Embracing the Management of Chronic

PainCOL Diane Flynn, MC, USA

LTC Mary V. Krueger, MC, USAUSAFP Scientific Assembly

7 April 2009

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Outline.

• Chronic pain concepts• Initial evaluation of patient with chronic pain • Treatment

– Nonpharmacologic– Pharmacologic

• Helpful tools

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Key Distinction.

Patients with Chronic Pain

90% of patients: easy to help

Biomedical model is useful

Pain is a problem

Complex Chronic Pain Patients

10% of patients: difficult to help

Biomedical model is iatrogenic

Pain is a potential solution

Chronic Pain

Red flags for Complexity.

• Belief that “pain means harm” and “all pain must go before return to work”

• Passive attitude toward rehabilitation, avoidance of normal ADLs

• Overprotective spouse• Poor work history, frequent job changes

Case.

• 24 yo active duty specialist, MEB pending

• Chronic mechanical LBP, fibromyalgia, trochanteric bursitis, trigeminal neuralgia

• PTSD related to sexual assault

History: Past Medical

• Specific diagnosis of underlying etiology helps to direct adjunctive therapy

• Past medical and surgical history• Comprehensive pain assessment*• Social history: Employment, legal history

(pending litigation), social network• Evaluation of occupational risks and ability to

perform dutiesPenny 1999; Level of Evidence : C

History: Pain Assessment

Pain Related History• Prior pain treatment and

results of this treatment• Adequate trial of non-opioid

therapy• Pain related fear• Interference with function:

Impact on work/family life• Review prior studies

Comprehensive assessment• Intensity of pain: 1 - 10*• Response to current pain

treatments• Other attributes of pain• Type of pain

– Nociceptive– Neuropathic

• Function in all domains*

Caldwell, Jensen, Peloso, Roth; Level of evidence: A

Breivik, De Conno, Jensen, Orgon, Serlin; Level of evidence: B

History: Psychiatric

• Depression– Frequently co-morbid with chronic pain– Presence can complicate chronic pain treatment– Inquire about prior suicidal ideation/attempt

• Anxiety disorders• Personality disorders

– Presence may be associated with manipulation, noncompliance, and impulsiveness

Carragee, 2005; Schultz 2004; Zautra 2005; Level of Evidence: B

History: Substance Abuse

• At risk for developing addiction to opioids– Young age– More recent history of abuse

• Consult with addiction specialist for co-management if history of substance abuse

Physical

• Thorough physical exam in every patient– Etiology of pain– Physical signs of substance abuse

• Mental Status Exam– Cognitive function– Anxiety– Depression– Other psychiatric disorders

Selected Studies

• Review any studies relating to source of pain– EMG– Radiologic studies: MRI, CT, plain films, etc

• Renal function• Liver function tests• Urine drug screen

– Presence of illicit metabolites– Be familiar with local sensitivity and specificity

Treatment Plan.

• Goal setting• Nonpharmacologic treatments• Pharmacologic treatment

– OTC meds– Prescription non-opioids– Opioids

All other problems

Pain

Patient’s perspective.

Self-management perspective.

Emotional problems

Family problems

Recreationalgoals

Financial/ Vocational

goalsDrugs/alcohol

Pain

Goal Setting.

• Help patients to identify their own goals, should be measurable and realistic

• Get family members involved• Should include many facets of life

– Exercise– Social/family– Vocation/avocational– Spiritual

Exercise Goals.

• Avoid telling patients to let pain be their guide.• Quota system:

– Set patient’s exercise baseline• Level of increased pain, weakness, fatigue. • Include aerobic, general strengthening, low level functional

activity

– Exercise program – six days per week• Start with ½ to ¾ of baseline• Increase incrementally with each exercise session, ie one

repetition, one minute, one flight of stairs per day• If patient cannot meet expected exercise on a given day,

maintain current level for a few days

Non-pharmacologic interventions.

• Exercise• Osteopathic manipulation• Biofeedback• Acupuncture• Ice/heat• Cognitive behavioral approaches

Pharmacologic approaches.

Table 1. — Three-step Analgesic Ladder*

Step Pain Medication

III Moderate to severe pain Non-opioids plus strong opioids

II Mild to moderate pain

Non-opioids plus opioids for moderate pain

I Mild pain Non-opioids

*In each step, adjuvants should be prescribed according to the clinical situations.

World Health Organization Analgesic Ladder.

Antidepressant use in Chronic Pain.

• For psychologic disorders– >50% of patients with chronic pain have major

depression– Depression decreases pain tolerance

• For sleep disturbance– 50% of chronic pain patients have sleep

disturbance• For neuropathic pain

Suggested Protocol for Opioid Therapy.

