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"WHAT IS PAIN, HOW DO WE ASSESS AND
TREAT IT, AND WHAT IS THE ROLE OF
OPIOIDS?"
Katherin Peperzak, MDActing Assistant Professor
UW Dept of Anesthesia & Pain Medicine
NAOEM 2017 Annual Meeting
✓ No financial conflicts of interest
✓ Many non-opioids are “off-label” for pain
✓ Much of pain treatment “best practice” has limited or no RCT
evidence-based support
✓ Much has been borrowed from David Tauben, MD, UW Chief
of Pain Medicine (with permission!)
Disclosures
1. Be able to access and deploy current evidence based treatment guidelines for pain management.
2. Use, interpret, and respond effectively to information derived from pain assessment tools that include measures of function, mood, sleep, risks, and adherence.
3. Know how and when to access pain expertise when chronic pain is not well controlled despite reasonable treatment efforts and/or when significant treatment risks are identified.
4. Take pride, not dread, your patients suffering with chronic pain
Objectives
What is Pain?
Cartesian View of Pain
6
Nociception Without Pain (15th century)
7
“People with something better to do
don’t hurt as much.”
University of Washington: Wilbur Fordyce, c.1970
Henry Beecher, MD
Anzio Beach, Italy 1942
“THERE IS A COMMON BELIEF that wounds are inevitably associated with pain, and, further, that the more extensive the wound the worse the pain. Observation of freshly wounded men in the Combat Zone showed this generalization to be misleading.”
Nociception Without Pain (1942)
Gate Theory
http://science.howstuffworks.com/life/inside-the-mind/human-brain/pain4.htm
What goes up must come down…
https://www.painscience.com/articles/pain-is-weird.php
“Once a danger message arrives at the brain, it has to answer a
very important questions: “How dangerous is this really?” In
order to respond, the brain draws on every credible information
– previous exposure, cultural influence, knowledge, other
sensory cues – the list is endless.”
-Lorimer Moseley
Pain really is in the mind, but not the way you think
TheConversation.com
When the knob gets turned up…
11
https://www.painscience.com/imgs/knob-pain-m.jpg
Pain modifies the CNS such that less
provocation can cause more pain
Any sensory experience of greater amplitude,
duration, or area than expected from a
particular peripheral input may reflect central changes
But how do we diagnose it?
Centralization Continuum
PROPORTION OF INDIVIDUALS IN CHRONIC PAIN
STATES THAT HAVE CENTRALIZED THEIR PAIN
Peripheral Centralized
Acute pain Osteoarthritis SC disease Fibromyalgia
RA Ehler’s Danlos
Tension HA
Low back pain
TMJD IBS
Slide courtesy of Dan Clauw
13
From: Stanos et al. Rethinking chronic pain in a primary care setting.
Postgraduate Medicine 2016
Mixed pain
conditions with
multiple pain
pathophysiologies
such as chronic low
back pain
The “Loeser Onion”
“Unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” (IASP 1979)
Nociceptors selectively respond to noxious stimulation
What we observe during exam of our patients
Response to diminishment of one’s capacity
How Do We Assess Pain?
16
1. Pain intensity*
2. Interference with Enjoyment/Quality of Life*
3. Interference with (General) Function*
4. Pain Impact on Mood
• Anxiety, Depression, PTSD
5. Pain Interference with Sleep
6. Treatment Risks
• Medical: ie. Sleep Apnea (i.e STOP-BANG)
• Addictions (i.e. ORT, SOAPP-R, COMM, DIRE)
How pain should be measuredLinks to pdfs available: search “UW Pain Provider Toolkit”
And, what exactly does “10/10” Pain mean?
18
So for “≥12/10”: “worse than… nothing else matters” ?
3-item “PEG” TOOL
19
Krebs et al. 2009
✓AnxietyGAD-7 (or PHQ-4)
✓DepressionPHQ-9 (or PHQ-4)
✓PTSD
Identifying co-occurring MOOD diagnoses
PC-PTSD Screen
In your life, have you ever had any experience that was so frightening, horrible, or upsetting, that in the past month you:
1. Have had nightmares or thought about it when you did not want to?
2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?
3. Were constantly on guard, watchful, or easily startled?
4. Felt numb or detached from others, activities, or your surroundings?
PHQ-4
“When your brain is on fire I can’t help your pain…”
Clinical Report
PainTracker™
• Clinically
actionable data/
just-in-time
decision-making
• “Big-data” for
registry
research, QI,
and ACO
reporting
How Do We Treat Pain?
