Chronic Pain Management

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1 Chronic Pain Management Page 1 of 57

2 Chronic Pain Management Release: 11/1/2014 Expiration: 11/1/2017 NEEDS STATEMENT It is estimated that one out of three Americans suffers from some type of chronic pain and yet it remains a misunderstood and undertreated health condition. Chronic pain has been identified as the primary cause of disability in the U.S. (American Chronic Pain Association, 2014). COURSE GOAL This activity is designed to change health provider attitudes on chronic pain and willingness to offer comprehensive assessment and comprehensive treatment. LEARNING OBJECTIVES Upon completion of this course, the participant will be able to: 1. Identify defining characteristics of chronic pain; 2. Recognize the impact of chronic pain impacts on individuals, families and U. S. health care; 3. Explain rationale for a comprehensive pain assessment; 4. Explain rationale for a multi-modal and comprehensive treatment approach to chronic pain; 5. Categorize pharmacologic and non-pharmacologic treatment modalities; 6. Review available opioid and non-opioid analgesic preparations when considering rationale for treatment; 7. Use current evidence to support recommended treatment approaches for common chronic pain conditions and syndromes. TARGET AUDIENCE This independent self study activity is designed for physicians and nursing professionals at all levels and settings in the healthcare industry. METHOD OF PARTICIPATION In order to receive credit, participants should read the entire monograph, complete and submit an evaluation and score at least 70% on the self-assessment test. AKH Inc. allows for one (1) re-test at no additional charge; additional re-tests must be purchased again at the full cost. Certificates will be available in the transcripts upon successful completion of the self-assessment test. If you have questions about this CME/CE activity, please contact AKH Inc. at service@akhcme.com. FACULTY Mary Kathleen Ebener, PhD, RN Dr. Ebener is employed by Florida State College at Jacksonville as the Associate Dean of Bachelor of Science in Nursing program. In addition, Dr. Ebener teaches courses related to nursing, health care and statistical analysis at the University of Phoenix, Jacksonville, Florida campus. She holds a BSN degree from Illinois Wesleyan University; her MSN is from Andrews University, MI; and her PhD. is from the University of Florida at Gainesville. Dr. Ebener discloses no significant financial relationships with pharmaceutical or medical product manufacturers. AKH Inc. Staff/Reviewers Dorothy Caputo, MA, BSN, RN Lead Nurse Planner Ms. Caputo discloses no significant financial relationships with pharmaceutical or medical product manufacturers. Bernadette Marie Makar, MSN, NP-C, APRN-C Nurse Planner Ms. Makar discloses no significant financial relationships with pharmaceutical or medical product manufacturers. AKH Inc. planners and reviewers have no relevant financial relationships to disclose. Page 2 of 57

3 ACCREDITATION STATEMENTS Physicians AKH Inc., Advancing Knowledge in Healthcare is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. AKH Inc., Advancing Knowledge in Healthcare designates this enduring activity for a maximum of 2.0 AMA PRA Category 1 Credit(s). Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physician Assistants NCCPA accepts AMA PRA Category 1 Credit from organizations accredited by ACCME. Nursing AKH Inc., Advancing Knowledge in Healthcare is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. This activity is awarded 2.0 contact hours. FL Nursing AKH Inc., Advancing Knowledge in Healthcare is an approved provider for nursing continuing education by the Florida Board of Nursing # This activity is awarded 2.0 contact hours. Nurse Practitioners AKH Inc., Advancing Knowledge in Healthcare is accredited by the American Association of Nurse Practitioners as an approved provider of nurse practitioner continuing education. Provider Number: This activity is awarded 2.0 contact hours, which includes 0 hours of pharmacology. Program ID # This program was planned in accordance with AANP CE Standards and Policies and AANP Commercial Support Standard. COMMERCIAL SUPPORT: This activity is NOT supported by a commercial educational grant. DISCLOSURE DECLARATION It is the policy of AKH Inc. to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its continuing education activities. The faculty must disclose to the participants any significant relationships with commercial interests whose products or devices may be mentioned in the activity or with the commercial supporter of this continuing education activity. Identified conflict of interest is resolved by AKH prior to accreditation of the activity. AKH planners and reviewers have no relevant financial relationships to disclose. DISCLOSURE OF UNLABELED USE AND INVESTIGATIONAL PRODUCTS This educational activity does not include discussion of uses of agents that are investigational and/or unapproved by the FDA. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings. DISCLAIMER AKH Inc. s courses are designed solely to provide healthcare professionals with information to assist in their practice and professional development. The courses are researched thoroughly, utilizing current literature and including practical experiences. AKH s courses are not to be considered a diagnostic tool to replace professional advice or treatment. The courses serve as a general guide to the healthcare professional, and therefore, they cannot be considered as giving legal, nursing, medical, or other professional advice in specific cases. AKH educational courses do not endorse commercial products. The author(s) and the publisher specifically disclaim responsibility for any adverse consequences resulting directly or indirectly from information in the courses. AKH further disclaims any responsibility for undetected errors, or from the reader s misunderstanding of the course. Copyright 2014, AKH Inc. No part of this publication may be produced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical photocopying, recording, or otherwise, without the prior permission of the publisher. Page 3 of 57

