Pain Management: A Primary Care Perspective

Educational Objectives

The goal of this program is to improve the management of chronic pain. After hearing and assimilating this program, the clinician will be better able to:

1.   Distinguish chronic pain from acute pain.

2.   Identify candidates for opioid use.

3.   Establish a care plan for patients experiencing chronic pain, based on clinical findings.

4.   Describe the effect of cognition and perceptions on chronic pain.

5.   Outline behavior modification techniques for comorbid pain and psychiatric disorders.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any per­sonal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and plan­ning committee reported nothing to disclose.

Acknowledgments

Dr. Timming spoke in Minneapolis, MN, at the 9th Annual Psychiatry Update, Selected Topics for the Non-Psychia­trist, presented April 24, 2009, by HealthPartners Medical Group & Clinics. Dr. Covington was recorded in Beach­wood, OH, at Pain Management for the Primary Care Physician, presented October 11, 2008, by Cleveland Clinic Anesthesiology Institute. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Managing Chronic Pain Without Losing Your Mind or License

Richard C. Timming, MD, Clinical Assistant Professor of Physical Medicine and Rehabilitation, University of Minnesota Medical School, Minneapolis, and Specialist, Physical Medicine and Rehabilitation, HealthPartners Medical Group and Clinics, St. Paul, MN

Chronic pain: persistent pain (continuous or recurrent) of sufficient duration and intensity to adversely affect pa­tient’s function or quality of life; focus treatment on pain and function; according to Institute for Clinical Systems Improvement (ICSI), chronic pain not time contingent, but pain lasting >4 wk more likely chronic pain than acute pain

Acute pain: specific and treatable cause; support patient with pain medication; duration of pain short

Benign chronic pain: cause often unknown; pain may persist after apparent healing (of, eg, skin changes in posther­petic neuralgia); high prevalence of undertreated pain

Assessment of chronic pain: determine amount of pain and function; determine whether pain caused by systemic disease (eg, cancer, abdominal aortic aneurysm); determine whether patient has neurologic disorder requiring sur­gical evaluation (eg, cauda equina syndrome); identify psychologic barriers or social factors that may delay recov­ery; patient history and examination  — identify red flags (eg, age ³50 yr, immunosuppression, history of cancer); significant trauma; dribbling urine (or numbness and weakness in limbs with urine retention); perform 2-min neu­romuscular examination; order diagnostic tests; use assessment tools for pain and function; establish care plan

Barriers to recovery: stress; anxiety; depression; sleep disorder; fear avoidance (ie, avoidance of activity due to fear of increasing pain); substance abuse; litigation; failed surgery or history of delayed recovery; personality disorder; language barrier; cultural barrier; unrealistic expectations; low motivation or poor compliance

Diagnostic tests: “we order too many tests”; most findings of imaging studies include signs of normal aging; 33% to 66% of tests not necessary

Biologic mechanisms of pain: neuropathic pain  — treatments specific; eg, complex regional pain syndrome, multi­ple sclerosis; muscle pain  —  eg, fibromyalgia; treatments specific; inflammatory pain  —  eg, arthropathies; mechan­ical pain  —  eg, low back and neck pain; types of pain can overlap

Pain assessment tools: pain inventory  —  eg, pain scale (eg, rating pain from 0-10); Oswestry Disability Index  —widely used for neck and back pain; according to some, “not very responsive”; Brief Pain Inventory  —  pain, func­tion, sleep, and mood rated from 0 to 10; helpful for setting patient goals; DIRE score  —  used to select patients for opioid use; considerations include diagnosis (lower score indicates less likelihood of benefit from opioids [as in, eg, fibromyalgia, migraine headaches]), intractability (eg, opioids may be more appropriate in patients who “have tried everything”), risk factors (eg, personality disorder, history of alcohol addiction, low reliability, poor social support), and efficacy; opioid agreement  —  patient agrees to obtain opioids only from primary care physician and from one pharmacy; opioids to be discontinued if patient takes illegal drugs or fails to follow care plan (eg, fails to attend physical therapy)

Chronic pain care plan: make diagnosis; set goals (eg, reduce pain score by 50%, improve function score); increase physical activity (eg, walking); manage stress and related disorders (consider cognitive behavioral strategies); de­crease pain; follow up; treatment strategies  —  limited data about cold laser therapy and epidural steroid injections; surgery; complementary medicine; massage therapy; cognitive behavioral strategies; acknowledge pain as real; in­volve patient in care plan; advise patients to be active and “don’t let pain be your guide”; use time-contingent med­ications; fear avoidance leads to physical deconditioning; assist patients in returning to work

Goals of opioid pain medication: reduce pain intensity; improve function; follow primary care model (eg, check DIRE score, work with referring physician and patient)

