patient selection what you must know 2010 nans joel r saper, md, facp, faan director/ founder...

Patient SelectionWhat You Must Know

2010 NANS

Joel R Saper, MD, FACP, FAAN

Director/ Founder Michigan Head Pain & Neurological Institute

Ann Arbor, Mi

Clinical Professor Neurology, MSU

DISCLOSURE !!!

•Honoraria: GlxSK, Merck,AstraZ,Allergan, OrthoMcNeil,Elan,Pfizer, Pharmacia

•Advisory Brd/Consultant:Allergan, OrthoMcNeil,Medtronic, Advanced Bionics, AZ, Ely Lilly, Pfizer, Esai, Pozen

•Research Grants: GlxSK,Merck,AstraZ,Abbott,Allergan, OrthoMcNeil, Esai, Pfizer, Pharmacia , Elan, Pozen, Medtronic, Advanced Bionics

jrsaper@aol.com

END OF PRESENTATION!

Interventional Procedure Success, and Adequate

Reimbursement, Depend on Fulfillment of Key Clinical

Outcomes:• Sustained reduction of pain

• Improved Function

• Overall cost reduction(utilization)

• These are achieved…

Successful Outcomes For all Interventional Procedures, and

Adequate Reimbursement, Depend on Fulfillment of Key

Clinical Outcomes:

• IDing of proper diagnosis and symptom complex in moderately refractory patients, at a time and evolution of the illness that assures reversibility

• Surgical/Procedural competence

• Selecting patients without barriers or conflicts to sustained benefit!

Barriers and Conflicts

• Wrong Diagnosis• In case of headache and occipital n. stim: must be

reasonably certain that the occipital nerve stim is a conduit to trigeminal mediated pain via dorsal horn modulation, or in 2nd and 3rd order trigeminal neuronal systems.

• The cervical dorsal horn is a therapeutic locus for trigeminal and occipital pain modulation via the O.N.

C2-3 & TRIGEMINAL/CERVICAL

COMPLEX

• Stimulation of C2-3 roots activates trigeminal complex (Goadsby, 2001)

• Suggests chronic stimulation could sensitize 2nd and 3rd order neurons, activating migraine or other HA mechanisms

Barriers and Conflicts

• Opioid Dependency

SYNDROME OF MEDICATION OVERUSE HEADACHE

Characteristics of Rebound Headache

• Occurs in patients with pre-existing HA

• Regular intake, more than 2-3d/wk, for months

• A self-sustaining rhythm of predictable, reliable & escalating HA frequency & med. use

• Refractory to otherwise appropriate symptomatic & preventive treatments

• Med withdrawal results in escalation of HA

Saper JR. 1983,1992,1999

MEDICATION OVERUSE HEADACHE, IHS,2004

Diagnostic criteria:

•Intake (triptans, ergots, opioids) on > 10 d/mo on a regular basis for > 3 mo

•15 d/mo for simple analgesics

•HA has developed or markedly worsened during overuse

•HA resolves or reverts to previous pattern within 2 mo after D/C

Applies to:

•Ergotamine, triptan, analgesic, opioid, & combination medication overuse HA

Opioids and the BrainReview of literature

• Opioids can cause receptor hypersensivity, opioid induced hyperalgesia (Mao et al,2002)

• Glutamate induced apototic cell death(Mao.2002)

• Induce CGRP increase in dorsal horn( Meng and Porecca, 2004)

• Morphine activates glia and increases pro-inflammatory cytokines(Watkins, 2002)

• Pro-nociceptive cholecystokinin (CCK) is upregulated in the rostral ventromedial medulla (RVM) during persistent opioid exposure

• CCK activates descending RVM pain facilitation, enhancing pain transmission and hyperalgesia (Ossipov,2004)

Opioids and the BrainReview of Literature

• Long-lasting receptor change after initial exposure to morphine(Lim,et al,Mao, 2005)

• Numerous endocrine disturbances

• Age dependant tolerance: exceptional receptor sensitivity and tolerance in adolescents(Buntin-Mushok, 2005)

• Opioid induced MOH more likely to be unrelieved following D/C than with triptans and ergots(Lake 2005; others)

• Prevents response to parenteral NSAIDS (Jakubowski,et al 2005)

Opioids: Endocrine/Immune System Effects

•In animals, opioids increase GH, inhibits LH, FSH, TSH

•Opioid induced hypogonadism d/t central suppression of gonadotropin releasing hormone