4 TABLE OF CONTENTS INTRODUCTION...5 DEFINING CHRONIC PAIN...7 COMPREHENSIVE ASSESSMENT OF CHRONIC PAIN...9 COMPREHENSIVE TREATMENT OF CHRONIC PAIN...12 MEDICATIONS...12 PHYSICAL TREATMENT APPROACHES...32 MIND-BODY TREATMENT APPROACHES...33 HERBAL PREPARATIONS AND DIETARY SUPPLEMENTS...35 COMPLEMENTARY AND ALTERNATIVE THERAPIES FOR PAIN RELIEF...37 OTHER SUBSTANCES AND STRATEGIES USED FOR PAIN RELIEF...38 ILLEGAL DRUGS AND MARIJUANA...41 FOCUS TOPICS IN CHRONIC PAIN...41 SUMMARY...50 REFERENCES...51 POST TEST Page 4 of 57

5 INTRODUCTION Pain is a health issue that affects each of us at one time or another. Sometimes the pain is a minor inconvenience, sometimes the pain is devastatingly severe. The acute pain associated with injury or illness is typically recognized and successfully treated. Health professionals are most familiar with acute pain. The cancer pain associated with tumor invasion and tissue destruction is also well recognized. Cancer pain treatment is not always as successful but there is a general willingness among health providers to prescribe drug and non-drug treatment, and a general willingness by the lay public to accept recommended treatment. It is chronic pain that is most problematic to recognize, understand, and successfully manage. No one understands chronic pain very well because it persists beyond the expected period of healing and responds very poorly to treatment. The intensity of chronic pain does not always correlate with the amount of known underlying pathology, and this lack of empirical evidence promotes relative invisibility of the pain and its sources. Chronic pain is far from invisible to those experiencing it, but at the same time very much hidden from those who must justify treatment. Impact Chronic pain is widespread, affecting an estimated one in three Americans, or approximately 50 million people (American Chronic Pain Association, 2014). Chronic pain can impact individuals of any culture, age, or economic status but it is known to be particularly prevalent among older adults and survivors of major trauma. Children and young adults rarely present to a health provider with chronic pain issues. It is the older adults and those recovering from major illness or traumatic injury who are the most vulnerable, typically experiencing multiple acute and chronic conditions along with their unrelieved pain (Denny & Guido, 2010). Barriers Health professionals encounter several barriers as they attempt to assess and treat chronic pain. Their own health provider attitudes are frequently outdated and erroneous. Our U.S. healthcare system challenges are difficult to navigate, and atypical pain reports by those reporting chronic pain lead to frustration and inadequate pain management. Major healthcare provider barriers typically include poorly informed attitudes about pain, exaggerated concerns about addiction, and a reluctance to treat unless demonstrable pathology is present using medical diagnostics such as imaging scans or laboratory reports. These barriers contribute to poor patient outcomes because of inadequate pain management. Profound healthcare system challenges include limited formularies, poorly designed documentation forms or checklists that unnecessarily limit pain assessment, restrictive laws and regulations concerning medication use, and a reluctance of third party payers to reimburse for alternative treatment strategies that may in fact be more successful than their approved medications. These barriers contribute to poor patient outcomes because of pain mismanagement. Page 5 of 57

6 The most common barriers among those who are experiencing chronic pain involve communication. Some tend to underreport pain, unnecessarily enduring a reduced quality of life while others tend to catastrophize and overreport pain simply so that someone will pay attention to their condition. There are also communication issues related to poorly described pain because many chronic pain patterns defy precise locations or consistent timing. Even if the healthcare provider has relationship or history with the individual reporting pain, accurate interpretation and further assessment can be difficult (Fitzcharles, DaCosta, Ware & Shir, 2009). Poor communication patterns contribute to poor outcomes such as inability to return to work, poor quality of life, and ongoing despair. The suicide rate among those reporting chronic pain remains 2-3 times higher than the general population (Clark & Galati, 2012) and has been so for several decades. The number of unintentional fatalities related to accidental injury and overdose are also higher among those with chronic pain. Healthcare professionals have an ethical obligation to appropriately assess and treat chronic pain. Persisting barriers prevented needed interventions and contribute to poor outcomes. Adequate management of chronic pain is a growing problem in the U.S. If all those living the chronic pain could unite, adequate pain management for their conditions might become a national priority. Implications Widespread prevalence of chronic pain has profound implications for U.S. healthcare. Chronic pain is a major driver of rising healthcare economics. People with chronic pain tend to be sick with multiple conditions. Treatments themselves are multiple, costly, and never-ending. People with chronic pain are usually unable to work, and the numbers of people claiming disability and economic hardship are growing. U.S. policy makers in healthcare are confronting both a shrinking workforce and an expanding group of people who will require decades of financial subsidy. As the number of Americans with chronic pain continues to rise, our national quality of life deteriorates. Frustration and hopelessness prevail when neither clinicians nor patients know how to approach a type of pain where nothing seems to help. Some individuals are abandoned to fend for themselves in a healthcare system that is becoming less stable over time. Other individuals are referred from one specialist to another, spending excessive amounts of money for sometimes questionable treatments. Those who live with chronic pain often live with depression, anxiety and social isolation. Families, neighbors and employers are not sure how to relate to someone who is consistently having a bad day. It is within this context that this course on chronic pain is situated. Clinicians who regularly interact with patients have a professional imperative to learn more about chronic pain. A large number of treatment options are available to assist the person with chronic pain but there should also be acknowledgement that the pain will often persist at some level because that is the very nature of the chronic pain experience. For this reason, the focus is should target enhancing level of function rather than achieving restoration of a totally pain-free life. Addressing chronic pain is about pain management, not necessarily about complete pain relief. Page 6 of 57

