Pointers in Pain Management

From “Chronic Pain: Challenges and Solutions for Primary Care,” sponsored bythe University of Minnesota Medical School, Minneapolis

Miles Belgrade, MD, Adjunct Professor, Department of Neurology, University of Minnesota Medical School and Medical Director, Fairview Pain Management Center, Minneapolis

Educational Objectives

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

1.   Distinguish between chronic and acute pain.

2.   Discuss the pitfalls or “seven deadly sins” in chronic pain management.

3.   Recognize flares of chronic pain and treat them appropriately.

4.   Identify forms of noncompliance in opioid users.

5.   Select patients for opioid use, based on risk and other factors.

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 following has been disclosed: Dr. Belgrade is on the Speakers’ Bureaus for Pfizer and PriCara. The planning committee reported nothing to disclose.

Acknowledgements

Dr. Belgrade spoke at Chronic Pain: Challenges and Solutions for Primary Care, presented October 30, 2009, by the Uni­versity of Minnesota Medical School and the Upper Midwest Chapter of the Society of American Pain Management Nurs­ing. The Audio-Digest Foundation thanks Dr. Belgrade and the sponsors for their cooperation in the production of this program.

Acute vs Chronic Pain

Definitions and characteristics: acute pain  —  has beginning, middle, and predictable end point; chronic pain  —  persists beyond expected time; independent of original cause; not curable; often becomes biopsychosocial problem

Pathophysiology of pain: glutamate  —  neurotransmitter contained in glutamate vesicles; mediates acute, normal, or adaptive pain; other neurotransmitters  —  eg, substance P, cholecystokinin, brain-derived neurotrophic factor, calci­tonin gene-related peptide; contained in dense-core vesicles; mediate chronic, inflammatory, persistent, neuro­pathic, pathologic, ongoing pain; families of nerve pairs carry predominantly glutamate or predominantly nonglutamate neurotransmitters; morphine less effective at blocking pathologic pain mediated by neurokinin and N-methyl-D-aspartate receptors; spontaneous ectopic firing  —  in dorsal horn of spinal cord, first synapse from un­myelinated pain nerve can result in spontaneous firing of nerve anywhere along nerve pathway; ephaptic impulse generation  —  injured nerve trunk that includes non–pain-associated nerves (eg, A-b fibers that carry touch, pres­sure, vibration) can result in “short circuiting” to pain nerve; even light touch can result in shock of pain; deaf­ferentation pain  —  on other side of synapse, sufficient damage to peripheral system can result in automatic firing of second-order neuron without input; central sensitization  —upregulation of second-order neurons with persis­tent pain; glial cells can generate and trigger pain signaling

Pain assessment: determine time course of pain (ie, whether pain acute, chronic, or recurrent); recognize and treat physiologic pain types

Treatment of physiologic pain types: psychogenic  —treat anxiety or depression; nociceptive  —inflam-matory or mechanical pain; treat with anti-inflammatory agent, or stabilize or decompress mechanical cause of pain; neuropathic  —  treat with drugs (eg, anticonvulsants, antidepressants); muscular  —  manage with physical rehabili­tation approach; consider muscle relaxant or botulinum toxin type A (eg, Botox); acute pain  —  treat with opioids, regional blocks for localized acute pain, and medical and surgical interventions; treat underlying disease; chronic pain  —  manage with self-care strategies, behavioral methods, long-term medications, complementary therapies, and multidisciplinary care; widespread pain  —  eg, fibromyalgia; treat with medications that affect entire body; manage with general exercise rehabilitation approach, mental measures (eg, relaxation techniques), education, and psychosocial measures; regional pain  —  use localized treatment (eg, topical treatment or regional block); reduce pain while instituting other therapies

Contributing factors: do not cause pain, but worsen or lengthen duration of pain; eg, poor posture contributes to chronic pain after car accident, or daily gum chewing contributes to daily headaches; consider depression and anx­iety; treat separately

Barriers to pain assessment or management: insurance noncoverage of potentially helpful services; language bar­riers; unmotivated patients

Time course of pain: time course for acute pain to become chronic pain varies (eg, 3-6 mo [“but that’s artificial; we’ve seen people who have a time course of 1 day and you already can see it’s chronic pain”])

