patient selection what you must know 2010 nans joel r saper, md, facp, faan director/ founder...
TRANSCRIPT
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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
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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
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END OF PRESENTATION!
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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…
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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!
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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.
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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
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Barriers and Conflicts
• Opioid Dependency
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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
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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
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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)
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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)
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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
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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
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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!
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Many use drugs to have a life; others to hide from life!
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Barriers and Conflicts
• Opioid Dependency
• The “PROBLEM PATIENT”
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“It not so much what’s done to the head but to whose head it’s
done”!Saper, 1992
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Identifying the problem patient is critical
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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)
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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
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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
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Some patients become “illness locked”!
“ I want to feel better, but not necessarily GET
better!”
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Some patients cannot/won’t get better!They are not good procedural
candidates!
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“Conversations With Borderlines, Narcissists, Sociopaths, Addicts,
Felons and Other Self-Loathing and Good Friends”
JRSAPER
Highlights from…
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TOP 20 QUOTES FROM BPD PTS
“Shove your behavior contract up your a-- !”
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TOP 20 QUOTES FROM BPD PTS
“I want my Demerol”
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TOP 20 QUOTES FROM BPD PTS
“You’re calling me a drug addict, aren’t you?”
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“My Oxy fell down the toilet”
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TOP 20 QUOTES FROM BPD PTS
“My dog ate my narcotics”
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Are there breeds of dogs that love opioids ONLY…?
• OxyCollie
• OxyRetriever
• PercoSpanial
• VicoCocker
• Morphi-Yorkie
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Dogs That Treat Misuse
•
• DetoxerBoxer
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“How did that cocaine get in my urine?”
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“Nurse Ratshitt, did you put cocaine in Herbie’s urine?!!!!”
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“My pain is no better, but I need more Oxycontin because it makes
ME feel better”.”
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“Let’s face it, I like the buzz!”
--a headache patient on Actiq
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“Let’s face it, it takes 30 seconds to say yes, but 30 minutes to say
no!”
Dr Howard Heit, 2004
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“Sometimes the best medicine is to stop taking something”
Ashleigh Brilliant
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“The head speaks when the mouth cannot”!
Saper, 2006
(Said in a moment of unrestrained psychobabble!)
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“Treating pain is a thinking sport”
Dr Jeff Okeson, 2003
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“Treating some borderline patients is a blood sport!
J Saper, 2006
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“What do you mean I have a borderline personality? I’ve never even been to Mexico!”
--a perplexed borderline patient
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“Justice will be served only when the last lawyer on earth has been strangled with the intestines of
the last politician”!
George Bernard Shaw
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“AIM HIGH”
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THE BITTER END… at long
last