reducing the risk of chronic pain and opioid use disorders ... · morlion b, coluzzi f, aldington d...
TRANSCRIPT
![Page 1: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/1.jpg)
Reducing the Risk of Chronic Pain and Opioid Use Disorders
Dr. Maureen Allen CCFP-EM(PC) FCFP
Chronic pain and Palliative care
October 2019
Promoting a SAFE-ED Approach to ACUTE pain
![Page 2: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/2.jpg)
No Disclosures
![Page 3: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/3.jpg)
![Page 4: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/4.jpg)
![Page 5: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/5.jpg)
What do we know
• Pain is the most common condition we see in clinical practice
• It’s also the only condition that we can say with certainty, we’ve been there
• Yet…
• Very little training
![Page 6: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/6.jpg)
Fact checking: Oct 2019
• We know how to reduce the risk of chronic pain and opioid use disorders
• WE understand the forces that are driving it
• The factors that increase the risk
• How to approach it
![Page 7: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/7.jpg)
Evidence is possibility.
It only has power if we use it.Kwick, 2017
![Page 8: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/8.jpg)
What I hope you learn
• What is Pain chronification ?
• What Factors increase it ?
• What forces drive it ?
• What to do when it happens?
• How to minimize it (SAFE-ED)
2015-2016 8
![Page 9: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/9.jpg)
Melissa
• 22 yo female• ORIF forearm Aug 2019 (altercation)• Surgeon: “Healing perfect”• No CRPS/No Infection/No C-spine• Pain 15/10 along incision “distressed”• Arm/incision look OK • Hyperalgesia• PMedHx: Anxiety, depression• Medications:• Seroquel 100mg qhs, Cannabis 4-5gm
![Page 10: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/10.jpg)
How Does Pain Communication Work?
2015-2016 10
Brain Interpretation:• How big is the threat?• What is the appropriate
response?
Higher-Learning Circuitry
NociceptiveCircuitry
• Injury• Illness• Surgery• Unknown
![Page 11: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/11.jpg)
Lets dig deeper
PAIN is triggered“Threat”
INFLAMMATORY RESPONSE
MAINTAIN HOMEOSTATIC BALANCE
(Survival and protection)
GLIAL cell activation
Neurobiology and ACUTE PAIN:Here’s what we know
![Page 12: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/12.jpg)
How cells communicate in the nervous system“All aboard"
MONTREAL
Neuronal
Chemokines, cytokines
GLIAL CELLS:Non-NeuronalGLIAL CELLS:PASSENGERS
![Page 13: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/13.jpg)
GLIAL CELL DYSREGULATION
(persistent neuroinflammation)
INFLAMMATORY RESPONSE
SENSITIZATION(synaptic plasticity)
LOSS OF NOCICEPTIVE
CIRCUIT REGULATION
HIGHER-LEARNING CIRCUITS
TAKEOVER
Pain Chronification
On going pain
“The fundamental problem regarding inflammation is not how often it starts, but how often it fails to subside”.
(Nathan and Ding 2008)
Trigger
Glial cell Activation
Pain resolves
Homeostasismaintained
Chronic pain is a GLIOPATHY not a NEUROPATHY
![Page 14: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/14.jpg)
When pain becomes chronic the peripheral neuroanatomy becomes less important and central mechanisms such as
central sensitization, neuroinflammation and psychological factors (fear, anxiety, pain avoidance) gradually take over necessitating a shift in management directed
more at the CNS .
Take Home MESSAGE
CHALLENGE
WHAT IS THEIR “READINESS” TO MOVE FROM A “FIX IT” TO “I NEED TO MANAGE IT”?
HEALTH CARE PROVIDERS NEED TO WORK TOGETHER WITH THE PATIENT
![Page 15: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/15.jpg)
ACUTE PAIN TREADMILL
![Page 16: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/16.jpg)
When do goals of care shift from ACUTE to CHRONIC?
2 weeks
![Page 17: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/17.jpg)
ANY ACUTELY Painful Condition Can lead to chronic pain
ACUTEPAIN
CHRONICPAIN
Pain Chronification
Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current Medical Research and Opinion. 34:7,1169-1178. (2018) DOI: 10.1080/03007995.2018.1449738.
“The normal, predicted physiological response to an adverse chemical, thermal, or mechanical stimulus” IASP
“Pain without biological value that has persisted beyond the normal tissue healing time” IASP
![Page 18: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/18.jpg)
Pain Chronification: What force matters most ?
Fiebich BL, Akter S, Akundi RS. The Two-hit hypothesis for neuroinflammation: Role of exogenous ATP in modulating inflammation in the brain. Front. Cell Neurosurgery. 2014; 260. Online access. DOI:10.3389/fncel.2014.00260.
