Chronic Pain Management A Structured ApproachDr Gordon IrvingMedical Director ,Swedish Pain Center.Clinical Associate Professor, University of Washington Medical School.

Lecturer Acorda, Xenoport Pain doc. 29 years and counting

Disclosures

For Providers www.swedish.org/pain “for referring physicians”

Videos Opioid prescribing, naïve and tolerant Adjuvants and antidepressants for chronic

pain Brain changes in chronic pain Spinal cord stimulators, intra-thecal pumps Acupuncture Ultrasound injections for pain

Structured Approach

Pre contemplative Passive, angry anxious victim, “fix

me” Contemplative

I know there must be something seriously wrong to have this much pain but the medications and injections are not helping.

Is there something else you could do?

Stages of Change

Action I am doing more I have made goals and am achieving them I do not need as many medications

Maintenance I am in a good program of self care. I know what to do if I flare up and how to avoid

it I am doing more now than I have done in

years

Stages of Change

For Patients www.swedish.org/pain “education and resources”

Videos CAM Fibromyalgia Opioids

www.swedish.org/stomp

Structured Approach

Introduction to the problem eg Anxiety and Depression

Practical ways to improve “Steps to Get There” Resources: active hyperlinks

Recommended reading Recommended web sites: e.g.PTSD

General Layout of STOMP

42-yr-old female with pain following MVA 5 years ago

Seen multiple doctors , tried acupuncture and chiropractic

She is disabled, irritable You review her hand carried records, extensive

work up including Xrays and MRI of C and LS spine

Multiple failed drug trials; only oxycodone helps a little

“No one is doing anything to help me”

Jane: Background

Jane: Current Symptoms

Sleep disturbance

“Pain all over” Fatigue

Persistent diarrhea Morning stiffness

Dry, itchy eyes Muscle tenderness Joint pain Tension headaches Depression and

irritability

Almost any activity makes her pain worse; now inactive Does not sleep well, does not feel rested upon

awakening Gained 40 lb since accident. BMI 35 Feels frustrated with herself for not coping better Appears depressed Doses of opioids have been escalating (numerous side

effects) Wants to be “fixed”

Initial Evaluation(Janet and Husband)

Walks in a stiff posture with limited movement of neck

Rubs neck frequently Walks in a guarded fashion Sighs Facial grimacing when gets in and out of chair Husband rolls his eyes when he observes her

“pain behaviors”

Jane’s Pain Behaviors

Jane’s Physical Examination

What would this consist of?

What if any laboratory test would you order?

Fibromyalgia tender points 14/18 positive

THE PRINCIPLES AND

PRACTICE OF MEDICINE

DESIGNED FOR THE USE OF PRACTITIONERS AND STUDENTS OF MEDICINE

BY WILLIAM OSLER, M. D.

FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS, LONDON PROFESSOR OF MEDICINE IN THE JOHNS HOPKINS UNIVERSITY AND PHYSICIAN-IN-CHIEF TO THE JOHNS

HOPKINS HOSPITAL, BALTIMORE, FORMERLY PROFESSOR OF THE INSTITUTES OF MEDICINE, McGILL UNIVERSITY, MONTREAL, AND PROFESSOR OF CLINICAL MEDICINE

IN THE UNIVERSITY OF PENNSYLVANIA, PHILADELPHIA

NEW YORK D. APPLETON AND

COMPANY 1892

William Osler

1849 - 1919

Neurasthenia appears to be the expression of a morbid, unhealthy reaction to stimuli acting on the nervous system

1. Sleeplessness is frequently concomitant 2. The majority are moody or depressed3. The aching pain in the back of the neck is

the most constant complaint4. There are spots of local tenderness in the

spine

The Principles and Practice of Medicine (1869)

fMRI Evidence for Pain Augmentation in Fibromyalgia Patients

1414

1212

1010

88

66

44

22

004.54.51.51.5 2.52.5 3.53.5

Stimulus Intensity (kg/cm2)Stimulus Intensity (kg/cm2)

Pai

n In

ten

sity

Pai

n In

ten

sity

Fibromyalgia

Control

Gracely et al. Arthritis Rheum. 2002;46:1333-1343.