7 DEFINING CHRONIC PAIN So what exactly is chronic pain? The American Society of Anesthesiologists (2010) define chronic pain as pain of any etiology not directly related to neoplastic involvement, associated with a chronic medical condition or extending in duration beyond the expected temporal boundary of tissue injury and normal healing, and adversely affecting the function or well-being of the individual. (p. 1). A defining characteristic is that the pain lasts for at least six months and has no anticipated or predictable end. It can remain for months or years, it can remain for a lifetime. Chronic pain can persist continuously or intermittently. There are multiple presentations for chronic pain, making both diagnosis and treatment very challenging. Severity ranges from mild to severe and it responds poorly to treatment. For reasons that are not understood, the pain persists after actual tissue healing has occurred and there are times when no physiological reason for the pain can be located. Sensitization Clinicians have the most trouble accepting that there could be pain when no pathology is identified. The concept of sensitization helps to explain how an initially painful acute experience can transition into a chronic pain experience. The initial painful experience is often significantly severe or repetitive. For reasons that are not yet understood, body tissues will sometimes respond abnormally as they heal. Sensitization refers to a heightened and prolonged state of neuron excitability which occurs after repeated tissue injury, nerve injury, or both (Woolf, 2011). Sensitization can have both a peripheral or central etiology. Peripheral sensitization refers to prolonged and enhanced excitability along the peripheral nerve transmitting painful impulses. Central sensitization refers to prolonged and enhanced excitability within the dorsal horn in the spinal cord that produces a broader and more generalized hyperalgesic response. It is not known why sensitization occurs other than the acknowledged plasticity of the human nervous system, meaning that the structure and functionality of nerve pathways are known to evolve in response to different stimuli (McCance, Huether, Brashers, & Rote, 2010). Researchers speculate that there may be a genetic predisposition to the development of central sensitization after initial injury but there is no current conclusive evidence to explain why it develops. Chronic Pain Categories Chronic pain can be further classified according to the origin of the pain within the body: nociceptive, somatic or visceral, and neuropathic. Nociceptive pain occurs when peripheral nerve fibers are stimulated by a noxious (harmful) stimulus or trigger (Adams, Holland & Urban, 2014). The initial trigger might be an intense thermal injury, a chemical injury, or a cutting or crushing injury that produces acute pain. Activity in the neural pathways is initiated and maintained by tissue-damaging stimuli. If the pain continues long after tissue healing, the person is said to suffer from chronic pain of nociceptive origin. It is important for the clinician to ascertain and then document if the pain is nociceptive in origin. Nociceptive pain tends to respond well to both non-opioid and opioid analgesics, as well as physical treatments, mind-body treatments, and some alternative strategies. Page 7 of 57

8 Somatic nociceptive pain arises from the bone, joint, muscle, skin or connective tissue due to some type of injury (including surgery) and is either surface somatic pain or deep somatic pain. Surface somatic pain is usually sharp and described as stabbing or pricking. Deep somatic pain is usually described as being dull, aching and localized (Pasero & McCaffery, 2011). Much of the soft tissue pain experienced in fibromyalgia can be classified as deep somatic pain. Visceral nociceptive pain arises from internal organs such as the liver, gallbladder or intestines. Visceral pain usually results from distention or compression, and is described as pressure, stabbing, or cramping. Visceral pain is not usually localized, making its description and localization difficult for both the person experiencing pain and the health provider trying to assess the pain. Non-localized pain most often occurs when hollow organs such as the intestines are involved (Pasero & McCaffery, 2011). Chronic chest pain or abdominal pain can be classified as visceral pain. According to Clark & Galati (2012), common chronic pain disorders involving nociceptive pain are mechanical low back pain (compressed vertebrae, scoliosis), arthritis (rheumatoid and osteo), chronic inflammatory conditions, sickle cell related pain, and postoperative pain or sports injuries that fail to resolve. Neuropathic pain occurs when the nerve itself is damaged (Adams, Holland & Urban, 2014). There might be a primary lesion or some type of nerve dysfunction. Nerve damage may involve the peripheral nervous system, the central nervous system, or both. Neuropathic pain can involve one nerve or several nerves and it is usually described as burning, tingling or electrical. A lot of chronic pain has a neuropathic component, particularly the neuralgias and any sympathetically maintained pain. Pathological nerve damage is not always detectable using our current diagnostics, yet its consequences are often severe, persistent, and resistant to treatment. Examples of neuropathic pain include post herpetic neuralgia and phantom limb pain. Any of the various forms of neuralgia are believed to be caused by biochemical nerve damage related to a disease processes or a noxious stimulus. Phantom pain is thought to be caused by injury to the severed nerves at the site of amputation. It is important for the clinician to ascertain and then document if the pain is neuropathic in origin. Neuropathic pain tends to respond very poorly to any type of analgesia, while antidepressants and anticonvulsants often significantly diminish perceived distress (Pasero & McCaffery, 2011). Documentation of neuropathic pain is therefore an important justification for prescribing adjunct medications along with physical treatments, mind-body treatments and possibly some alternative strategies. According to Clark & Galati (2012), common chronic pain disorders involving neuropathic pain are peripheral neuropathies (diabetes and HIV related), post herpetic neuralgia, trigeminal neuralgia, central post-stroke pain, spinal cord injury and neuropathic low back pain. Mixed Pain is a category describing a situation where the pain originates from multiples origins (Pasero & McCaffery, 2011). A lot of people living with chronic pain have both nociceptive and neuropathic pain origins, or mixed pain. Designation of mixed pain is important to the treating clinician because this implies that the pain may Page 8 of 57