Problems with opioids: between 1997 and 2004, opioid prescriptions increased 108%; problems include  —  hyperalgesia with use of higher doses; hypogonadism; ineffectiveness in opioid-resistant pain, eg, fibromyalgia; side effects; increasing rates of abuse and misuse; lack of data about efficacy in improving function; addiction  —  neurobiologic, multifactorial disease characterized by loss of impulse control and compulsive drug use despite harm; physical dependence  — more common; often leads to withdrawal symptoms when drug stopped abruptly; pseudoaddiction  —  “they need more rather than less”

Opioid management: thoroughly assess patients for pain diagnosis; justify and document use of opioid; have care plan that involves team of health care givers (eg, physical therapist, behavioral health therapist); assess risk; keep thorough records; follow up often to ensure patient adhering to opioid agreement (eg, obtaining opioids from one physician and pharmacy, ordering refills in person); watch for abuse of illicit drugs and misuse of medication; when to refer to addiction specialist  —  history of substance abuse or prescription drug misuse; patient increases dose in spite of physician’s recommendations; failure to adhere to physical therapy or behavioral health programs; poor compliance with treatment program; social instability; risky behavior; proper documentation  —  analgesia (eg, Brief Pain Inventory score); adverse drug effects; activity (function); aberrant drug-related behaviors

Management of chronic pain: comprehensive evaluation (eg, psychologic assessment); history and physical exami­nation; make diagnosis; recommended physical activity (eg, walking program); behavioral health therapy; set care plan and specific goals; follow up and measure function and pain

Case example: man, 25 yr of age, with chronic back pain due to disputed work injury (followed by motor vehicle collision 1 yr later); lumbar x-rays and magnetic resonance imaging (MRI) normal; exhibits pain behavior (eg, groaning); gives vague responses when asked about previous treatment; requests oxycodone (eg, Oxycontin) and oxycodone and acetaminophen (eg, Percocet); man diagnosed with nonspecific back pain; plan of care  —  physical therapy; behavioral health therapy; drug screening; opioid agreement; man currently on oxycodone, 80 mg bid; other tests  —  Brief Pain Inventory score, 7.5; interference score high; Patient Health Questionnaire (PHQ)-9 score, 3; DIRE score, 11 (not suitable candidate for opioids); plan to taper opioids by 20% per week; 1-wk follow-up  —Brief Pain Inventory score, 9.5; interference score high; drug screening test negative for oxycodone, and positive for marijuana and cocaine; oxycodone discontinued; nonopioid program offered

Teasing Out the Psyche in Chronic Pain Patients

Edward C. Covington, MD, Director, Neurological Center for Pain at the Cleveland Clinic, Cleveland, OH

Introduction: medications used for pain (eg, opioids, antiepileptic drugs, antidepressants, intrathecal morphine) re­sult in »30% improvement at 1 yr; many patients remain miserable and dysfunctional; consider psychogenic pain; unexplained pain not necessarily psychogenic (may be due to neurobiologic process); psychologic issues  —  eg, self-image, perception of health, and others; incentives for being well or sick; personality strengths and weak­nesses; comorbid psychiatric illness

Cognition and pain: misunderstanding and misinformation lead to inactivity; inactivity leads to deconditioning and cycle of escalating pain and disability (fitness and education important); perceptions and pain  —  aversive quality of pain modified by its interpretation; catastrophic interpretations (eg, “these exercises must be tearing something loose”) worsen pain; patients who perceive pain as mysterious or as indicator of body damage, patients who per­ceive themselves as fragile or helpless, and patients who view world as indifferent, hostile, or without opportunity have more pain, more suffering, more depression, and less function; patients with perceptions of helplessness often do little to make themselves well; fear  —  patients believe that all pain results in body damage; fosters decondition­ing and fear of movement; mood  —  modulates pain; study found patients who read funny short stories had higher pain thresholds than those who read sad short stories

Depression and pain: mutually reinforcing; study of neurology outpatients  —  patients who were depressed at intake remained depressed at 1 yr (especially if pain did not improve); patients with pain at intake remained in pain at 1 yr (especially if depression did not improve); depression contributes to intractability of pain, and pain contributes to intractability of depression; must treat depression and pain; study found amount of psychologic distress affects out­come of spinal pain; patients with chronic pain who become unable to function likely to have emotional and physi­cal suffering; depression, substance use, and anxiety disorders common comorbidities in patients with chronic pain; 55% to 87% of patients in pain clinics have depression (28%-62% have anxiety disorders)

Hyperalgesia: visceral  —  conditions, eg, irritable bowel syndrome, noncardiac chest pain, nonulcer dyspepsia due to encoding innocuous stimuli as pain; responds to drugs used to treat neuropathic pain (eg, tricyclic antidepressants, selective norepinephrine reuptake inhibitors [SNRIs], gabapentin, pregabalin); somatic  —  lack of structural expla­nation in 85% of cases of chronic back pain (leading pain-related cause of disability in industrial countries); lack of structural abnormality in patients with fibromyalgia; patients reported pain with application of low levels of quanti­fied thumb pressure (higher cortical activity confirmed on functional magnetic resonance imaging [fMRI]; implies sensitization of central nervous system [CNS]); consider sensitization of CNS in patients who complain of back pain discordant with back pathology