“Seven deadly sins” in management of chronic pain: 1) lumping; treating acute pain same as chronic pain, or treat­ing pain of different mechanisms in same way (eg, treating trigeminal neuralgia with nonsteroidal anti-inflamma­tory drug [NSAID]); 2) opioid worship; believing that opioids highly effective for chronic pain; opioids not gold standard for chronic pain; according to American Pain Society guidelines, >200 mg/day of opioids “probably too high”; 3) stupidity; repeating ineffective treatment; patients who do not respond to treatment should be reassessed for contributing factors, barriers, or different physiologic cause; 4) servitude; feeling obligated to control patient’s pain; patients may threaten to obtain pain medications “on the streets”, or inflict guilt (eg, “I just don’t think you’re giving me good pain control”); patients must recognize pain cannot be resolved completely and that they must work with physician (ask patient, “what are you willing to do to help your pain improve?”); 5) perfectionism; be­lieving chronic pain can be eliminated completely; breakthrough pain defined in cancer patients with advanced ill­ness as 20% fluctuation in pain intensity over 48 hr, from baseline of 72 hr; important to distinguish chronic pain from flares; assure patients that increasing dose will not eliminate pain; advise patients that any dose of opioid can be expected to reduce pain by »40%; 6) asking for trouble; engaging in problematic or high-risk treatments with noncompliant or unselected high-risk patients; avoid establishing untenable treatment (eg, providing opioids to woman with bipolar disorder and chronic back pain hospitalized for overdosing on oxycodone and acetamino­phen); 7) ignoring “elephant in office” (eg, chemical dependency, psychologic comorbidity, patients who “need” their pain); personality features, anxiety, and depression contribute to and may cause pain; some patients’ lives structured around pain (ego-syntonic pain), and taking away pain may affect structure of patient’s life; counsel pa­tients (eg, say, “it’s obvious you’ve had your pain for a long time; we cannot eliminate your pain”); focus on im­proving quality of life

Opioid Management

Introduction: good outcomes of opioid use  —  quality of life measurably better; stable doses of opioids maintained over years; patients reliable with prescriptions; bad outcomes of opioid use  —  escalating doses; no improvement or decline in function; level of misery and pain score remain constant; patients unable to manage prescriptions reliably

Fears associated with prescribing opioids: fear of loss of control of prescribing process; fear of regulatory scrutiny; fear of adverse effects (eg, respiratory depression, addiction, tolerance)

Reasons to avoid opioids: not highly effective for chronic pain; no studies show improvement in patient’s function with long-term opioid use; significant adverse effects (eg, dysphoria, irritability, apathy, increased pain)

Flares: temporary increase in pain intensity (ie, pain intensity returns to baseline); patients perceive flare as worsen­ing disease, or that pain medication becoming ineffective; medication doses often increased to treat flare, resulting in new baseline at higher dose; “vicious cycle” of increasing dose continues as flares occur; pseudotolerance  —  apparent failure of pain medication to maintain stable control of chronic pain, resulting in repeated dose escala­tions during flares, without returning to baseline doses once flare resolves; distinguishing flares from progression of medical condition  —  increase in pain intensity with unchanged distribution, quality, and physical findings most likely flare; provide patients with tools (eg, additional 2-wk supply of medication) to manage flares

Documentation with opioid use: 4 As  —  1) analgesia; 2) adverse effects (eg, constipation, sedation, drowsiness, itching, nausea) and management; 3) activity level, eg, changes in work hours, ability to play with children, or walking; 4) adherence to prescribing protocol; initial evaluation  —  document pain type, contributing factors, and barriers to treatment

Noncompliance: prevalence high; compliant patients tend to be older, and noncompliant patients tend to be in younger age groups (“but there is so much overlap”); forms  —  increasing dose without authorization; nonparticipa­tion in recommended therapies; multiple prescribers; illegal drug use; diversion; poor communication (eg, threats); alcohol abuse; declining function due to medications