Acute Pain: a “symptom”
Expected to resolve
Goal is facilitation of recovery from the underlying injury,
surgery, or disease
Chronic Pain: a “disorder”
Illness or injury resolved but pain persists
Goal is improved function
Palliative Care: end-of-life goals
Support and treatment
Goal of care is comfort
“Kind” of pain determines treatment goals
24
1. Medical specialties
2. Nursing
3. Pharmacy
4. Physical therapy
5. Occupational therapy
6. Behavioral health
7. Social work
8. Chaplain
9. Addiction (when assessment & management has gone wrong)
Health Professionals Involved In Pain Management
25
Cognitive:
• Identify distressing negative cognitions and beliefs
Behavioral approaches:
• Mindfulness, relaxation, biofeedback
Physical:
• Activity coaching, graded exercise land & aquatic with PT, class, trainer, and/or solo
Spiritual:
• Identify and seek meaningfulness and purpose of one’s life
Education (patient and family):
• Promote patient efforts aimed at increased functional capabilities
Non-drug Multimodal Analgesia
26
Argoff CE, et al. Pain Medicine 2009;10(S2):53–S66.
Opioids: ≤ 30%
Tricyclics/SNRIs: 30%
Anticonvulsants: 30%
Acupuncture: ≥ 10+%
Cannabis: ? 10-30%
CBT/Mindfulness: ? 30-50%
Graded Exercise Therapy: variable
Sleep restoration: ≥ 40%
Hypnosis, Manipulations,Yoga: “+ effect”
CHRONIC PAIN TREATMENTS“COMPARING” EFFECTIVENESS
Extrapolated averages of reduction in Pain Intensity
Turk, D. et al. Lancet 2011; Davies KA, et al. Rheum. 2008;
Kroenke K. et al. Gen Hosp Psych. 2009; Morley S Pain 2011;
Moore R, et al. Cochrane 2012; Elkins G, et al. Int J Clin Exp
Hypnosis 2007.
Post Herpetic Neuralgia
NNT* 2.1-2.7
Diabetic Peripheral
Neuropathy
NNT 1.2-1.5
Atypical Facial Pain
NNT 2.8-3.4
Fibromyalgia/Central Pain
NNT 1.7
* Number needed to treat: (NNT)
“TRICYCLIC” ANTIDEPRESSANT DRUGSAnalgesic Effectiveness
SOME EVIDENCE:
• Osteoarthritis
• Low Back Pain
• Chronic Pelvic Pain
• Headache
CONFLICTING EVIDENCE:
• Radiculopathy
NO EVIDENCE, but does
help with sleep and mood:
• HIV and Chemotherapy PN
Saarto T, Wiffen PJ. Cochrane 2007
Diabetic Neuropathy
•Duloxetine
Fibromyalgia
•Milnacipran
•Duloxetine
•Venlafaxine
OTHER ANTIDEPRESSANT DRUGS
Clinical Effectiveness Trials
SNRIs SSRIs
• Diabetic Neuropathy– NNT 5-15
• Fibromyalgia
– No evidence of benefit
in reduction of pain
intensity
Norepinephrine is a
principal neurotransmitter
facilitating the
“descending inhibitory
systems”
Multimodal benefits:
✓ PAIN, SLEEP, & MOOD
Antidepressant Analgesia
Millan MJ Prog Neurobio 2002
Ossipov MH, et al. Curr Opin Support Palliat Care 2014
DeFelice M, et a. Pain 2011 (see commentary by Dickenson)
• Antidepressants that elevate synaptic norepinephrine(TCAs > SNRIs) are effective analgesics
• Sedating antidepressants are useful agents to improve both sleep initiation and maintenance
• Anticholinergic side-effects are most common with TCAs• Nausea is common with SNRIs• Dose related QTc prolongation occurs with TCAs >SNRIs• Warn patient and family about risks of suicidality when
any antidepressant is prescribed• Mania may be precipitated by any category of
antidepressant
RX CLINICAL KEY POINTS
ANTIDEPRESSANT ANALGESIA
31
Gabapentin
Pregabalin
Well studied
Fewer side effects than
other anticonvulsants
Limited drug-drug side
effects
100% excreted in the urine
Often used off-label
RX CLINICAL KEY POINTS: “GABAPENTINOIDS”PROTOTYPIC CA++ CURRENT MODULATORS
32
➢Side-effects:
Weight Gain
Edema
Cognitive slowing
Dizziness/Ataxia
Twitching
Suicidality
Pharmacodynamics (“mechanism”):
Selective inhibitory effect on
voltage-gated calcium channels
containing the α2δ-1 subunit.
Larsen MS, et al. Res. Pharm Res. 2014
•Lack of evidence for sustained benefits
•Rebound insomnia
•Risk of over-sedation especially when combined with
opioids
•Complicating development of tolerance, dependency, and
addiction.
Use of benzodiazepines for sleep & anxiety are not
recommended in chronic pain
BENZODIAZEPINES
33
Antispasm drugs have limited evidence for effectiveness,
are predominantly sedative, and add polypharmacy to
chronic pain management with little benefit.
Carisoprodol should never be used because of no benefit
and high risk.