9 be responsive to either analgesic medications or adjunct medications along with physical treatments, mind-body treatments, and possibly some herbal supplements or alternative strategies. There are a variety of chronic pain disorders that typically have components of both nociceptive and neuropathic pain. The pain accompanying these disorders is always difficult to manage and so there numerous types of treatment plans that all meet with variable success. Disorders include migraine and chronic daily headache, fibromyalgia, phantom limb pain, complex regional pain syndrome (CRPS l and ll), multiple sclerosis, skeletal muscle pain, myofascial pain syndrome and low back pain. Because the pain and discomfort associated with chronic pain disorders sometimes fall into more than one category, the comprehensive assessment becomes valuable. COMPREHENSIVE ASSESSMENT OF CHRONIC PAIN The chronic pain experience is widely recognized as involving more than physical pain (Clark & Galati, 2012) because it touches every part of a person s daily life. Beyond the physical burden of pain and fatigue, chronic pain impacts a person s psychological and social approach to life. Chronic pain leads to both functional and psychic disability, eroding at the ability to be independent and self-reliant. Most people living with chronic pain are frustrated not only with their physical symptoms but the attitudes of others since most of their pain is invisible to others. Common cultural values, belief systems and social relationships are challenged as the person begins assuming a more dependent role. Income declines because of lost productivity while expenses keep escalating. In summary, chronic pain is a multi-dimensional and life-changing experience to the individual, family, and community as a whole. A multi-dimensional phenomenon requires a thorough assessment of all the dimensions affected by chronic pain. Taking the time to elicit a through and complete history is as important as the complete physical examination with appropriate diagnostics (Pasero & McCaffery, 2011). It is rare that the individual with chronic pain has not seen multiple health professionals, usually with disappointing outcomes. The unusual characteristics of chronic pain make the historical progress, or lack of progress, in pain management a priority so that a comprehensive treatment plan can logically build on what has already been attempted. Comprehensive assessment should be completed before planning treatment, and then subsequently reviewed to evaluate the effects of any treatment. In addition to physical history and assessments, it would be appropriate to review finances related to current insurance status, legal status related to any current or past claims or proceedings, significant social history such as divorce or history of abuse, and any significant spiritual history such as a recent separation from a church or place of worship. The American Society of Anesthesiologists (2010) recommends conducting a history and physical examination and review of diagnostic studies to provide a foundation upon which the individual treatment plan can be developed. The American Chronic Pain Association (2014) recommends including a psychosocial evaluation and a complete assessment of functional status. Based on the recommendations of these two professional organizations, the following components should be included in every comprehensive chronic pain assessment: Page 9 of 57

10 Pain questionnaire (previously described) that addresses all pain locations and the quality, severity, modifying factors, impact on function, effect of previous treatments, and patient perspectives related to each location Complete medical history and assessment of current status for all identified health conditions Complete psychosocial history and assessment of current status (include sleep patterns, emotions, relationships, mood, risk for suicide) Functional assessment questionnaire that focuses on both history of functionality and/or disability and demonstration of current status (activities of daily living, gait, strength, hand grip, range of motion) Elements of a Comprehensive Pain Assessment Instrument A variety of pain assessment instruments and guides have been developed over the years by numerous pain organizations. A typical comprehensive pain assessment addresses more than just the physical characteristics of pain and includes the following information for each separate source of pain (Pasero & McCaffery, 2011). The person experiencing pain is the one who can best describe it, but it is not unusual for someone to have a difficult time describing the pain. Since many people experiencing chronic pain can identify many separate areas or types of discomfort, expect the comprehensive pain assessment to be lengthy. Most healthcare providers who routinely work with chronic pain patients have developed a questionnaire to be completed before the initial visit. Pain Location Where does it hurt most? Does it go anywhere? How does your pain change over time? How long have you had this pain? Did it begin gradually or all of a sudden? Does it come and go, or do you have it all the time? Quality What words might you use to describe the pain? Severity Rate your pain using a scale from 0 representing no pain to 10 representing the most pain you have ever felt How bad is your pain on average? At its worst? Is the pain progressing or remaining stable? Modifying Factors Does it feel better when you re in a certain position? Do you notice any change with [various activities]? Impact on Function To what extent does the pain interfere with your normal activities? What about your sleep? Your ability to walk? Your relationship with others? Page 10 of 57

