1. Acute Pain Conditions 2. Narcotics 3. Chronic Pain

Transcription

1 Dr. Bertus 1/22/14

2 1. Acute Pain Conditions 2. Narcotics 3. Chronic Pain

3 An unpleasant sensory and emotional experience......caused by actual or potential tissue injury,...or described in terms of such injury. International Association for the Study of Pain

4 1. Acute - is a relatively brief sensation, usually less than six months duration - usually a response to a specific trauma - forms the basis for danger warnings and subsequent learning.

5 2. Chronic - lasts more than six months - exists beyond the time for normal organic healing The pain begins to impair other functions Patients may begin to experience learned helplessness and hopelessness this leads to the classic signs of depression (lethargy, sleep disturbance, weight loss) May quit work and adopt a self imposed invalid existence.

6 1. Prevents serious damage. If you touch something hot, you are forced to withdraw your hand before it gets seriously burnt. 2. Teaches one what to avoid 3. If pain is in joints, pain limits the activity, so no permanent damage can occur. 4. Pain can become the problem and its purpose can take on a stealing, destroying and killing attitude in ones life!

7 1. COMPLEX REGIONAL PAIN SYNDROME 2. PHANTOM LIMB PAIN 3. POST HERPATIC NEURALGIA

8 1. Reflex Sympathetic Dystrophy 2. Types A. Type 1 Diffuse B. Type 2 Nerve Injury 3. Presentation and Symptoms

9 1. COMPLEX REGIONAL PAIN SYNDROME 2. PHANTOM LIMB PAIN 3. POST HERPATIC NEURALGIA

10 1. Acute Pain Conditions 2. Narcotics 3. Chronic Pain

11 HAVE YOU HEARD OF THIS BEFORE? Albutt At such times I have certainly felt it a great responsibility to say that pain, which I know is evil, is less injurious than morphia, which may be an evil

12 1. What is the meaning of Nonmedical Use of Prescription Drugs (Rx)? Not prescribed for you OR You took the drug only for the experience or feeling it caused (excludes Over-the-Counter medicine) Office of Applied Studies, SAMHSA Anesthetic and Life Support Drugs and Drug Safety and Risk Management Advisory Committees November 13,

13 UW Project ROAM 13

14 Where do nonmedical users get pain reliever prescription drugs?

15 National Vital Statistics system, multiple cause of death dataset

16 Unintentional and Undetermined Intent Drug Overdose Death Rates by State, NH 11.7 VT 7.9 MA 12.5 RI 11.1 CT 11.1 NJ 7.5 DE 9.8 MD 12.5 DC Age-adjusted rate per 100,000 population

17 Nebraska Prescribing controlled substances for oneself or except in a medical emergency an immediate family member is considered grounds for disciplinary action Schedule II prescriptions expire in 6 months Adopted Model Policy for the Use of Controlled Substances for the Treatment of Pain. The guidelines consist of evaluating the patient, development of a treatment plan, obtaining informed consent and agreement for treatment, periodically reviewing the treatment plan, consulting with the patient, maintaining good medical records, and demonstrating compliance with controlled substances laws and regulations. Salvia is a Schedule I substance. Nebraska Department of Health and Human Services Physician and Surgeon Regulations and Statutes

18 UNMC TEAM PROVIDES ORTHOPAEDIC RELIEF IN GUATEMALA November 29, 2011 As a UNMC team and other groups from North America performed 73 joint replacement surgeries during a recent health care mission in Guatemala, Kevin Garvin, M.D., was struck by the sheer toughness of the patients he encountered. "We took 100 Vicodin -- a narcotic pain medication -- with us and we didn't use them all," the professor and chairman of UNMC's orthopaedic surgery department said. "We would have gone through thousands of narcotic pills for the same number of patients in the U.S."

19 Old Definition Adverse Effects Constipation Nausea/vomiting Dry Mouth Itching Seating RESPIRATORY DEPRESSION

20 New Definition Adverse Effects Aberrant drug-related behavior Abuse Misuse Diversion Addiction UNINTENDED DEATHS

21 History of Psychosocial pathology Substance abuse/dependence Prolonged recovery from previous painful experience Psychological or physical trauma or abuse

22 OPIOID INDUCED HYPERALGESIA IS DEFINED AS A STATE OF NOCICEPTIVE SENSITIZATION CAUSED BY EXPOSURE OT OPIOIDS. MANIFESTATIONS HYPERALGESIA ALLODYNIA DEVELOPMENT OF DIFFUSE, SPONTANEOUS PAIN SYNDROME EXCESS PAIN FOLLOWING PROCEDURES AND SURGERY RELATED BUT DISTINCT FROM TOLERANCE