1. That she has fibromyalgia, a disease that has no cure; suggest a handout, book, or Web site

2. That she has generalized pain syndrome of unclear etiology and will have to learn to live with it; and have her come back at your next routine check-up (3 mo)

3. That she has fibromyalgia syndrome (FMS); suggest further investigation and symptom management

What Do You Tell the Patient?

Population studies have showed that providing the FMS label did not increase illness behavior, disability, or office visits

Labeling the Patient

White KP, et al. Arthritis Rheum. 2002;47:260–265. [Evidence Level B]; Moldofsky H, et al. J Rheumatol. 1993;20:1935–1940. [Evidence Level B]

1. CBC, TSH, CRP, ?ANA2. Vitamin D 3. Possibly a sleep study4. Avoid over investigating

Appropriate Laboratory Workup

CBC = complete blood count; ESR = erythrocyte sedimentation rate; TSH = thyroid-stimulating hormone; CRP = C-reactive protein; ANA = antinuclear antibody; LP = lipoprotein; MRI C = cardiac magnetic resonance imaging; LS = lumbosacral.

Education www.swedish.org.pain

Video on fibromyalgia www.swedish.org/stomp

Look for comorbidities Anxiety PTSD Depression

Suggested Structured Approach

Few proven treatments in randomized controlled trials Amitriptyline1, Tramadol2, Cyclobenzaprine3

Duloxetine, Pregabalin Exercise4

Cognitive-behavioral interventions5

Most prescribed—anti-inflammatories Patient preference—opioids

Fibromyalgia: Treatment

1. O’Malley PG, et al. J Gen Intern Med. 2000;15:659–666 [Evidence Level A]; 2. Furlan AD, et al. CMAJ. 2006;174:1589–1594 [Evidence Level A]; 3. Tofferi JK, et al. Arthritis Rheum. 2004;51:9–13 [Evidence Level A]; 4. Busch A, et al. Cochrane Database Syst Rev. 2002;3:CD003786 [Evidence Level A]; 5. Goldenberg DL, et al. JAMA. 2004;292:2388–2395. [Evidence Level A]

Fibromyalgia: Treatment (cont)

Education Biofeedback Pacing Treat mood

disturbance Avoid opioids Avoid

benzodiazepines Exclusion diets

Cognitive restructuring

Group support Medications Exercise Low dose

naltrexone Vitamin D

Changes in Brain Gray Matter with Chronic Low Back Pain (CLBP)

Age related losses in gray matter =

0.5%/year

Chronic low back pain patients = 5.4% decrease

Reduced in bilateral prefrontal cortex and right thalamus

Impact of chronic low back pain is an additional 10 years of brain atrophy

Duration of chronic low back pain is a strong predictor of gray matter changes

Apkarian et al. J Neuroscience 2004

Achieving Goals

Change the way you think about your vices. Resisting temptation: more successful if

participants said “I don’t” eg I don’t eat sugar instead of “I can’t”

“I don’t” makes one feel empowered and better able to resist temptation J of Consumer Research Aug 2012

Accept pain as real Protect from excessive invasive

testing/procedures Get patient to set SMART goals

S= Specific: M=Measurable: A=Achievable: R=Realistic: T=Timely

Expect to treat, but not to cure Evaluate in terms of what they do, not what

they say Avoid opioids and benzodiazepines

Steps to Help Patients WithFibromyalgia

Life Satisfaction Wheel and SMART goals

Exclusion diets2 Weeks off

dairygluten

Reintroduce foodstuff “super sensitized

Get the patient “involved”

64 year old male BMI 42 Type 2 diabetes Painful peripheral neuropathy OA bilateral knees Co-morbidities

Smoking one pack a day Sleep Apnea Depression

Jim: Background

Stop smoking: Why? One hour post cigarette CO causes

decreased O2 to poorly perfused tissues “discs, tight muscles”

Interferes with metabolism of opioids You have a choice to smoke “I have a choice

to prescribe opioids and I elect not to for patients who are not taking an active role in their own health care”