Drug screening: of 205 patients, 78 had aberrant drug screening results; useful monitoring tool; in 27 patients, pre­scribed opioid not present; cannabinoids present in 30 patients, unauthorized opioids in 11 patients, and other unau­thorized drugs (eg, amphetamine) in 10 patients; presence of cocaine, alcohol, and nonprescribed amphetamine and altered urine (eg, cold, diluted urine) found; no significant difference in addictive qualities between opioids (ie, risk for noncompliance similar for all agents); monitoring  —important; use 1 to 2 monitoring tools; Screener and Opi­oid Assessment for Patients with Pain (SOAPP), Opioid Risk Tool (ORT), and Diagnosis, Intractability, Risk, and Efficacy (DIRE) score helpful

DIRE score: risk  —  1) psychologic health; 2) chemical health; 3) reliability; 4) social support; each scored 1 to 3 (more compelling to prescribe opioids to patients with higher scores); score of 7 to 13 predicts unsuccessful out­come; score of 14 to 21 predicts good outcome and better efficacy in pain control; diagnosis  —determine how com­pelling diagnosis is, eg, severe peripheral vascular disease or severe ischemic pain may be scored as 3, while muscular pain, fibromyalgia, benign conditions, or lack of diagnosis may be scored as 1; intractability  —  determine patient’s level of motivation to participate in array of treatments; consider past attempts to incorporate therapy other than drugs (eg, physical therapy, behavioral treatments); strong efforts may be scored as 3; patients with lack of re­sources, response, or interest in other therapies may be scored as 2; patients who have not tried customary treat­ments or have low motivation may be scored as 1; psychologic health  —  patients with good communication and no significant personality dysfunction or mental illness may be scored as 3; patients with some personality issues (eg, depression, mild to moderate anxiety) scored as 2; patients with serious personality dysfunction that impairs com­munication, or patients with severe mental illness scored as 1; chemical health  —  chemical copers and patients with chemical dependency in remission may be scored as 2; patients with no history of chemical dependence scored as 3; active users of eg, marijuana or cocaine scored as 1; reliability  —  patients with low social support, life in chaos, low family support, few relationships, and loss of most life roles scored as 1; patients with supportive family, close relationships, involvement in work, school, and other important life roles scored as 3; efficacy  —  patients with poor function or minimal pain relief in spite of moderate to high opioid doses scored as 1; patients with moderate benefit with improved function, or when efficacy unclear (eg, short-acting opioids in lower doses) scored as 2; good im­provement in pain and function with stable doses over time scored as 3

Initiating prescription management: opioid agreement; urine drug screen; discuss expectations; set goals; discuss and determine signs of success

Monitoring: monthly visits (consider more frequent visits with higher risk patients); occasional urine drug screening; pill count to identify noncompliance (eg, overuse, diversion); consider appropriate methods of escalating or taper­ing dose and withdrawing medication; refer patients to detoxification and/or chemical dependency treatment as in­dicated

Suggested Reading

Chou R: 2009 Clinical Guidelines from the American Pain Society and the American Academy of Pain Medicine on the use of chronic opioid therapy in chronic noncancer pain: what are the key messages for clinical practice? Pol Arch Medi­cine Wewn 119:469, 2009; Colameco S et al: Continuous opioid treatment for chronic noncancer pain: a time for moder­ation in prescribing. Postgrad Med 121:61, 2009; Dysvik E et al: Coping with chronic pain. Int J Nurs Stud 42:297, 2005; Dysvik E et al: The effectiveness of a multidisciplinary pain management programme managing chronic pain. Int J Nurs Pract 10:224, 2004; Haugli L et al: Learning to have less pain - is it possible? A one-year follow-up study of the effects of a personal construct group learning programme on patients with chronic musculoskeletal pain. Patient Educ Couns 45:111, 2001; Lang E et al: Multidisciplinary rehabilitation versus usual care for chronic low back pain in the community: effects on quality of life. Spine J 3:270, 2003; 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 10:858, 2009; Pas­sik SD: Issues in long-term opioid therapy: unmet needs, risks, and solutions. Mayo Clin Proc 84:593, 2009; Sng BL et al: The role of opioids in managing chronic non-cancer pain. Ann Acad Med Singapore 38:960, 2009; Wilsey BL et al: Documenting and improving opioid treatment: the Prescription Opioid Documentation and Surveillance (PODS) Sys­tem. Pain Med 10:866, 2009.