11 Your relationship with your God? Effect of Previous Treatments What have you been doing for the pain? Have you taken any medications? How much relief does that provide? Patient Perspectives What do you think is causing the pain? What does the pain mean to you? Would you like a medication or physical treatment to be prescribed? The comprehensive pain assessment is most appropriately a physician or nursing role, but every health provider should know enough about pain and the importance of assessment or screening to at least inquire about pain and comfort at each patient encounter. Licensed and unlicensed health workers should be routinely inquiring about the presence or absence of pain. Since pain is subjective, it cannot be measured with any particular device. No one has ever developed a pain meter to objectively measure or standardize pain. Usually a statement or indication from the patient describing the intensity and location of pain is used to establish its presence. When someone can t report their pain, clinicians are asked to utilize observation of behaviors and when even that strategy becomes unavailable, it is suggested that the presence of pain be assumed when it is reasonable to do so (Pasero & McCaffery, 2011). Pain Intensity Part of the initial comprehensive pain assessment is a rating of intensity, to be used a baseline measure. Healthcare providers rely on the verbal pain report for communication and identification of the pain (Pasero & McCaffery, 2011). When asking the person about pain intensity, the easiest and simplest method is to rate severity using a range of numbers from 0 to 10. Sometimes a different range of numbers is used, but 0-10 seems to be the most common. The number O is used to indicate no pain and the number 10 is used to represent the worse pain ever. Pain intensity rating scales are used to transform the subjective pain experience into an objective, measureable number that can be quickly communicated and documented. Subsequent assessments of pain intensity help to monitor its presence, trend its intensity, and measure the effectiveness of any treatments. Use of pain rating scales helps both the health provider and the person experiencing pain to more easily communicate the presence or absence of pain and its intensity. When verbal report is inadequate alternate pain intensity instruments can be used. Pain intensity rating scales can use numbers, colors or faces. When verbal report is not feasible, behaviorally based pain scales can be used to rate observable indicators of pain (Dirksen, Lewis, Heitkemper & Bucher, 2011; Pasero & McCaffery, 2011). Behavioral indicators typically address facial expression, arm and leg movements, vocalizations such as groaning, and response to any efforts to console the individual. The healthcare provider is asked to score each behavioral indicator in such a way to then report and document a numerical value between 0 and 10. Page 11 of 57

12 COMPREHENSIVE TREATMENT OF CHRONIC PAIN There are strong professional recommendations from several health providers suggesting that a multimodal and/or multidisciplinary treatment plan is most appropriate for the care of those living with chronic pain (American Society of Anesthesiologists, 2010; ACPA, 2014). A multimodal treatment plan involves the use of more than one type of therapy, such as using both analgesic medications along with applications of cold and heat plus physical stretching. A multidisciplinary treatment plan represents using several approaches from more than one professional discipline, such as using a pharmacist, medical physician and physical therapist. The most effective treatment requires familiarity with patient-specific past diagnoses, treatment failures and successes, persistent complaints and confounding psychosocial variables such as history of abuse, anxiety, depression, fear-based avoidance of activity, catastrophizing, self-medication with alcohol or other drugs, patient/family expectations, medical-legal claims, and employer/supervisor/worksite issues (California Department of Workers Compensation, 2009). Knowledge of any past or current legal issues is important to uncover any subtle benefits that contribute to the persistence of chronic pain. For example, someone may believe that their social security disability status will be denied if they report that their chronic pain is improving. Treatments for chronic pain can be categorized in several different formats. In this course study the treatment categories are listed as medications, physical treatment approaches, herbal medicines and dietary supplements, mind-body treatment approaches, and other non-prescription substances and interventions used for pain relief. MEDICATIONS Medications alone should not be relied upon to manage chronic pain but they are an important part of the comprehensive and multimodal treatment plan. When they are used, prescribing healthcare providers should be monitoring and then documenting effectiveness. The American Chronic Pain Association (2014) has identified the most relevant areas for monitoring of opioid use, but these same guidelines are appropriate for any chronic pain medications. Areas for monitoring have been named the Four A s and are listed below: Analgesia assess for pain relief including level of intensity and general well being Activities of daily living assess physical, psychological, and social functioning Adverse effects assess for unwanted side effects Aberrant of abnormal drug-related behaviors assess for history or current indications of any drug or alcohol abuse Family members and close friends may be the best source of information when trying to assess level of functioning in a person with chronic pain. While they are still biased, those living with the person in pain or those who have known that person over a lifetime are the ones who can be more objective in reporting and trending changes in physical, psychological and social function. Page 12 of 57