Opioid lack, unlike insulin, is NOT life threatening

Jim Recommendations: Stop smoking

How? Make a SMART goal Set a quit date www.swedish.org/stomp “smoking chapter” Follow up 2 weeks

Nicotine gum; lozenge, nasal spray, inhaler, patch Buproprion SR 150mg Varenicline

Chandler MA, Chest. 2010;137(2)

Cysteine (Tabex) Weight Gain

Average 11lb end first year6-7 more pounds next 4 years

US Dept Health Human Serv. 1990

Jim: Stopping Smoking

“I need pain killers to exercise, then I can lose weight” Physical exercise by itself leads to <3% weight loss Answer: Decrease calories

Mediterranean diet “Paleo Diet” “New Atkins Diet” www.swedish.org/stomp

Combined exercise and decreased calories is best 10 mins 2-4 times a day better than single longer

sessionBurke L et al J Nursing Scholarship 2011.43(4):368-75

Jim Recommendations: Weight loss

Hooked on food

Foods dense in fat and sugar prompt striatum to produce endorphins “feel good” chemicals

Dopamine released goes to prefrontal cortex (decision making)

Feedback loops spur people to seek more and more

Get tolerance to the reward effect so have to eat more

Decreased reward system causes depression

Hooked on food

Morphine injected into striatum of brain in mice triggers binge like over eating.

Opioids work on the same pathways as fat and sugar

Opioid blockers can cause withdrawal type symptoms in obese mice

Congenital low dopamine D2 receptors increase risk of addiction to opioids and obesity

Behavioral therapySelf monitoringOnly take enough cash to the supermarketSmall meals frequentlyLearn other clues to over eating

“Smart aids”PedometerFitbit activity and sleepSmart phone appSmart provider encouragement

Jim: Weight loss

Participation in mindfulness based stress reduction for 8 weeks increases in grey matter concentration: hippocampus, post cingulate cortex, temporo-parietal junction and cerebellum Hotzel BJ, Psychiatry research: Neuroimmaging 2011;191:36-43

Changing the Brain

44 year old male Low back and bilateral leg pain Status post 3 back surgeries. Last one fusion

L4-S1 On 150 Morphine Equivalents a Day (MED)

opioid Clonazepam 1mg tid. Poor sleep Temazepam 20 mg hs Pain 9/10 Smoking BMI 28

Sam: Background

Benzodiazepines and Pain

Opioids and benzodiazepines are commonly prescribed together-

Lifetime prevalence non-medical sedative use among adults is 7% (according to NCS in US)

Most patients using BZs do not escalate dose, but long-term use is common and associated with adverse health effects, esp. older adults MVA, falls, fractures, dementia, global mortality,

poor driving reflexes.

Review the patient on the Washington Prescription Monitoring Program.

Do a urine toxicology screen Ask “what drugs do you expect we will find in your

urine?” Have the significant other there whilst you

are explaining the “plan”

Sam: Suggested Structured Approach

Patients w/ 2 or more Prescribers

HB 2876: Washington State Opioid Prescribing law Refer to a “specialist” for an opinion as to the

appropriateness of therapy and what other treatments Pain management specialist, rheumatologist,

anesthesiologist, physical medicine rehab, neurologist Or 18 hours CME pain management, within the last two

years 2 hours on long acting opioids

Sam: Suggested Structured Approach

SMART goals Patient decides: www.swedish.org/stomp Physician decides

Stopping smoking: have a stop date next visit Not stopping, or no goals identified and planned, start

decreasing opioids Encourage patient to buy a pain management

book “Managing pain before it manages you” Caudill $9-15 on

Amazon “The pain survival guide” Turk $6.50-15

Consider sleep study Obstructive or central sleep apnea or both

Sam: Suggested Structured Approach

Have significant other at initial visits to assess Physical function level Adherence to “the program” Support “too much or too little”

Sam: Suggested Structured Approach

Logical Evidence based Safe Gets patient involved “patient centered

health care” Gets the best results Least extra time for the provider

A Structured Approach

Be compassionate Be knowledgeable and have a “hook” Patient directed SMART goals

Structured Approach