Pain as a diagnosis and comprehensive management. Peter Stiles, MD Medical Director TRIA Pain Program

Transcription

1 Pain as a diagnosis and comprehensive management Peter Stiles, MD Medical Director TRIA Pain Program

2 Objectives Understand pain as a symptom vs pain as a diagnosis Review available tools and comprehensive pain management If time: review CDC and MN Opioid Prescribing Guidelines and clinical utility Q&A especially any questions about pain procedures

3 Disclosures Vice Chair of the Board of the Steve Rummler Hope Network Paid consultant for Chrono Therapeutics with a non-reimbursable patent (2016)

4 Pain as a diagnosis

5 Pain as a diagnosis

6 Explain it

7 Explain it

8 Explain it

9 Treat it

10 Treat it

11 Barriers to a solution Decades deep in the problem Quick Fix society Incentivization to maximize satisfaction Addiction is incredibly powerful Lack of perfect, or even good, pain relief options

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14 Multimodal Meds Treat at multiple sites on pain pathway Improved pain control Opioid-sparing Decreased side effects Image credit to: American Academy of Family Physicians -

15 Opioids Cyclooxygenase inhibitors NSAIDs Norepi modulators Alpha-2 agonists Membrane stabilizers Magnesium Topicals And more Image credit to: American Academy of Family Physicians -

16 Interventions Pain procedures are only to facilitate functional improvement Decrease Bad Stuff Steroid Injections Radiofrequency Neurotomy Increase Good Stuff Prolotherapy Stem Cell Therapy Other Neuromodulation

17 Goals of pain interventions Facilitate function and therapy Set conditionings for healing Confirm or refute diagnoses Surgical planning Palliative measures

18 Functional Therapy Promises: Lack of activity and exercise will make pain worse It will get worse before it gets better Physical therapy is not a place you go, or even a thing you do, it is a lifestyle

19 Behavioral health At the very least, this must be recognized Sometimes, it must be addressed professionally Coping strategy development Cognitive behavioral therapy Education about pain Pacing activity Biofeedback Group therapy Anxiety management Addressing abuse/trauma

20 Addiction medicine At least for now, addiction management is wed to pain management Addiction specialists are critical.and rare Important to ensure we are NOT contributing to statistics

21 Integrative medicine

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23 CDC Prescribing Guidelines March 15, 2016 Made it OK to have guidelines that impact prescribing Spawned states and health systems to develop additional guidelines Some insurers are starting to enforce the guidelines

24 CDC Prescribing Guidelines Establish functional goals and employ non-pharmacologic treatment when possible Review risks with patients frequently, monitor for side effects check urine drug screens and evaluate within 1 month of starting any opioids. Provide the lowest possible dose, stick to short acting medications; try to provide less than 50 MEDs, definitely not more than 90 MEDs. Prescribe Naloxone and act quickly if you suspect opioid use disorder. Always check a prescription monitoring report. Don t mix opioids and benzodiazepines. Three day max prescription for injury or flares

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26 Minnesota Prescribing Guidelines CDC and then some Chronologic breakdown Present options for tapering and discontinuing Address women of childbearing years Suggest ways to move upstream and reduce new chronic users

27 Minnesota Prescribing Guidelines CDC and then some Chronologic breakdown Present options for tapering and discontinuing Address women of childbearing years Suggest ways to move upstream and reduce new chronic users

28 Minnesota Prescribing Guidelines Specifies some conditions in which NOT to use any opioids: fibromyalgia, headaches including migraine, self-limited illness (i.e. sore throat), and uncomplicated acute musculoskeletal pain

29 Utility of Guidelines Doc Patient

30 Utility of Guidelines Prescribing Guidelines?

31 Questions?

32 Citations All fluoroscopic and MRI images were from my own interventions; deidentified All spine renderings were from ViewMedica, which we license as an educational tool for patient and providers All other photos were stock images, apart from slide 7: Gary M. Franklin Neurology 2014;83: and slide 18 &19:American Academy of Family Physicians -