13 Analgesic medications are the most commonly used forms of treatment when someone has chronic pain. While they are often helpful, they are not universally effective because each person experiences pain differently and each person responds to medication differently (ACPA, 2014). While it may be hard to believe, there are some people who actually experience worsening of their symptoms over time when taking analgesic medications (Pasero & McCaffery, 2011). Without appreciating this hyperalgesic phenomenon, there is a chance that some individuals will keep escalating their medication doses which in turn keep intensifying their pain. Medication management by someone skilled in the treatment of chronic pain is needed to recognize when someone might be taking too much medication. The American Chronic Pain Association (2014) has identified signs that a person is being harmed more than helped by medications being taken for chronic pain. These signs include the following: Sleeping too much or having days and nights confused Decrease in appetite Inability to concentrate or short attention span Mood swings (especially irritability) Lack of involvement with others Difficulty functioning due to drug effects Use of drugs to regress rather than to facilitate involvement in life Lack of attention to appearance and hygiene Escalation of pain Health providers, particularly those who are prescribers, need to have a solid understanding of all medication categories. A review of over-the-counter and prescription pain medications is presented below. 1. Over the Counter (OTC) Analgesics OTC pain medications can be useful and effective for mild to moderate pain but their potential for harm should not be underestimated. Anyone taking an OTC medication should be aware of potential harm related to side effects, drug-drug interactions, and inappropriate dosing. OTC medications are frequently discounted as not really medicine and so health professionals need to routinely ask about their use in order to provide needed education and monitoring (California Department of Workers Compensation, 2009). The most common types of pain relieving medications that are available over-the-counter contain acetaminophen or a non-steroidal-anti-inflammatory-drug (NSAID). All drugs in these categories have some evidence of increasing relative risk for cardiovascular and renal dysfunction when used in large doses over extended periods of time. Since people with chronic pain may consume these medications for years, health professionals should carefully evaluate individual risk. Page 13 of 57

14 Acetaminophen: According to the American Chronic Pain Association (2014), acetaminophen is the active ingredient in more than 600 OTC and prescription medications used to treat pain and discomfort. Acetaminophen is widely known by its U.S. trade name Tylenol. Acetaminophen is sold by itself but is also very common in combination products intended to treat cold, flu and allergy symptoms. Recall that acetaminophen does not have anti-inflammatory properties, and so its use may not be the best choice for treating the chronic pain associated with inflammation. Acetaminophen is well known to be hepatotoxic: the recommended maximum daily dose should never exceed 4 grams/day and most dosing guidelines cut the maximum dose to 2.4 grams/day when there is evidence of compromised liver function (Pasero & McCaffery, 2011). Non-Steroidal-Anti-Inflammatory-Drugs: NSAIDs are also readily available in a variety of OTC products intended for musculoskeletal pain relief, fever reduction, and sinus problems. The most commonly used medications in this class are aspirin, naproxen and ibuprofen. Their most widely known trade names are Bayer, Aleve and Motrin. As a group, NSAIDs are associated with decreased inflammation which is helpful for pain relief but also increased bleeding due to antiplatelet properties. NSAIDs might not be the best analgesic choice when the potential for bleeding is high. NSAIDs are specifically associated with the side effect of gastric bleeding because they reduce the stomach s protective mucous layer and natural protection against stomach acid (ACPA, 2014). Celecoxib (Celebrex ) is an alternative (available by prescription only) that does not appear to interfere with antiplatelet properties and has a reduced effect on the stomach s protective mucosa but cost is significantly higher in proportion to the small amount of decreased risk. NSAIDs are known to be associated with increased risk of cardiovascular disease and kidney failure (McCance, Huether, Brashers, & Rote, 2010). Topical Analgesics: Topical creams, gels, liquids, patches, rubs or sprays must be applied directly over the painful area because they work locally. Rigorous scientific evidence supporting their use is limited or non-existent, but continued sales indicate that they are being used. Many OTC topical products contain salicylates or small amounts of NSAID (ACPA, 2014). These products are intended to relieve mild to moderate pain and some degree of local inflammation. Other OTC topical products are most appropriately categorized as counterirritants because they stimulate nerve endings in the skin to cause feelings of cold, warmth, or itching and paradoxically these sensations counter the more severe underlying pain. Examples include BenGay, Icy Hot, and Salonpas. Clinicians should be asking whether these products are being used, and also advising others that these products should not be applied over open sounds, damaged skin, or on the face. 2. Non-Opioid Prescription Analgesics The primary prescription medications in this category include non-steroidal-anti-inflammatory-drugs (NSAIDS) that are formulated for use when OTC medications have been tried and found to be insufficient to produce pain relief. Other prescription analgesics in this category include topical and transdermal applications. Compounded medications available as topical applications are also used. Non Steroidal Anti Inflammatory Drugs (NSAIDS) Page 14 of 57

