Staying SANEStaying SANEWhile Treating PAINWhile Treating PAIN

Nathan J. Rudin, M.D.Nathan J. Rudin, M.D.Assistant Professor, Rehabilitation MedicineAssistant Professor, Rehabilitation Medicine

University of Wisconsin Medical SchoolUniversity of Wisconsin Medical SchoolMedical Director, Pain Treatment and Research CenterMedical Director, Pain Treatment and Research Center

Patient VisitPatient Visit

Whole-body pain for six yearsWhole-body pain for six years Depression; anxiety; physical abuseDepression; anxiety; physical abuse Psych hospitalizationsPsych hospitalizations Anxiolytic medication somewhat helpfulAnxiolytic medication somewhat helpful Wants opioid medicationWants opioid medication Goal – “Get rid of all pain now”Goal – “Get rid of all pain now”

History of Present IllnessHistory of Present IllnessHistory of Present IllnessHistory of Present Illness

How Do You Feel???How Do You Feel???

         

How Do You Feel?How Do You Feel?

Acute PainAcute Pain

Temporally related to injuryTemporally related to injury Resolves during the healing processResolves during the healing process Usually responds to analgesics and/or Usually responds to analgesics and/or

treatment of underlying causetreatment of underlying cause

Chronic PainChronic Pain

Persistent pain serving no useful biological Persistent pain serving no useful biological purposepurpose

Outlasts the healing processOutlasts the healing process Cutoff? Cutoff?

Usually 6 monthsUsually 6 months Often refractory to analgesicsOften refractory to analgesics Underlying cause may be hard to identifyUnderlying cause may be hard to identify

Chronic Pain - PsychosocialChronic Pain - Psychosocial

Pain becomes primary Pain becomes primary focus of lifefocus of life

Altered social, family, Altered social, family, work roleswork roles

Depression, anxiety, Depression, anxiety, panicpanic

Preexisting psych issues Preexisting psych issues in certain patientsin certain patients

Chronic Pain - BehavioralChronic Pain - Behavioral

Learned, reinforced pain behaviorLearned, reinforced pain behavior Limited coping skillsLimited coping skills Unconscious enabling by family, Unconscious enabling by family,

friendsfriends Compensation concerns – WC, Compensation concerns – WC,

litigationlitigation

Chronic Pain SyndromeChronic Pain Syndrome

Pain lasting six months or morePain lasting six months or more Pain assumes a primary importance in the Pain assumes a primary importance in the

patient’s lifepatient’s life Psychological comorbiditiesPsychological comorbidities Dysfunction in multiple life domainsDysfunction in multiple life domains

Medical-Palliative ModelMedical-Palliative Model

PAIN Diagnosis TreatmentPain Relief

RecoveryOf

Function

Medical-Palliative Pain CareMedical-Palliative Pain Care

Often successfulOften successful High patient satisfaction; minimal expenseHigh patient satisfaction; minimal expense But: But:

Treatment cannot end until pain stops.Treatment cannot end until pain stops. Pain is subjective, placing patient in control of treatment, Pain is subjective, placing patient in control of treatment,

but without responsibility.but without responsibility. Pain and dysfunction are rewarded by additional attention Pain and dysfunction are rewarded by additional attention

& medication.& medication.

Medical-Palliative ModelMedical-Palliative Model

NO RELIEF or INCOMPLETE

RELIEFPAIN Diagnosis Treatment

Rehabilitation ModelRehabilitation Model

RecoveryOf

Function

PAINNO RELIEF or INCOMPLETE

RELIEFDiagnosis Treatment

Rehabilitative Pain CareRehabilitative Pain Care

Recovery of function is the primary treatment Recovery of function is the primary treatment goal.goal.

Pain relief is not promised, and may or may Pain relief is not promised, and may or may not occur.not occur.

Patients must take an active role in improving Patients must take an active role in improving their own function and capacity.their own function and capacity.

Where To Begin?Where To Begin?

Understand the Understand the patientpatient

DiagnosisDiagnosis

Understand the nature of the patient’s problemUnderstand the nature of the patient’s problem Careful physical examinationCareful physical examination ImagingImaging Ancillary testing (EMG/NCS, etc.)Ancillary testing (EMG/NCS, etc.) Specialist evaluation where neededSpecialist evaluation where needed

Psychological DiagnosisPsychological Diagnosis

Screen for depression, anxietyScreen for depression, anxiety Psychiatric hospitalizationsPsychiatric hospitalizations

Screen for history of Screen for history of abuseabuse Ask about prior diagnoses Ask about prior diagnoses Ask about prior treatment Ask about prior treatment

PsychiatryPsychiatry CounselingCounseling RxRx

Specialist evaluation where neededSpecialist evaluation where needed

Motivational IssuesMotivational Issues

Income / insuranceIncome / insurance Workers’ CompensationWorkers’ Compensation

LitigationLitigation Family attitudesFamily attitudes

Enabling, over-supportive families need education Enabling, over-supportive families need education to stop encouraging pain behaviorsto stop encouraging pain behaviors

Evaluate The SituationEvaluate The Situation

Can you treat the problem adequately?Can you treat the problem adequately? Will psychological status and motivation allow Will psychological status and motivation allow

the patient to participate?the patient to participate? Is specialist input needed?Is specialist input needed?