Interactions of conditions: consider positive feedback loop in which pain, depression, anxiety, and insomnia worsen each other; “helping one usually helps the others”

Addiction: without addiction recovery, difficult to achieve lasting benefits in patients with chronic pain and comorbid addiction; screening questions  —  1) “has anybody close to you expressed concern about your use of alcohol, drugs, or medications?” 2) “have you had any concerns about your use of alcohol, drugs, or medications?” 3) “does your spouse think you have a drinking problem?”; correlates highly with diagnosis

Psychogenic pain: may be facile explanation for mysterious conditions; pain behavior that does not reflect activity in pain transmission pathways unlikely to improve with treatment (eg, surgery, spinal cord stimulation); signs of non­organic pain complaints  —  regression unexplained by pathology (eg, pain questionnaire for patient with back pain completed by spouse); extreme somatic preoccupation (eg, patient discusses only medications, procedures, and symptoms); inconsistencies with time, audience, and anatomy (eg, patient walks with aid of cane only when spouse present); pain disproportionate to disease; response to extreme trauma  —  study of 520 patients found posttraumatic stress disorder, dissociation, somatization, and affect dysregulation highly interrelated; extreme trauma may in­volve neuroplasticity that produces spectrum of unexplained physical complaints (eg, posttraumatic stress symp­toms and mood dysregulation)

Environmental contingencies: rewarding behavior often leads to repeated behavior; behaviors not rewarded become extinguished; changes often occur without awareness of subject or person who reinforces; rewarding maladaptive behavior (eg, advising patient to “take it easy”) done out of compassion rather than malice; timing of reward critical (patients do things to feel better in short-term that make them feel miserable in long-term)

Management of comorbid pain and psychiatric disorders: address pain, mood, and depression for good outcome; targets  —  pain; function; affect; inappropriate health care utilization; comorbid psychiatric disorder; multifacto­rial illness requires multifactorial treatment; fitness; psychotherapy to improve coping and to treat psychologic symptoms; medications to reduce pain and anxiety, and improve mood

Reconditioning psychotherapy: important; helps improve feelings of helplessness, hopelessness, and fragility; en­ables patients to participate in enjoyable activities; self-regulation training  —  many techniques (eg, biofeedback, yoga, guided imagery, meditation); reduce anxiety, anger, autonomous hyperactivity, musculoskeletal tension; behavior modification  —  reward well behaviors and small successes; distinguish help from enabling; educate families and staff that enabling leads to regression; ignore maladaptive behaviors; different patients need differ­ent kinds of psychotherapy

Medication management: polypharmacy common; consider using drugs that treat >1 condition (eg, antiepileptic agents treat anxiety and pain; SNRIs and tricyclic antidepressants treat anxiety, pain, and depression) to reduce health care costs and toxic complications

Suggested Reading

Aragona M et al: DSM-IV-TR "pain disorder associated with psychological factors" as a nonhysterical form of so­matization. Pain Res Manag 13:13, 2008; Deyo RA et al: Low back pain. N Engl J Med 344:363, 2001; Deyo RA et al: Overtreating chronic back pain: time to back off? J Am Board Fam Med 22:62, 2009; Dionne CE et al: Predicting long-term functional limitations among back pain patients in primary care settings. J Clin Epidemiol 50:31, 1997; Dolce JJ et al: Prediction of outcome among chronic pain patients. Behav Res Ther 24:313, 1986; Fishbain DA et al: Male and female chronic pain patients categorized by DSM-III psychiatric diagnostic criteria. Pain 26:181, 1986; Meghani SH et al: Predictors of Resolution of Aberrant Drug Behavior in Chronic Pain Patients Treated in a Struc­tured Opioid Risk Management Program. Pain Med Jun 11, 2009 (Epub ahead of print); Moore JE et al: Outpatient group treatment of chronic pain: effects of spouse involvement. J Consult Clin Psychol 53:326, 1985; Osborne TL et al: Psychologic interventions for chronic pain. Phys Med Rehabil Clin N Am 17:415, 2006; Silverman SM: Opioid induced hyperalgesia: clinical implications for the pain practitioner. Pain Physician 12:679, 2009; Sinnakaruppan I: Changing perceived coping in chronic pain patients using a newly developed scale: a pilot study. Int J Rehabil Res 25:345, 2002; Timming RC et al: Inpatient treatment program for chronic pain. Wis Med J 79:23, 1980; Van der Kolk BA et al: Dissociation, somatization, and affect dysregulation: the complexity of adaptation of trauma. Am J Psychiatry 153:83, 1996; Zelman DC et al: The effects of induced mood on laboratory pain. Pain 46:105, 1991.