23 CONSIDER OIH IN PTS WITH UNEXPLAINED, AGGRAVATED OR ATYPICAL PAIN COMPLAINTS CONSIDER OIH IN PTS WHO SHOW INCREASED PAIN IN RESPONSE TO DOSE EXCALATION BALANCE USE OF HIGH OPIOD DOSES AGAINST RISK OF OIH MAKE GET WORSE BEFORE IT GETS BETTER

24 EUROPEAN STUDY GROUPS GR1 = CHRONIC PAIN + MSO4 GR2= PREMEDICATION GR3= COWORKERS ALCOHOL LEVELS > 0.08% GR4= COWORKERS ON CALL < 4 HOURS OF SLEEP GR5= HEALTHY DRUG FREE VOLUNTEERS

25 TESTED DRIVING SIMULATOR, QUESTIONS FOR MENTAL STATUS AND VIGILANCE MISTAKES GR1 (PAIN NARCOTICS) 1.1 GR2 (BNZ) 1.6 GR3 (BOOZE) 2.7 GR4 (NO SLEEP) 1.5 GR5 (HEALTHY) 0.6

26 1. Acute Pain Conditions 2. Narcotics 3. Chronic Pain

27 Characteristics of Symptoms last longer than 6 months Few objective medical findings Medication abuse Difficulty sleeping Depression Manipulative behavior Somatic preoccupation

28 35% of Americans have some element of chronic pain. 50 million Americans are disabled to some degree related to chronic pain. Results in $61 billion in lost productivity. Most common symptom to which patients seek medical care.

29 Chronic recurrent pain -- benign condition consisting of intense pain alternating with pain-free periods. eg, migraine, tension headaches, endometriosis. Chronic intractable-benign pain -- benign condition where pain is persistent with no pain free periods, although the pain may vary in intensity eg low back pain.

30 Chronic progressive pain --malignant condition where pain is continuous and increases in intensity as the organic condition (disease) worsens eg. Cancer and rheumatoid arthritis.

31 Normal Life Pain

32 As Pain Continues Life Pain Pain Life

33 Pain Life G A P Life Pain

34 THE DECADE S MOST IMPORTANT DISCOVERY IS THAT A PAINFUL, PERIPHERAL INJURY MAY IMPRINT/ENCODE/EMBED THE SENSATION/MEMORY OF PAIN IN THE CENTRAL NERVOUS SYSTEM.

35 A STATE OF INTRACTABLE/INCURABLE PAIN AND OTHER PHYSIOLOGIC AND BEHAVIORAL MANIFESTATIONS DEPENDING UPON ANATOMICAL, TISSUE ALTERATIONS. CLINICAL HALLMARKS CONSTANT POOR RESPONSE TO PERIPHERAL TREATMENTS DIAGNOSTIC CHALLENGE PERIPHERAL CENTRAL BOTH

36 1-8 WEEKS CAN BE IMMEDIATE OR PROLONGED ANY INJURY CAN CAUSE ARTHRITIS, TRAUMA, SPINE DEGENERATION, HEADACHE, NEUROPATHIES, FIBROMYLAGIA, PLANTAR FASCIITIS.

37 INFLAMMATORY GLIAL CELLS 70% OF ALL CNS CELLS SUPPORTIVE MATRIX 2 TYPES ARE ASTROCYTES AND MICROGLIA

38 INJURED PERIPHERAL NERVE RETROGRADE ELECTRIC/CHEMICAL SIGNALS GLIAL CELL ACTIVATION RELEASE OF EXCESS GLUTAMATE/NEUROTOXINS CELL DEATH, APOPTOSIS, REFORMATION IMPRINTING OF PAIN SENSATION

39 ANATOMIC BRAIN CHANGES BY MRI REDUCTION IN CORTICAL GRAY MATTER THINNING OF CORTEX FUNCTINAL CHANGE COGNITIVE AND MENTAL IMPAIRMENT HORMONAL AND AUTONOMIC CHANGES PITUITARY STIMULATION SYMPATHETIC DISCHARGE

40 MAJOR HISTORY OF NERVE INJURY PAIN IS CONSTANT LOCAL, PERIPHERAL TX WITH MARGINAL EFFECT INJECTIONS MEDS PT/OT

41 MINOR INSOMNIA ALLODYNIA HYPERALGESIA EXCESS SYMPATHETIC DISCHARGE TACHY NAUSEA/DIARRHEA EXTREMITIES DIAPHORESIS SEVERE DISABLING HTN COLD MEDS INEFFECTIVE PARTIAL OR TEMP

42 1. Acute Pain Conditions 2. Narcotics 3. Chronic Pain

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