MEANING NOT MECHANISM
![Page 19: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/19.jpg)
2-Hit Hypothesis
FIRST HIT“PRIMES”
SECOND HIT“Disruptive
pain experience”
Recover Chronic pain
Fiebich BL, Akter S, Akundi RS. The Two-hit hypothesis for neuroinflammation: Role of exogenous ATP in modulating inflammation in the brain. Front. Cell Neurosurgery. 2014; 260. Online access. DOI:10.3389/fncel.2014.00260.
![Page 20: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/20.jpg)
ACUTEPAIN
CHRONICPAIN
#1What the patient brings
#2How they experience
Acute Pain
Factors that Increase the Risk of Pain Chronification
• Life story/experiences• “Habits and Behaviours”
Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current Medical Research and Opinion. 34:7,1169-1178. (2018) DOI: 10.1080/03007995.2018.1449738.
#3Our approach
Resolution0/10
![Page 21: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/21.jpg)
2-Hit Hypothesis
FIRST HIT“PRIMES”
SECOND HIT“Disruptive
pain experience”
Recover Chronic pain
Fiebich BL, Akter S, Akundi RS. The Two-hit hypothesis for neuroinflammation: Role of exogenous ATP in modulating inflammation in the brain. Front. Cell Neurosurgery. 2014; 260. Online access. DOI:10.3389/fncel.2014.00260.
![Page 22: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/22.jpg)
5 FORCES that DRIVE the “CHRONICITY” of chronic pain
(Protection and Survival)
1. Neuroinflammation (Glial cell dysregulation)
2. Central sensitization (pain amplification)
3. The messenger : Higher learning circuits (brain based) take over from the nociceptive regulation circuits
4. Brain/Pain Memory
5. Pain Protective Behaviours (Muscle memory, Movement memory)
![Page 23: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/23.jpg)
Resiliency and Vulnerability Factors
![Page 24: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/24.jpg)
Patient DEMOGRAPHICS
GENETICS/BIOLOGY
ENVIRONMENTEpigenetics
(environmental cues)
CHRONIC PAIN
• Genetics• Age (older)• Poor health status• Gender (female)
Acute Pain Characteristics
• Chaotic home • Adverse childhood experiences• Social support• Work satisfaction• Communication with HCP• Stress litigation• Level of education
PSYCHOSOCIAL FACTORS
DRUG FACTORSOpioids
PaclitaxelHIV meds
Immunotherapies
BRAIN FACTORSNeuroinflammationCentral sensitization
![Page 25: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/25.jpg)
#3: How we MANAGE ACUTE PAIN MATTERS!!!
• Do we stop and listen?
• Do we validate or dismiss?
• Poor management can contribute to significant morbidity
• Overuse of high risk medications can also contribute to morbidity and death (opioids, BZD, sedative-hypnotics)
Oyler DR, et al. Non Opioid Management of Acute Pain Associated with Trauma: Focus on Pharmacological Options. J Trauma Acute Care Surg.
79(3):475, September 2015
![Page 26: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/26.jpg)
We have a responsibility to……
• Manage risk • Manage expectations• Be more mindful of the “habits
and behaviours” we give patient’s to manage their suffering
• Help them address pain protective behaviours that could be driving pain
![Page 27: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/27.jpg)
PharmacotherapyPharmacotherapy:
TREATMENT GOALS
ACUTE PAIN
80-90% Pain reduction
MINIMIZE Sedation
Improve Function
CHRONIC PAIN AND
CHRONIC PAIN FLARE-UP
30-40% Pain reduction
AVOID Sedation
Improve Function
CANCER PAIN OR PAIN AT THE END
OF LIFE
80-100% Pain reduction
May Cause Sedation
May Compromise Function
• Lynch, Mary MD. Drugs and Therapeutics for Maritime Practitioners. Pharmacology of Chronic Pain. Vol 20, No 5/6 October/November, 1997.• National Opioid Use Guidelines for the safe and Effective Use of Opioids for Chronic Non-Cancer Pain. Hamilton: National Opioid Use Guideline Group; 2010.• Allen MA, Jewers H, McDonald JS. A Framework for the treatment of pain and addiction in the emergency department. J Emerg Nurs. Vol 40, Issue 6, pages 552-59. November 2014.