Trea tm en t S u ccess fu l D ose E sca la tion Trea tm en t F a iled

S tab le P h asem ain ta in s tab le m od era te d ose

D ose A d ju s tm en t P h ase(u p to 8 w eeks )

D ec is ion P h ase

Table 1. — Three-step Analgesic Ladder*

Step Pain Medication

III Moderate to severe pain Non-opioids plus strong opioids

II Mild to moderate pain

Non-opioids plus opioids for moderate pain

I Mild pain Non-opioids

*In each step, adjuvants should be prescribed according to the clinical situations.

When Pain Remains

Indications for Opioid Therapy

• Failure of relief of moderate to severe pain with non-opioid therapies*– Pharmacologic– Adjunctive therapies

• Inability to safely be treated with non-opioids • No absolute contraindications to opioids• Answers ethical imperative to relieve pain*

Breivik; Level of evidence: I

Joranson, Laval; Level of evidence: I

Contraindications to Opioids

Absolute• Allergy to opioid agents• Co-administration of

contraindicated drug• Active diversion of

controlled substances

Relative• Acute psychiatric instability• High suicide risk• Inability to manage opioid

therapy responsibly• Unwilling to comply with

treatment plan• Elderly patients• COPD patients• Patient with uncontrolled

sleep disorders • Intolerable adverse effects

Opioid Use for Non-Malignant Pain

• Tailor use to patient’s circumstances and characteristics of their pain

• Consider continuing/initiating adjuncts– Opioids are rarely the only treatment– Therapeutic exercise, biofeedback, CBT

• Acknowledge trial period of dosing• Choose initial dose and taper to effect/goals• Establish written plan to monitor progress*

Federation of State Medical Boards: Level of Evidence: C

Referrals

• Medical home key for success• Multidisciplinary team often necessary*

– Development of integrated treatment plan– Routine communication between team members

• Addiction specialist if evidence of substance abuse

• Pain management specialist

Becker, Flor, Malone, Guzman; Level of evidence: B

Patient Education

• Risks– Addiction– Side effects

• Benefits• Limitations• Importance of expectation management

– Primary goal is restoration of function– Important to be realistic / have common ground

Treatment Agreement

• Defines responsibilities of patient and provider

• Ensures common goals in objective form• Resources on CD:

– Sample pain agreements from MTFs– Sample agreement form– www.partnersagainstpain.com

Agreement Content

• Goals of therapy• Requirement for sole

provider• Limitation on dosage and

number of pills• Prohibition for use with

other substances• Need for periodic re-

evaluation• Prohibition for medication

sharing/sales

• Responsibility for safe keeping of medication

• Limitation on refills• Compliance with overall

plan• Role of random UDS• Acknowledgement of

safety issues• Consequences for non-

adherenece

Suggested Protocol for Opioid Therapy.

Trea tm en t S u ccess fu l D ose E sca la tion Trea tm en t F a iled

S tab le P h asem ain ta in s tab le m od era te d ose

D ose A d ju s tm en t P h ase(u p to 8 w eeks )

D ec is ion P h ase

Initiate Therapeutic Trial of Opioid.

Opioid selection, initial dosing and titration based on• Patient heath status• Previous exposure to opioids

– Low, standard dose for opioid-naïve patients– Previous effective dose for those with previous use

Strong recommendation, low quality evidence

Insufficient evidence to recommend• Short-acting vs long-acting opioids • As needed vs around-the-clock dosing

Choice of Agent.Long-Acting Agents

Consider– Long acting morphine, ie MS contin – good

standby strong recommendation, mod-quality evidence

Caution with– Methadone – dosing tricky, long and varied half-

life. Maximum recommend dosage 30-40 mg daily. Use only if familiar with its use and risks.

– OxyContin – avoid – high abuse risk, high cost– Transderm fentanyl – avoid – high abuse risk,

high overdose potential, high cost

Choice of Agent.Short-acting Agents

• Consider – hydromorphone or oxycodone– Avoid prescribing more than 4 doses per day;

consider long-acting if 4 doses insufficient• Avoid

– Darvocet – major cause of drug-related deaths• Propoxyphene• Acetaminophen

– Demerol – American Pain Society, ISMP recommends against use as analgesic

• Unique neurotoxicity• If used, limit to <48 hrs, <600 mg daily

Choice of AgentBreakthrough Pain.

Controversial– May consider for patients on around-the-clock

opioids with breakthrough painweak recommendation, low-quality evidence

– If used, recommend no more than average of 1-2 tabs per day (30-60 tabs per month, in addition to long acting agent)

Ceiling opioid dosage?.

