol 40, Issue 6, pages 552-59. November 2014.• Belgrade M, St. Marie B. Understanding and Managing Flares in Chronic Pain. Fairview Pain Management Centre.

How Complicated can it be?

Pharmacological choices?• Acetaminophen (Tylenol)

• NSAID’s (Advil, Aleve etc)

• TCA (Elavil)

• Anticonvulsants (Lyrica, Gabepentin)

• Broad spectrum antidepressants

(Duloxetine, Effexor)

• Topicals

• Opioids (SA vrs LA)

• Cannabinoids (Smoke, drink or ingest) Maximum is <2 grams a day

• Lidocaine, Ketamine etc...

• Low dose naltrexone

• Gamma hydroxybutyrate (GHB)

• Lynch, Mary MD. Drugs and Therapeutics for Maritime Practitioners. Pharmacology of Chronic Pain. Vol 20, No 5/6 October/November, 1997.• Golberg et al. JAMA, 2004;292 2381-95.• Ware, Mark. Marijuana as medicine; does it have a future? Clin Pharmacol Ther 83(4): 515-517; 2008.

Should they be used?

• It depends…

• Co-analgesic

• Right patient

• Right condition

• Right amount of time

Opioid Analgesics

• Many forms

• Short-acting

• Long-acting

• Agonist/Antagonist

• Dual active

• Euphoric and non-euphoric

Major complications of Opioid use are…

• Opioid induced pain

• Opioid addiction

• Opioid Diversion

2015-2016 35

What is the RISK of Opioid Addiction when opioids are used to manage Acute Pain ?

NNH1:7864

ADDICTION needs:1. Time

2. Repetition3. Vulnerable brain DIVERSION more of a concern

Heins SE, et al, EARLY OPIOID PRESCRIPTION AND RISK OF LONG-TERM OPIOID USE AMONG US WORKERS WITH BACK AND SHOULDER INJURIES: A RETROSPECTIVE COHORT Injury Prev 22(3):211, June 2016Yearly DM, Green SM. Opioids and the emergency physician: Ducking between pendulum swings. Ann Emerg Med 2016 (In press) Pub Med ID 26973177.

What is the NNH when opioids are used to manage Chronic Pain ?

NNH1:9-11

You have:1. Time

2. Repetition3. Vulnerable brain DIVERSION still a concern

Heins SE, et al, EARLY OPIOID PRESCRIPTION AND RISK OF LONG-TERM OPIOID USE AMONG US WORKERS WITH BACK AND SHOULDER INJURIES: A RETROSPECTIVE COHORT Injury Prev 22(3):211, June 2016Yearly DM, Green SM. Opioids and the emergency physician: Ducking between pendulum swings. Ann Emerg Med 2016 (In press) Pub Med ID 26973177.

Opioids-Pain-2017-Newsletter.pdf

How long should opioid’s be used?

• It depends….

• Tolerance (days)

• Dependency (days)

• Addiction (months)

If Discharged: How much opioid and for how long?

• Chai et al (2017)

• Acute fracture in 15 opioid-naïve patients (mean age 45 years; 60% male)

• As few as six pills may be sufficient for acutely painful conditions

Chai PR, et al. Oxycodone Ingestion Patterns In Acute Fracture Pain With Digital Pills. Anesth Analg 125(6):2105, December 2017

Promote a SAFE-ED approach to ACUTE pain: Reducing the risk of Chronic pain and opioid use

disorders.

• Make them feel SAFE and cared for

• Calm “Worst-case Scenario” thinking

• Address pain specific Fear’s and pain protective behaviours

• Exam carefully for any new pathology or progression of a pre-existing disease

• Manage treatment Expectations

• Dispense small quantities of short-acting, non-euphoric opioids over a short period of time

Melissa

• 22 yo female (ACE)

• ORIF forearm Aug 2019 (altercation)

• Surgeon: “Healing perfect”

• No CRPS/No Infection

• Pain 15/10 along incision “distressed”

• Looks OK

• PMedHx: Anxiety, depression

• Medications:

• Tylenol/NSAID/Seroquel 100mg qhs

Talking points • Listen and validate suffering• Exam carefully• Address fears and Pain Protective

Behaviours• Re-framing: CBT• “Ask-tell-ask”

Interventions • Desensitization (OT)

Alternative therapies • Acupuncture

Pharmaceuticals • Topicals• TCA (sleep)

Risk Stratification • Cannabis/opioids

Talking points

• Here’s what I know…..

• “What you feel is real, but it’d doesn’t always mean dangerous or bad”

• “When pain doesn’t go away it can feel chaotic”

• “You’re not causing damage by moving, it’s how you move that matters most”

Summary

• What you say and do matters• Get good at talking with patient’s

about pain• Reach out to colleagues if you’re

unsure• “Care enough” to set boundaries

regarding high risk pharmacology • Manage risk if opioids and

cannabinoids are used• Never let a patient tell you how

to prescribe a dangerous drug

Acute Pain

• “The normal, predicted physiological response to an adverse chemical, thermal, or mechanical stimulus” IASP

• More about tissue damage or potential damage

• NOCICEPTIVE circuitry > Higher-learning (protective)

• Gone in 3 months• Butler D, Moseley GL. Explain Pain. Noigroup Publications, Adelaide South Australia. ISBN-10 097509 100X. June 2003. • Allen MA, Jewers H, McDonald JS. A Framework for the treatment of pain and addiction in the emergency department. J Emerg Nurs. Vol 40, Issue 6, pages 552-59. November 2014.

Time

PainIntensity

10

00/10

3 monthsInjury

Illness

Surgery

Unknown

Chronic “persistent” pain

• “Pain without biological value that has persisted beyond the normal tissue healing time” IASP

• Lacks acute warning function of physiological nociception

• More about CNS or HIGHER-LEARNING circuitry

Butler D, Moseley GL. Explain Pain. Noigroup Publications, Adelaide South Australia. ISBN-10 097509 100X. June 2003.

PainIntensity

TimeInjury

Illness

Surgery

Unknown

10

0

>3 months

5/10

Chronic Pain “Flare-up”

• Often confused with acute pain

• NOT caused by a new condition or progression of a pre-existing condition

• Investigations unchanged

PainIntensity

Time

0InjuryIllnessSurgeryUnknown

Daily baseline pain5/10

Flare-up Pain15/10

• Allen MA, Jewers H, McDonald JS. A Framework for the treatment of pain and addiction in the emergency department. J Emerg Nurs. Vol 40, Issue 6, pages 552-59. November 2014.

• Belgrade M, St. Marie B. Understanding and Managing Flares in Chronic Pain. Fairview Pain Management Centre.

Chronic pain can co-exists with ANY medical condition

• Diabetes

• Addiction

• Concussion

• “Arthritis”

• Migraines

• Degenerative Disc Disease

• Osteoarthritis

• Fibromyalgia

• Ehler-Danlos Syndrome

• Previous broken bones

• Spinal stenosis

• And many others

BUT IT IS… a unique illness that requires a unique approach

Jeff

“Chronic pain”

Degenerative disc disease

Crohn’s Disease Alcohol use disorder Chronic pain

Who Has a VULNERABLE BRAIN?

Biology/Genes Environment

ADDICTION

Brain Mechanisms

DRUG• Genetics• Gender• Psychiatric disorders

• ACE• Chaotic home• Poor school performance• Peer support

• Delivery route• Brain effect

• Age

Documents

Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current