![Page 28: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/28.jpg)
Pain Protective Behaviours
• Muscle work
• Pain Tuck
• Pain avoidance (protection)
![Page 29: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/29.jpg)
General Approach to “all” pain
• Talking points (CBT: Re-framing)
• Interventions
• Alternative therapies
• Pharmacotherapy
• Risk Stratification
![Page 30: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/30.jpg)
![Page 31: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/31.jpg)
Pharmacotherapy
• Elia N, Lysakowski C, Tramer MR. Does multimodal analgesia with acetaminophen, nonsteroidal anti-inflammatory drugs, or selective cyclooxygenase-2inhibitors and patient-controlledanalgesia morphine offer advantages over morphine alone? Meta-analyses of randomized trials. Anesthesiology. 2005;103(6):1296-304.
• Allen MA, Jewers H, McDonald JS. A Framework for the treatment of pain and addiction in the emergency department. J Emerg Nurs. Vol 40, Issue 6, pages 552-59. November 2014.• Belgrade M, St. Marie B. Understanding and Managing Flares in Chronic Pain. Fairview Pain Management Centre.
How Complicated can it be?
![Page 32: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/32.jpg)
Pharmacological choices?• Acetaminophen (Tylenol)
• NSAID’s (Advil, Aleve etc)
• TCA (Elavil)
• Anticonvulsants (Lyrica, Gabepentin)
• Broad spectrum antidepressants
(Duloxetine, Effexor)
• Topicals
• Opioids (SA vrs LA)
• Cannabinoids (Smoke, drink or ingest) Maximum is <2 grams a day
• Lidocaine, Ketamine etc...
• Low dose naltrexone
• Gamma hydroxybutyrate (GHB)
• Lynch, Mary MD. Drugs and Therapeutics for Maritime Practitioners. Pharmacology of Chronic Pain. Vol 20, No 5/6 October/November, 1997.• Golberg et al. JAMA, 2004;292 2381-95.• Ware, Mark. Marijuana as medicine; does it have a future? Clin Pharmacol Ther 83(4): 515-517; 2008.
![Page 33: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/33.jpg)
Should they be used?
• It depends…
• Co-analgesic
• Right patient
• Right condition
• Right amount of time
![Page 34: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/34.jpg)
Opioid Analgesics
• Many forms
• Short-acting
• Long-acting
• Agonist/Antagonist
• Dual active
• Euphoric and non-euphoric
![Page 35: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/35.jpg)
Major complications of Opioid use are…
• Opioid induced pain
• Opioid addiction
• Opioid Diversion
2015-2016 35
![Page 36: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/36.jpg)
What is the RISK of Opioid Addiction when opioids are used to manage Acute Pain ?
NNH1:7864
ADDICTION needs:1. Time
2. Repetition3. Vulnerable brain DIVERSION more of a concern
Heins SE, et al, EARLY OPIOID PRESCRIPTION AND RISK OF LONG-TERM OPIOID USE AMONG US WORKERS WITH BACK AND SHOULDER INJURIES: A RETROSPECTIVE COHORT Injury Prev 22(3):211, June 2016Yearly DM, Green SM. Opioids and the emergency physician: Ducking between pendulum swings. Ann Emerg Med 2016 (In press) Pub Med ID 26973177.
![Page 37: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/37.jpg)
What is the NNH when opioids are used to manage Chronic Pain ?
NNH1:9-11
You have:1. Time
2. Repetition3. Vulnerable brain DIVERSION still a concern
Heins SE, et al, EARLY OPIOID PRESCRIPTION AND RISK OF LONG-TERM OPIOID USE AMONG US WORKERS WITH BACK AND SHOULDER INJURIES: A RETROSPECTIVE COHORT Injury Prev 22(3):211, June 2016Yearly DM, Green SM. Opioids and the emergency physician: Ducking between pendulum swings. Ann Emerg Med 2016 (In press) Pub Med ID 26973177.
Opioids-Pain-2017-Newsletter.pdf
![Page 38: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/38.jpg)
How long should opioid’s be used?
• It depends….
• Tolerance (days)
• Dependency (days)
• Addiction (months)
![Page 39: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/39.jpg)
If Discharged: How much opioid and for how long?
• Chai et al (2017)
• Acute fracture in 15 opioid-naïve patients (mean age 45 years; 60% male)
• As few as six pills may be sufficient for acutely painful conditions
Chai PR, et al. Oxycodone Ingestion Patterns In Acute Fracture Pain With Digital Pills. Anesth Analg 125(6):2105, December 2017
![Page 40: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/40.jpg)
Promote a SAFE-ED approach to ACUTE pain: Reducing the risk of Chronic pain and opioid use
disorders.