Define GoalsDefine Goals

““Before you begin, Before you begin, have an end in have an end in mind.”mind.”-- Astute fortune cookie -- Astute fortune cookie

authorauthor

Define GoalsDefine Goals

Patient’s goalsPatient’s goals Pain relief; pain medication; ? improved functionPain relief; pain medication; ? improved function

Your goalsYour goals Reduced pain; improved function; appropriate Reduced pain; improved function; appropriate

medication usemedication use Time frame for treatment?Time frame for treatment? If treatment fails, next steps?If treatment fails, next steps?

Discuss GoalsDiscuss Goals

Bring your goals and the patient’s goals Bring your goals and the patient’s goals into into congruencecongruence

If you are working from different sets of If you are working from different sets of goals, success is unlikelygoals, success is unlikely

Agree upon goals and Agree upon goals and write them downwrite them down Copies to patient and medical recordCopies to patient and medical record

Sample Treatment PlanSample Treatment Plan

Patient name, MR#, birth datePatient name, MR#, birth date DiagnosesDiagnoses GoalsGoals

Specific treatments for each goalSpecific treatments for each goal Identify who is responsible for each treatment Identify who is responsible for each treatment Time frame for each goalTime frame for each goal

Reassessment intervalReassessment interval

Be FirmBe Firm

Patient should participate in Patient should participate in entireentire treatment treatment planplan

Reassess pain and function periodicallyReassess pain and function periodically If no improvement, consider terminating If no improvement, consider terminating

ineffective treatmentineffective treatment

Set LimitsSet Limits

““I’m out of my pain medication early”I’m out of my pain medication early” ““Picking and choosing” from prescribed Picking and choosing” from prescribed

treatments treatments Missed appointmentsMissed appointments Emergency department or urgent care overuseEmergency department or urgent care overuse Inappropriate treatment of staffInappropriate treatment of staff Excessive or unnecessary telephone callsExcessive or unnecessary telephone calls

Set LimitsSet Limits

Enforce adherence to all clinic and medication Enforce adherence to all clinic and medication policiespolicies

Exceptions reinforce unwanted behaviorExceptions reinforce unwanted behavior Variable intervalVariable interval

Set out policies clearlySet out policies clearly Spell out consequences at the start of treatmentSpell out consequences at the start of treatment

Controlled SubstancesControlled Substances

Use with defined purpose and goals in mindUse with defined purpose and goals in mind Educate patient on appropriate useEducate patient on appropriate use For chronic conditions, minimize short-acting For chronic conditions, minimize short-acting

medicationsmedications Use Use and enforce and enforce controlled-substance controlled-substance

agreement/contractagreement/contract Reevaluate efficacy periodicallyReevaluate efficacy periodically

Dependence And ToleranceDependence And Tolerance

Tolerance = need for more drug to achieve Tolerance = need for more drug to achieve same effectsame effect May lessen if pain is abruptly relievedMay lessen if pain is abruptly relieved

Physical dependence = physiologic adaptation Physical dependence = physiologic adaptation to regular dosageto regular dosage Withdrawal syndrome if abruptly discontinuedWithdrawal syndrome if abruptly discontinued

Addiction / AbuseAddiction / Abuse

Most patients with acute or chronic pain Most patients with acute or chronic pain do notdo not develop addictiondevelop addiction

Hallmarks of addiction:Hallmarks of addiction: Compulsive useCompulsive use Loss of control of use: self-escalationLoss of control of use: self-escalation Use despite harmUse despite harm Use despite lack of benefitUse despite lack of benefit

Do not use addiction as reason to withhold Do not use addiction as reason to withhold acute acute treatmenttreatment

Abuse / Addiction / DiversionAbuse / Addiction / Diversion

Provide an appropriate and safe taper of medicationProvide an appropriate and safe taper of medication Can usually taper 30% every 1-2 daysCan usually taper 30% every 1-2 days Can use clonidine, low-dose benzodiazepines to attenuate Can use clonidine, low-dose benzodiazepines to attenuate

withdrawalwithdrawal Get specialist’s advice for tapering methadoneGet specialist’s advice for tapering methadone

Give patient phone numbers for drug rehabilitation Give patient phone numbers for drug rehabilitation programsprograms

Continue other parts of treatment, if patient is willingContinue other parts of treatment, if patient is willing Document your actions in the medical record; if Document your actions in the medical record; if

appropriate, notify EDappropriate, notify ED

Measuring EfficacyMeasuring Efficacy

Analog pain scale (0-10)Analog pain scale (0-10) Percent change in pain (better or worse)Percent change in pain (better or worse)

These two scales don’t measure the same thing!These two scales don’t measure the same thing! Vocational statusVocational status

Return to work; improved activityReturn to work; improved activity Psychosocial statusPsychosocial status

Drug ScreensDrug Screens

Use when initiating treatment, or when diversion Use when initiating treatment, or when diversion or other drug abuse is suspectedor other drug abuse is suspected

Urine Mass Spectroscopy Panel Urine Mass Spectroscopy Panel is the most is the most effective testeffective test Indicate specific drugs you are looking forIndicate specific drugs you are looking for

Routine screening?Routine screening?