15 Different NSAIDS have properties that may promote better pain relief than others and so people with chronic pain might need to try several of them before identifying the medication that seems to work best. As a group, all NSAIDS are associated with significant cardiovascular, hepatic and GI side effects (McCance, Huether, Brashers & Rote, 2010). It is generally recommended to use the lowest effective dose for the shortest duration possible. Long term treatment is not recommended but remains a current strategy for those with chronic pain when perceived benefits outweigh perceived risks. In the U.S., most available NSAIDS are nonselective inhibitors of prostaglandins but one NSAID believed to have fewer GI side effects is the selective COX-2 NSAID celecoxib (Celebrex ). Most NSAIDs are administered orally and several can be compounded by a pharmacist for topical use. A few are formulated for intramuscular or intravenous use. The table below summarizes typical uses and a few comments regarding many of these drugs. Table: NSAID Summary (ACPA, 2014; California Department of Workers Compensation, 2009) Medication Indications Comments Aspirin, salicylic acid Reduces fever, mild to moderate pain, and inflammation. Inexpensive, daily dosing. Believed to have cardioprotective benefits. Known to irritate the stomach lining. Enteric coated tablets available. Do not administer to children or adolescents due to potential for Reyes Syndrome. Salicylate Salts such as Choline magnesium trisalicylate (Trilisate ) Ketoprofen (Orudis or Oruvail ) Meloxicam (Mobic ) Selective COX-2 inhibitor celecoxib (Celebrex ) Diclofenac (Voltaren, Zipsor ) Diflunisal (Dolobid ) Etodolac (Lodine ) Fenoprofen (Nalfon ) Pain associated with osteoarthritis and rheumatoid arthritis, Pain associated with bone cancer Headache, muscle ache, fever, menstrual cramps, cold or flu aches Pain associated with osteoarthritis Muscle aches, joint pain, pain and inflammation Pain associated with osteoarthritis Pain associated with osteoarthritis Pain associated with rheumatoid and osteoarthritis Pain associated with osteoarthritis, also helpful for bone pain. Has fewer GI side effects than other NSAIDs but still known to irritate the stomach. Reduces inflammation, more gentle to the stomach than aspirin.may be harmful for those with kidney or liver disease or those who drink alcohol heavily. Not recommended for children. Less risk of stomach ulcers than other NSAIDs. Relatively expensive compared to other NSAIDS. Generally well tolerated but still need to be concerned about GI side effects Helps reduce inflammation, less stomach irritation than other NSAIDs. Generally well tolerated but still need to be concerned about GI side effects. Relatively expensive than other NSAIDS. No effect on bleeding time. Available by prescription only. Not recommended as first line therapy due to increased cardiovascular and hepatic risk Derivative of salicylic acid, possible risk for Reyes Syndrome when administered to children and adolescents. Often makes skin more sun sensitive. Not indicated for long term use without periodic labs and diagnostic studies. Taking this medication during the last three months of pregnancy is known to cause birth defects Page 15 of 57

16 Flurbiprofen (Ansaid ) Osteoarthritis pain Taking this medication during the last three months of pregnancy is known to cause birth defects Ibuprofen (Caldolor ) Short term pain or fever episode of limited duration, typically post operative Intravenous or intramuscular injection preparation only. Usually administered in inpatient setting or post procedure, identified cardiovascular and GI risks Indomethacin (Indocin ) Kertorolac (Toradol and others) Mefanamic acid (Ponstel ) Pain associated with gout, rheumatoid arthritis, ankylosing spondylitis and many inflammatory conditions Acute pain episode of limited duration Headache and migraine pain, pain associated with dysmennorhea Osteoarthritis pain Available in a variety of forms including suppository, IV, and sustained release. Can makes skin more sun sensitive. Intravenous or intramuscular injection preparation only. Usually administered in inpatient setting or post procedure, identified cardiovascular and GI risks Indicated for recurrent episodes of short duration rather than daily over long period of time Nabumetone (Relafen ) Available as generic but discontinued as a trade name medication Oxaprozin (Daypro ) Pain associated with Designed to be taken once daily rheumatoid arthritis Piroxicam (Feldene ) Pain associated with Has both analgesic and antipyretic properties. Available rheumatoid and as transdermal patch in China. osteoarthritis Sulindac (Clinoril ) Pain associated with Available in twice daily dosing. Avoid in the last three rheumatoid arthritis months of pregnancy Tolmetin (Tolectin ) Osteoarthritis pain Available as tablet or capsule Combination NSAID/GI Pain associated with Do not administer to pregnant women as it can cause protectant osteoarthritis abortion. diclofenac/misprostel (Arthrotec ) Prescription Topical and Transdermal Pain Relievers: Topical agents work locally and may contain aspirin or capsaicin (the active ingredient in hot peppers that produces a hot, burning sensation when applied to the skin). The Qutenza patch with 8% capsaicin is approved by the FDA for neuropathic pain attributed to post herpetic neuralgia (ACPA, 2014) and is recommended for continued use while the individual has symptoms. EMLA cream (Eutetic Mixture of Local Anesthetic) contains both lidocaine and prilocaine and is applied to the skin, covered with an occlusive dressing, and left on for at least one hour but no longer than two hours to produce locally effective analgesia (Pasero & McCaffery, 2011). This cream is typically prescribed for use prior to an anticipated procedure such as blood draw but not used to treat chronic pain. Transdermal agents work systemically but are applied to the skin in an effort to decrease the side effects associated with oral ingestion and to enhance convenience. Transdermal products containing an NSAID such as diclofenac (Voltaren ) are used to minimize the side effects of oral NSAID use. Another treansdermal product contains buprenorphine (Buprenex ) and is used to mitigate the effects of an opioid. Transdermal products containing a local anesthetic such as lidocaine (Lidoderm patch) are intended to produce a local effect with minimal systemic involvement. Page 16 of 57