• Make them feel SAFE and cared for
• Calm “Worst-case Scenario” thinking
• Address pain specific Fear’s and pain protective behaviours
• Exam carefully for any new pathology or progression of a pre-existing disease
• Manage treatment Expectations
• Dispense small quantities of short-acting, non-euphoric opioids over a short period of time
![Page 41: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/41.jpg)
Melissa
• 22 yo female (ACE)
• ORIF forearm Aug 2019 (altercation)
• Surgeon: “Healing perfect”
• No CRPS/No Infection
• Pain 15/10 along incision “distressed”
• Looks OK
• PMedHx: Anxiety, depression
• Medications:
• Tylenol/NSAID/Seroquel 100mg qhs
![Page 42: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/42.jpg)
Talking points • Listen and validate suffering• Exam carefully• Address fears and Pain Protective
Behaviours• Re-framing: CBT• “Ask-tell-ask”
Interventions • Desensitization (OT)
Alternative therapies • Acupuncture
Pharmaceuticals • Topicals• TCA (sleep)
Risk Stratification • Cannabis/opioids
![Page 43: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/43.jpg)
Talking points
• Here’s what I know…..
• “What you feel is real, but it’d doesn’t always mean dangerous or bad”
• “When pain doesn’t go away it can feel chaotic”
• “You’re not causing damage by moving, it’s how you move that matters most”
![Page 44: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/44.jpg)
Summary
• What you say and do matters• Get good at talking with patient’s
about pain• Reach out to colleagues if you’re
unsure• “Care enough” to set boundaries
regarding high risk pharmacology • Manage risk if opioids and
cannabinoids are used• Never let a patient tell you how
to prescribe a dangerous drug
![Page 45: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/45.jpg)
Acute Pain
• “The normal, predicted physiological response to an adverse chemical, thermal, or mechanical stimulus” IASP
• More about tissue damage or potential damage
• NOCICEPTIVE circuitry > Higher-learning (protective)
• Gone in 3 months• Butler D, Moseley GL. Explain Pain. Noigroup Publications, Adelaide South Australia. ISBN-10 097509 100X. June 2003. • Allen MA, Jewers H, McDonald JS. A Framework for the treatment of pain and addiction in the emergency department. J Emerg Nurs. Vol 40, Issue 6, pages 552-59. November 2014.
Time
PainIntensity
10
00/10
3 monthsInjury
Illness
Surgery
Unknown
![Page 46: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/46.jpg)
Chronic “persistent” pain
• “Pain without biological value that has persisted beyond the normal tissue healing time” IASP
• Lacks acute warning function of physiological nociception
• More about CNS or HIGHER-LEARNING circuitry
Butler D, Moseley GL. Explain Pain. Noigroup Publications, Adelaide South Australia. ISBN-10 097509 100X. June 2003.
PainIntensity
TimeInjury
Illness
Surgery
Unknown
10
0
>3 months
5/10
![Page 47: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/47.jpg)
Chronic Pain “Flare-up”
• Often confused with acute pain
• NOT caused by a new condition or progression of a pre-existing condition
• Investigations unchanged
PainIntensity
Time
0InjuryIllnessSurgeryUnknown
Daily baseline pain5/10
Flare-up Pain15/10
• Allen MA, Jewers H, McDonald JS. A Framework for the treatment of pain and addiction in the emergency department. J Emerg Nurs. Vol 40, Issue 6, pages 552-59. November 2014.
• Belgrade M, St. Marie B. Understanding and Managing Flares in Chronic Pain. Fairview Pain Management Centre.
![Page 48: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/48.jpg)
Chronic pain can co-exists with ANY medical condition
• Diabetes
• Addiction
• Concussion
• “Arthritis”
• Migraines
• Degenerative Disc Disease
• Osteoarthritis
• Fibromyalgia
• Ehler-Danlos Syndrome
• Previous broken bones
• Spinal stenosis
• And many others
![Page 49: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/49.jpg)
BUT IT IS… a unique illness that requires a unique approach
Jeff
“Chronic pain”
Degenerative disc disease
Crohn’s Disease Alcohol use disorder Chronic pain
![Page 50: Reducing the Risk of Chronic Pain and Opioid Use Disorders ... · Morlion B, Coluzzi F, Aldington D et al. Pain chronification: What should a non-pain medicine specialist know? Current](https://reader034.vdocument.in/reader034/viewer/2022051813/6033bf80dddc672302645fd6/html5/thumbnails/50.jpg)
Who Has a VULNERABLE BRAIN?
Biology/Genes Environment
ADDICTION
Brain Mechanisms
DRUG• Genetics• Gender• Psychiatric disorders
• ACE• Chaotic home• Poor school performance• Peer support
• Delivery route• Brain effect
• Age