•75% of men have clinically significant lowered testosterone levels

•Loss of muscle strength, compression fractures, osteoporosis, galactorrhea, etc,

Katz,et al, 2009, Clin J Pain; Maggi, 1995; Kavelaars,1991

REBOUND: A Neurobehavioral Disorder

• Not all pts with daily/frequentHA overuse drugs

• Physical (receptor) alterations (Srikiatkhachorn, 1998, Mao,2003)

• Behavioral – excessive/obsessive drug-taking, anticipatory anxiety, fear of pain (cephalgiaphobia), “orality/security dynamic”

Saper et al, Cephalalgia,2006

In HA patients, and perhaps others, opioid dependence

induces progression of pathology, alterations in personality, a prolonged

craving and reliance on the tranquilizing effects, well

beyond the analgesic need. Getting better poses a

conflict!

Many use drugs to have a life; others to hide from life!

Barriers and Conflicts

• Opioid Dependency

• The “PROBLEM PATIENT”

“It not so much what’s done to the head but to whose head it’s

done”!Saper, 1992

Identifying the problem patient is critical

PSYCHOBIOLOGY OF PAIN• Psychological variables modulate PAG and nociceptive neurons in

dorsal horn (Fields, 1997)

– Bidirectional control over pain transmission (somatosensory, cortical, limbic via PAG, engaged by psychological factors)

– Physiological mechanisms convert psychological distress to painful symptomatology (Fields, 1997)

– Limbic enhanced pain via neuroplastic mechanisms(Rome,2002)

– Stress evokes proinflammatory cytokines (Watkins, 2005)

The Troubled Patient Must be Recognized and Confronted Early

• Overt drug misuse/ addictive disease• Severe anxiety / depression/ somatization• “Pain Theater” starring the Drama Queen/King and cast of supporting

enablers and sympathizers• Missed visits• Lost/ “ran short” of scripts• Noncompliance• Anger• Family dysfunction• Usually Axis ll, Cluster B

How can some patients say they are better?

• Disability lost• Performance expectations: job, family, marital• No more opioids• Relinquishing special status/protections/reduced

expectations• Some spouses/relatives are only attentive when partner is

ill• Illness can be the glue that binds a weak relationship Chronic impairment and disability, role reversals and

drug dependency may lock even motivated people into a sick role

Some patients become “illness locked”!

“ I want to feel better, but not necessarily GET

better!”

Some patients cannot/won’t get better!They are not good procedural

candidates!

“Conversations With Borderlines, Narcissists, Sociopaths, Addicts,

Felons and Other Self-Loathing and Good Friends”

JRSAPER

Highlights from…

TOP 20 QUOTES FROM BPD PTS

“Shove your behavior contract up your a-- !”

TOP 20 QUOTES FROM BPD PTS

“I want my Demerol”

TOP 20 QUOTES FROM BPD PTS

“You’re calling me a drug addict, aren’t you?”

“My Oxy fell down the toilet”

TOP 20 QUOTES FROM BPD PTS

“My dog ate my narcotics”

Are there breeds of dogs that love opioids ONLY…?

• OxyCollie

• OxyRetriever

• PercoSpanial

• VicoCocker

• Morphi-Yorkie

Dogs That Treat Misuse

•

• DetoxerBoxer

“How did that cocaine get in my urine?”

“Nurse Ratshitt, did you put cocaine in Herbie’s urine?!!!!”

“My pain is no better, but I need more Oxycontin because it makes

ME feel better”.”

“Let’s face it, I like the buzz!”

--a headache patient on Actiq

“Let’s face it, it takes 30 seconds to say yes, but 30 minutes to say

no!”

Dr Howard Heit, 2004

“Sometimes the best medicine is to stop taking something”

Ashleigh Brilliant

“The head speaks when the mouth cannot”!

Saper, 2006

(Said in a moment of unrestrained psychobabble!)

“Treating pain is a thinking sport”

Dr Jeff Okeson, 2003

“Treating some borderline patients is a blood sport!

J Saper, 2006

“What do you mean I have a borderline personality? I’ve never even been to Mexico!”

--a perplexed borderline patient

“Justice will be served only when the last lawyer on earth has been strangled with the intestines of

the last politician”!

George Bernard Shaw

“AIM HIGH”

THE BITTER END… at long

last