17 Compounded Medications: These medication products are not commercially available as prepared substances, they are prescribed and then prepared by a compounding pharmacist to meet an individual need. The most common compounded medications are topical gels with ketoprofen, gabapentin or other active ingredients. Hospice providers often use compounded topical products for use at end of life when individuals have trouble swallowing. As a group, compounded medications have a limited use when treating those with chronic pain. They do not go through the same FDA approval processes and so their safety and efficacy is not assured. Compounding pharmacists who prepare a topical product prescribed by a physician typically offer a safe and effective product but there have been some situations where the products were prepared incorrectly. Continued use of these products should be monitored and then supported by documented evidence of effectiveness. Ideal documentation of effectiveness should include any functional improvement or decreased use of other pain medications (ACPA, 2014). 3. Adjuvant Medications Additional prescription medications used for pain relief fall into a variety of categories. The definition of an adjuvant medication in pain management is a substance that is primarily used to treat a condition other than pain but in fact also contributes to pain relief (Pasero & McCaffery, 2011). Some are used to relax muscles or address spasticity. Others are primarily used to treat depression or convulsions but are known to also decrease the severity of chronic pain related to nerve damage. Antidepressants The optimal role for antidepressants in chronic pain when addressing chronic pain is unclear but as a group these medications are known add to an overall reduction in pain and increase perceived quality of life. The American Chronic Pain Association (2014) identifies the following benefits: Low potential to cause stomach inflammation and bleeding (unlike NSAIDS) Do not seem to interfere with the body s production of endorphins (unlike opioids) and in fact are known to increase the effects of norepinephrine and serotonin Many act to promote restful sleep and have a better safety profile than true sedatives Treat depression which is common among those with chronic pain Help to relieve anxiety and panic attacks with a better safety profile than anxiolytics May increase analgesic effects when used along with pain medications Loss of effect due to tolerance is not an issue once optimal dosing is achieved The pain states that seem to best respond to treatment that includes antidepressant therapy include post herpetic neuralgia, diabetic neuropathy, phantom limb pain, stump r neuroma pain, central pain following stroke, sympathetic dystrophy (CRPS, RSD), chronic musculoskeletal pain, migraine and tension headache, chemotherapy induced peripheral neuropathy, fibromyalgia, irritable bowel syndrome, rheumatoid arthritis, neuropathic pain, Page 17 of 57

18 and low back pain with radiculopathy (ACPA, 2014). These pain states all have either neuropathic or mixed pain etiologies. Tricyclic antidepressants (TCAs) are a class of drugs within the antidepressant group that have long been recommended for the treatment of either acute or chronic neuropathic pain, especially when insomnia, anxiety or depression co-exist (Moore, Derry, Aldington, Cole, & Wiffen, 2012). The mechanism of action is not completely understood, but thought to be partly due to the inhibition of re-uptake serotonin and norepinephrine plus other mechanisms including inhibition of nicotinic receptors in unmyelinated axons of human peripheral nerves (Freysoldt, Fleckenstein, Land, Irnich, Graafe, & Carr, 2009). As a class, TCAs are relatively safe but they have strong anticholinergic properties and should be avoided in people with known cardiac arrhythmias or other cardiac history. Since many people with chronic pain also have other chronic conditions including heart disease, the TCAs are used more for younger and relatively healthy individuals with no suggestion of any cardiac history. Typical side effects for TCAs include dry mouth, blurred vision, constipation, difficulty urinating, worsening of glaucoma, impaired thinking and fatigue. Amitripyline (Elavil ) is a common tricyclic antidepressant and is considered a first-line agent unless proven ineffective, poorly tolerated, or considered unsafe due to medical history. Mirtazapine (Remeron ) is another common TCA and is known to increase cholesterol and increase appetite, leading to weight gain. The unusual characteristic of mirtazapine is that lower doses lead to more sedation while higher doses are associated with less sedation. The clinician should be aware of this opposite side effect because when the person reports oversedation, the strategy should be to increase the dose rather than reducing or splitting the dose. Monoamine oxidase inhibitors are another class of antidepressant drugs but they are not typically considered for the treatment of any type of chronic pain. If someone with chronic pain is using them, it will be because they are being treated for major depression and it was found that this class of drug is most effective for them. Selective serotonin reuptake inhibitors (SSRIs) and selective serotonin and norepinephrine reuptake inhibitors (SNRIs) are other classes of antidepressant drugs recommended as adjunctive therapy for any type of chronic pain (Pasero & McCaffery, 2011). These drugs are considered to be a little safer for older adults because of less anticholinergic properties. SSRIs have not been found to be specifically helpful for neuropathic pain but are used along with analgesics for their synergistic effects in improving painful symptoms. SSRIs should be used with caution in anyone having a history of epilepsy, mania, cardiac disease, diabetes, angle-closure glaucoma, bleeding disorders or high risk for bleeding tendencies, liver or kidney disease, pregnancy and breastfeeding. Fluoxetine (Prozac ) and sertraline (Zoloft ) are common examples. SNRIs are known to reduce musculoskeletal and nerve related chronic pain. They are typically prescribed for diabetic neuropathy, fibromyalgia, and chronic low back pain. Venlafaxine (Effexor ), duloxetine (Cymbalta ) and buproprion (Wellbutrin ) are commonly used drugs in this category. Blood pressure should be monitored in those taking venlafaxine since this drug is known to increase systolic blood pressure. Duloxetine (Cymbalta ) is Page 18 of 57

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