• No evidence of benefit with opioid dosages >180 morphine-equivalents per day

• Potential harms of high-dosage opioids:– Hormonal effects – Immunosuppression– Hyperalgesia

Expert consensus

Monitoring

• Progress towards goals• Titrate to effect• Assess adherence• Assess efficacy• Address adverse effects• Need for referral to specialized services

Progress Toward Goals

• Ensure identification of medical home– Follow-up schedule based on patient risk factors,

titration of medication, side effects, pain control– Frequency of follow up may change based on

clinical course• Progress towards goals involves evaluation of:

– Functioning in ADLs at home and at work– Sense of well being/worth– Control of pain to tolerable level

Titrate to Effect (1 of 2)

• Utilize medication with best pain relief and fewest adverse effects at lowest dose

• Optimal level of analgesia and function obtained in absence of unacceptable side effects

• Utilize equianalgesic conversion table when switching between preparations

Titrate to Effect (2 of 2)

• Evaluate breakthrough pain for new etiology• Repeated dose escalations may be marker for

substance abuse or diversion• Consider opioid rotation if inadequate benefit

or intolerable adverse effects– Incomplete cross tolerance to opioid effects– Reduce calculated equianalgesic dose by 20 – 25%

Assess Adherence/Abuse

• Document adherence with medication– Pill counts– Urine drug screens

• Document adherence to treatment plan– Compliance with adjunctive therapies– Follow-up with referrals

• Assess patient motivation/barriers to adherence

• Assess for behaviors predictive of addiction

Predictors of Misuse

• Illegal or criminal behavior• Dangerous behavior: MVA, suicide attempt• Behavior suggestive of addiction

– Multiple episodes of prescription “loss”– Refusal to perform UDS– Deterioration of home or work functioning

• Aberrant behavior– Requesting more of the drug– Requesting specific drugs– Missing appointments

Adverse Effects (1 of 2)

• Constipation– Initiate bowel regimen for those at risk– Increase fluid/fiber, consider stool softeners

• Nausea and vomiting– Tends to diminish over initial weeks

• Sedation or clouded mentation– Decreases over time– Patient must take precautions driving/operating

machinery until this resolves

Adverse Effects (2 of 2)

• Hypogonadism– Fatigue, decreased libido, sexual dysfunction– Test for hormonal deficiencies if symptoms present

• Itching– Tends to diminish over initial weeks– Due to histamine release with morphine

• Respiratory depression– Worse when doses titrated too quickly– Caution in patients with sleep apnea, COPD

Suggested Protocol for Opioid Therapy.

Trea tm en t S u ccess fu l D ose E sca la tion Trea tm en t F a iled

S tab le P h asem ain ta in s tab le m od era te d ose

D ose A d ju s tm en t P h ase(u p to 8 w eeks )

D ec is ion P h ase

Stable Phase.

• Maintain stable moderate dosage• Monthly refills

– Assess and document pain score and side effects of opioid– Treat side effects– Recommend patient for comprehensive follow up if

indicated• Comprehensive follow up

– Require at least every year and optimally every 3 months– Assess pain relief, well being, achievement of treatment

goals, functioning and quality of life– Toxicology screening, if indicated

Low-quality evidence

Suggested Protocol for Opioid Therapy.

Trea tm en t S u ccess fu l D ose E sca la tion Trea tm en t F a iled

S tab le P h asem ain ta in s tab le m od era te d ose

D ose A d ju s tm en t P h ase(u p to 8 w eeks )

D ec is ion P h ase

Indications to Stop Opioids.

• Pain is resolved• No progress toward therapeutic goals• Inability to tolerate side effects• Serious or repeated aberrant behaviors

– Request for early renewals – does not usually require discontinuation

– Doctor/pharmacy shopping– Positive urine tox screen

Strong recommendation, low-quality evidence

• Periodic requests for escalation of opioids• Periodic threats to find another doctor• Little sustained progress toward goals • Did not follow through on multiple referrals

for mental health counseling

Clinical Course.

Clinical Course.

• Required mental health referral as condition of continued opioids– Social worker helped with goal

setting

• Required pain specialist referral– Suspected opioid associated hyperalgesia and

recommended taper off opioids for 3+ months prior to evaluation for other treatment

• Started slow taper late December 08– Much support given, declined ASAP referral– Reached crisis off opioids – ASAP evaluation – inpatient

program of detox and treatment of sexual trauma

Conclusion

• Family physicians are well qualified to manage chronic pain in most patients

• Medical home with team approach is key in chronic pain management

• Emphasis on function and well-being, rather than pain level will increase chance of success

• Use caution with opioid dosages over 120 morphine equivalents per day

Resources

• VA/DoD CPG summary for the management of opioid therapy for chronic pain; March 2003

• Sample MTF pain agreements• Side effect tables for pain medications• Internet links to:

– Clinical Guidelines for Use of Chronic Opioid Therapy in Chronic Noncancer Pain: Feb 2009

– AAFP online: Assessment and Management of Chronic Pain: June 2008; link to podcasts

– Partners against pain website