When true spasticity is present, as in spinal cord injury and
multiple sclerosis, baclofen and tizanidine may be useful.
Avoid abrupt withdrawal off baclofen because of the
potential for severe rhabdomyolysis and fever.
“Anti-spasm” Drugs
34
van Tulder MW et al. Cochrane Library 2008
Procedures
35
http://minnlawyer.com/files/2014/09/Can-of-Worms.jpg
May have role in selected patients
-Epidural steroid injections
-Sympathetic nerve blocks
-Joint Injections
-Peripheral nerve injections
-Radiofrequency ablation
-Trigger point injections
In general, procedures tend to be most useful in those we see early on in pain treatment
Procedures
36
What is the role of opioids?
65 mg of morphine per fluid ounce
From Battlefields
United States Civil War Casualties
Legal (without prescription)
until 1914:
Harrison Narcotics Tax Act
Marketing
still, today,
with discount
coupons!
Accessed Memorial Day, May 29, 2017
…to the general store…to the Internet: Americans Love Their Opioids
OPIOIDS FOR CHRONIC PAIN The Clinical Conundrum
Annals of Internal Medicine • Vol. 162 No. 4 • 17 February 2015
Chronic pain management today: a shocking over-reliance on opioids
40
Every year, 16,000 people die from prescription drug
overdose and 500,000 come to Emergency Departments
due to over-use of opioid pain medications in the US
Source: IMS Prescription Audit 2012
3rd Largest Epidemic In America Influenza Pandemic (1918: 500,000)
HIV (1981-2005: 550,000);
Prescription Opioid ODs (1999-2014: 165,000, and counting)
41
OD DEATHS Ripple Across America
NYT 1/20/2016
OPIOID OVERDOSE RISK by Morphine Equivalent Dose
0
1
2
3
4
5
6
7
8
9
10
<20 mg/day 20-49 mg/day 50-99 mg/day >=100 mg/day
Risk Ratio
Dose in mg MED
Risk of Adverse OD Event
Dunn 2010
Bohnert 2011
Gomes 2011
Zedler 2014
Point of
deflection
9-fold
increased
risk
Calculate the “MED”
Methadone
<20 mg 4x
>20-40 mg 8x
>60-80 mg 10x
>80 mg 12x
AMDG on-line calculator
www.agencymeddirectors.wa.gov
Administration
• On initial visit
• Prior to LA Opioid Therapy
Scoring
• 0-3: low risk (6%)
•> 8: high risk (> 90%)
Assessing Opioid MISUSE Risk
“Opioid Risk Tool” Webster & Webster 2005
Sleep Disordered Breathing on Opioids
Walker JM., et al. J
Clin Sleep Med 2007
46
www.agencymeddirectors.wa.gov/Files/2015AMDGOpioidGuideline.pdf
“Bending The Curve” Of The PRESCRIPTION Opioid Crisis
47
Source: Jennifer Sabel PhD Epidemiologist, WA State Department of Health, April 18, 2014
Jones, 2013; Muhuri et al., 2013
And so it goes, Opioid Overdoses Continue on the Rise
49
Source: C. Banta-Green WA State Department of Health
50
1. When to initiate
or continue
1. Selection,
dosage,
duration,
follow-up, and
discontinuation
1. Assessing risk
and addressing
harms
12 Recommendations
3 Topic Areas
1. Patient engagement is crucial determinant of timing and ease
• Co-occurring severe psychiatric/behavioral issues may require formal detox program
• Patients with high fear and pain anticipation will benefit from concurrent behavioral health support
2. 5-10% reduction at scheduled intervals (weekly to quarterly)
• Set patient expectations early!
3. Clonidine to partially mitigate withdrawal symptoms
4. Buprenorphine induction and taper over 3-12 weeks
5. ALWAYS avoid benzodiazepines
•When benzos ALSO on board: choose the path that targets least risk (if possible to determine), and that is most easily accomplished (NOTE: neither is “easy”)
Tapering Opioids Isn’t Easy
IMPROVING ACCESS TO PAIN SPECIALISTS
UW TelePain
Contact Information: Cara Towle RN MSN [email protected]://depts.washington.edu/anesth/care/pain/telepain/index.shtml
or search:
uw telepain
Sessions:
(Pacific time)
Wednesdays
noon-1:30
Thursdays
7:00-8:00 am
University of Washington
“Pain Medicine Provider Toolkit”
http://depts.washington.edu/anesth/care/pain/index.shtml
Access to
Evidence-based
Pain Care
Reflections on the Management of Pain
“Doctors pour drugs of which they know little, for
diseases of which they know less, into patients –
of which they they know nothing at all.”
“The secret of the care for the
patient is in caring for the patient.”
Francis Peabody, 1927
attributed to Voltaire, mid-18th century
John Loeser, MD University of Washington
“Chronic Pain is not a state of opioid deficiency.”