Protect YourselfProtect Yourself

Document all opioid prescriptionsDocument all opioid prescriptions Keep photocopies where possibleKeep photocopies where possible Copies can be scanned into WISCR-Copies can be scanned into WISCR-

ITIT Document rationale for prescribingDocument rationale for prescribing Document efficacy, with periodic Document efficacy, with periodic

reevaluationsreevaluations

Psychosocial IssuesPsychosocial Issues

Is the patient emotionally stable?Is the patient emotionally stable? Can the patient think straight?Can the patient think straight? Are life circumstances stable or chaotic?Are life circumstances stable or chaotic? Can the patient participate fully and effectively Can the patient participate fully and effectively

in treatment?in treatment?

Psychosocial IssuesPsychosocial Issues

If answer is no: If answer is no: Refer for psychiatric evaluation and/or counselingRefer for psychiatric evaluation and/or counseling Make this a Make this a condition condition for other treatmentfor other treatment If a treatment is unlikely to succeed, defer it until If a treatment is unlikely to succeed, defer it until

patient’s psychological status has stabilizedpatient’s psychological status has stabilized

PsychopharmacologyPsychopharmacology

AntidepressantsAntidepressants TCAs best for pain, but bad side effectsTCAs best for pain, but bad side effects SSRIs, SNRIs helpful for anxiety and SSRIs, SNRIs helpful for anxiety and

depressiondepression Antiepileptics – can help “stabilize Antiepileptics – can help “stabilize

mood”mood” Specialist referral where neededSpecialist referral where needed

Personality DisordersPersonality Disorders

Borderline: perhaps the toughestBorderline: perhaps the toughest Labile moodLabile mood Staff “splitting”Staff “splitting” May threaten suicide if not granted their requestsMay threaten suicide if not granted their requests

If they do not withdraw that threat, call 911 for emergency If they do not withdraw that threat, call 911 for emergency psychiatric workup psychiatric workup

Again: Again: set limitsset limits and enforce them! and enforce them! Don’t let yourself be manipulatedDon’t let yourself be manipulated

Terminating Pain TreatmentTerminating Pain Treatment

If pain treatment is ineffective or patient does If pain treatment is ineffective or patient does not/cannot participate, it can be terminated.not/cannot participate, it can be terminated.

For drug therapy, use safe taper as aboveFor drug therapy, use safe taper as above Refer for drug rehab if neededRefer for drug rehab if needed Refer for psych, other services as neededRefer for psych, other services as needed Encourage patient that you will still provide Encourage patient that you will still provide

other aspects of careother aspects of care

Pain Center ConsultationPain Center Consultation

Refer for: Refer for: Complex cases needing interdisciplinary careComplex cases needing interdisciplinary care Diagnostic dilemmasDiagnostic dilemmas Questions about appropriate managementQuestions about appropriate management Specific procedures (epidurals, nerve blocks, Specific procedures (epidurals, nerve blocks,

trigger point injection, etc.)trigger point injection, etc.) Diagnostic testing (EMG/NCS, tilt table, QST)Diagnostic testing (EMG/NCS, tilt table, QST)

RecapRecap

The patient needs to The patient needs to shareshare responsibility for responsibility for care.care.

Use a functionally-oriented care model.Use a functionally-oriented care model. Set goals and assess progress. Set goals and assess progress. Enforce your rules.Enforce your rules. Don’t be manipulated. Don’t be manipulated. You can terminate pain treatment if it isn’t You can terminate pain treatment if it isn’t

working.working.

Guidelines For Treatment With Controlled Substance MedicationsGuidelines For Treatment With Controlled Substance Medications

Available online - CRIT: Pain Management GuidelinesAvailable online - CRIT: Pain Management GuidelinesStandard Register: UWHC Form # 4002754Standard Register: UWHC Form # 4002754

Other ReferencesOther References

CRIT Web page: Guidelines: CRIT Web page: Guidelines: Pain Pain Management GuidelinesManagement Guidelines

Health Facts For You: search under Health Facts For You: search under PainPain Guidelines for the Assessment and Treatment Guidelines for the Assessment and Treatment

of Chronic Pain: of Chronic Pain: www.wisconsinmedicalsociety.orgwww.wisconsinmedicalsociety.org

Rudin NJ (2001). Chronic pain rehabilitation: Rudin NJ (2001). Chronic pain rehabilitation: principles and practice. principles and practice. WMJWMJ 100(5): 36-43, 100(5): 36-43, 66.66.