Principles of Pain Management for the PCP. Andréa Sciberras, DO, AAHIVS, FACOI, FACP Sciberras Internal Medicine, Inc. Dania Beach, FL 33004

Transcription

1 Principles of Pain Management for the PCP Andréa Sciberras, DO, AAHIVS, FACOI, FACP Sciberras Internal Medicine, Inc. Dania Beach, FL September 2012

2 Objectives At the end of this lecture, participants will be able to: Recognize the definition of pain, as well as the various pain pathways and syndromes Identify the multidisciplinary approach to treating pain Identify pharmacological agents used to treat various types of pain Be aware of interventional techniques used to treat pain Recognize psychosocial and psychological factors associated with pain syndromes Know the basics of the Florida laws regarding the dispensing of controlled substances

3 Case presentation 56yo M, initials DF, well known to me with a history of Failed Back Syndrome s/p 4 back surgeries, last encounter with neurosurgeon stated he was not a candidate for a 5th Has been alternating between Vicodin and Percocet, taking up to 5 tablets a day; Epidurals helped in past Pain radiates down both legs posteriorly, R > L Pain is currently preventing him from working and enjoying life

4 Case presentation: Pertinent Positives BP elevated at 150/90 due to pain Severe muscle spasm and ttp lumbosacral region 1+ patellar DTRs

5 What is pain?? An unpleasant sensory or emotional experience associated with actual or potential tissue damage; or described in such terms. Impact on daily living: mood, relationships, activity, valued life roles

6 Pain Institute of Medicine report, May 23, 2012: 116 million Americans live in pain Worsening, devastating, expanding inequalities in the prevalance of pain and in the adequacy of treatment Frequent experiences of stigmatization Jean Jackson: chronic pain sufferers rate the alienation they experience from their physicians as qualitatively worse than alienation from loved ones

7 PAIN has an element of blank; It cannot recollect When it began, or if it were there A day when it was not. It has no future but itself, Its infinite realms contain Its past, enlightened to perceive New periods of pain. -Emily Dickinson (1890)

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11 Pain types Acute Chronic Chronic Pain Syndromes Nociceptive Neuropathic Neuroplastic (Phantom limb, RSD/CRPS) Migraine Fibromyalgia

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13 Goals of Pain Management Decreased pain Improved functional status Improved mood/affect Decreased healthcare utilization When deciding on treatment: Are patient goals attainable? Is there a support system in place?

14 Multidisciplinary approach BioPsychoSocial

15 Pain descriptors Helpful in differentiating nature of pain syndrome Pain scale 0-10 Watch for emotionally loaded content fireballs exploding in my gut like a thousand bees stinging my legs twelve inch dagger twisting in my ribs

16 Nociceptive pain Results from activation of peripheral nociceptors in response to tissue injury Tends to respond to conventional analgesics such as NSAID s, opioids and TCA s

17 Neuropathic pain Develops secondary to direct nerve injury. Presents with complaints of burning, lancinating and/or dysesthetic pain. Concomitant neural deficits often present. Tends to respond to TCA s, anticonvulsants or sodium channel blockade.

18 HIV/AIDS

19 Medications NSAID s Tricyclic antidepressants Anticonvulsants Opioids

20 NSAIDs Great for acute pain, nociceptive pain, inflammatory pain Limited by renal toxicity, GI concerns, elevating BPs COX 2 vs. COX 1 inhibitors

21 Antidepressants Older classes of antidepressants tricyclics most effective Increase the central nervous system s production of endogenous pain killers Tend to improve sleep hygiene Newer antidepressants such as Cymbalta excellent for pain control as well

22 Anticonvulsants Effective for neuropathic pain syndromes Gabapentin, pregabalin Newer agents have improved side effect and toxicity profiles Lamotrigine, topiramate, carbamezapine

23 Opioids Benefits of pain relief must be weighed against the potential toxicity of addiction Newer meds such as Butrans patch and Nucynta have less risk of addiction (downside: they are rarely covered by insurance) For chronic pain, whenever possible, switch to long-acting agents (and use shorter-acting ones for breakthrough)

24 Interventional Therapies Trigger point injections Epidural steroid injections Facet denervation Spinal cord stimulation Intrathecal drug delivery

25 Alternative &/or Adjuvant therapies Osteopathic manipulation Acupuncture Massage Physical therapy Meditation, biofeedback, etc.

26 Physical Therapy Passive modalities used in moderation Functional outcomes emphasized over pain reduction Goal should be to make the patient independent in a maintenance exercise program

27 Psychosocial Factors Psychological history Coping styles Pain score and descriptors Patient goals Pending litigation?malingering

28 Psychological evaluation Past history of trauma or abuse? Comorbid depression or anxiety? Past history of substance abuse? Coping styles Avoidant verses active Locus of control Maladaptive strategies & substance abuse

29 Florida laws: HB 7095 (now ) If you prescribe ANY controlled substances at all, you must designate yourself as a controlled substance prescribing practitioner on the physician s practitioner profile Comply with the requirements of the new law and all applicable board rules (see appendix A)

30 Penalties for Violations 10,000 fine 6 month suspension of license FOR EACH ACTION

31 Exceptions to the new Standards of Practice Those exempt: board certified anesthesiologists, psychiatrists, rheumatologists, neurologists Surgeons Board certified pain medicine specialists Doctors practicing inpatient medicine

32 Chronic nonmalignant pain Pain unrelated to cancer or rheumatoid arthritis which persists beyond the usual course of disease or the injury that is the cause of the pain or more than 90 days after surgery

33 Key elements Must document H&P, previous therapies, treatment plan, etc. Must follow-up every 3 months or less Pain contract Drug testing Any patient with a past history of substance abuse or has a comorbid psychiatric disorder MUST be referred to a psychiatrist or addictionologist

34 Tips Make sure you use a drug testing program with confirmatory testing

35 Re: the new FL pain laws They should not make you afraid of prescribing opioids and other controlled substances; rather, they should make you well-informed and practice judiciously.

36 Case presentation: Rather than continue DF on taking many shortacting pills during the day, I decided to put him on something long-acting After dose adjustment, he was started on Fentanyl 50 mcg/hr transdermal patch. Given Vicoprofen for breakthrough pain. Referred to physical therapy and acupuncture. Also awaiting interventional treatment - epidural

37 Case presentation One week later, patient calls me and says Thank you for giving me my life back To date, he has not needed any Vicoprofen for breakthrough pain

38 Thank you!! Andréa Sciberras, DO, AAHIVS, FACOI, FACP, President, Sciberras Internal Medicine, Inc. 101 S. Federal Hwy Dania, Florida (954)

39 References Dickinson E. Pain has an element of blank. In: Todd ML, Higginson TW, eds. Collected Poems of Emily Dickinson. New York: Avenal Press; Goldberg D. The Lived Experiences of Chronic Pain. The American Journal of Medicine. August 2012; 125(8): Hansson PT, et al. Neuropathic pain: Pathophysiology and Treatment. IASP Press; 2001:1-18. Jackson JE. Stigma, liminality, and chronic pain: mind-body borderlands. American Journal of Ethnology. 2005; 32: y.pdf Institute of Medicine. Relieving pain in America: a blueprint for transforming prevention, care, education, and research. Blueprint-for-Transforming-Prevention-Care-Education- Research.aspx. Accessed May 23, 2012.