Carl Melling, MD Associate Director, St Cloud Family Medicine Residency Assistant Professor, University of Minnesota Department of Family Medicine

Transcription

1 Carl Melling, MD Associate Director, St Cloud Family Medicine Residency Assistant Professor, University of Minnesota Department of Family Medicine and Community Health

2 Acute Pain = less than 30 days Subacute Pain = 1 to 6 months Chronic Pain = greater than 6 months

3 How Common is Chronic Pain? 100,000,000 Americans have chronic pain of some type 2011 study by Institute of Medicine Nearly 1 in 3 adults in U.S. Women more commonly affected Cost to society: $635 billion a year, which is more than the yearly costs for cancer, heart disease and diabetes

4 Chronic Pain can also Cause: Fatigue Sleeplessness Withdrawal from activity Changes in mood including hopelessness, fear, depression, irritability, anxiety, and stress Disability

5 Why Is There Pain?

6 Congenital Insensitivity to Pain The inability to feel pain and temperature Symptoms appear early, usually at birth or during infancy Leads to repeated severe injuries Unintentional self-injury is common Biting the tongue, lips or fingers May lead to spontaneous amputation of the affected area, destruction of bones and joints Many do not live into adulthood

7 Diabetic Foot Ulcer

8 Wired for Pain

9 Nociceptor = Pain Receptor Types Thermal - temperature Mechanical - excess stretch, pressure, cuts Chemical spices (hot peppers), tear gas

10 Conscious Thought Limbic System Emotional Thought Fear Anxiety Anger Flight Spinal reflex Automatic No thought involved

11 Scientists used the structure of the brain's white matter (green lines) to predict whether a subject would recover from low back pain. Red dots represent differences in white matter structure between subjects who recovered and who suffered chronic pain.

12 Limbic System Receives and stores emotional memories Sounds (music) Sights Smells Sex Joy Pain Tends to lock in the first experiences with a powerful stimulus Involved in PTSD, chronic pain and addiction

13 Chronic Pain Pain Resolves

14 Types of Chronic Pain Nociceptive normal function of pain receptors 1. Damage to tissue - Cut, skinned knee, broken bone, heart attack, cancer 2. Abnormal stretch gallbladder attack, bowel obstruction, kidney stone, visceral pain 3. Thermal injury burns, frostbite

15 Types of Chronic Pain Neuropathic - abnormal function of nerve endings or nerve pathways. Burning, stinging, pins and needles. Shingles, phantom limb pain, carpal tunnel syndrome, diabetic neuropathy

16 Types of Chronic Pain Central abnormal reception of pain in the brain low intensity pain signals are misinterpreted as more severe Certain types of stroke, fibromyalgia Likely plays a role in most forms of chronic pain.

17 Most Common Chronic Pain Syndromes Back Pain Headache Neck Pain Fibromyalgia Diabetic neuropathy Abdominal pain Pelvic pain Chest Pain Shingles

18 Treatment Attempt to pin down an accurate diagnosis If possible, fix the underlying problem

19 For Chronic, Unfixable Problems: Lifestyle modification Physical therapy Behavioral therapy Interventional treatment Medication

20 Lifestyle Modification KEEP MOVING! Even if it hurts!

21 Lifestyle Modification

22 Physical Therapy

23 Behavior Therapy

24 Interventional treatments

25 Medications Topical

26 Medications OTC Aspirin Good for pain, inflammation Can cause bleeding, ulcers, Reye's syndrome in children Non-steroidal anti-inflammatory drugs Ibuprofen (Motrin. Advil) Naproxen (Aleve) Good for pain, inflammation Can cause ulcers, kidney damage Acetaminophen (Tylenol) Does not reduce inflammation Safe for the stomach Can cause liver damage, especially mixed with alcohol Caffeine Found in many OTC pain relievers. May help some migraines

27 Medications Prescription Gabapentin, Lyrica Anticonvulsants calm damaged nerve tissue Amitriptyline, Cymbalta, Savella Antidepressants - act in the brain Prescription NSAIDs diclofenac, etodolac, fenoprofen, flurbiprofen, indomethocin, ketoprofen, ketoralac, meclofemanate, meclofemic acid, meloxicam, nabumatone, piroxicam, nabumetone, high dose ibuprofen and naproxen, sulindac

28 Medications Opioids (Narcotics) Hydrocodone plus acetaminophen Hydrocodone plus ibuprofen Oxycodone immediate relase Oxycodone 12 hour Oxycodone plus acetaminophen Morphine immediate release Morphine slow release Codeine Hydromorphone Fentanyl skin patch Vicodin, Norco Vicoprofen Oxycontin Percocet MS Contin Dilaudid Duragesic

29 The Story on Opioids (Narcotics) Opium is an extract from the fluid of the poppy seed pod Active compound is morphine Probably used by Neanderthals 30,000 years ago First described in writing 6,000 years ago

30 But then Helen had a happy thought. Into the bowl in which their wine was mixed, she slipped a drug that had the power of robbing grief and anger of their sting and banishing all painful memories. No one who swallowed this dissolved in their wine could shed a single tear that day, even for the death of his mother or father, or if they put his brother or his own son to the sword and he were there to see it done..."

31 But then Helen had a happy thought. Into the bowl in which their wine was mixed, she slipped a drug that had the power of robbing grief and anger of their sting and banishing all painful memories. No one who swallowed this dissolved in their wine could shed a single tear that day, even for the death of his mother or father, or if they put his brother or his own son to the sword and he were there to see it done... Telemachus in The Odyssey, by Homer 800 B.C.

32 **1986 Dr. Russell Portenoy, a New York pain specialist, published a paper advocating using long-term opioids in patients with chronic nonmalignant pain. **Offered suggestive evidence that opioid medications can be safely and effectively prescribed to selected patients with risk of addiction less than 1%. **Dr. Portenoy hit the lecture circuit. Charming and articulate, he became a sought after public speaker. He argued that opioids are a gift from nature that were being forsaken because of opiophobia among doctors **Other prominent pain specialists jumped on the bandwagon **2001 The Joint Commission mandated that hospitals focus on monitoring and treating patients pain. Introduced the 1-10 pain score

33 **2004 The Federation of State Medical Boards urged that state boards punish physicians and hospitals for not treating pain adequately. **VA developed similar policies So What Went Wrong??

34 **Portenoy s conclusions were based on 38 of his own patients who were hand picked for the study. **The 1% addiction rate was based on a 1 paragraph letter to the editor of the NEJM that was about ACUTE pain, not chronic. The Federation of State Medical **The Federation of State Medical Boards had received $2,000,000 dollars in funding from drug companies who make opioid drugs **The Joint Commission guidebook, stating There is no evidence that addiction is a significant issue when persons are given opioids for pain control was paid for by Purdue Pharma, maker of Oxycontin **In 2007, Purdue Pharma and three executives pleaded guilty to misbranding of the drug as less addictive and less subject to abuse than other pain medicines and paid $635 million in fines

35 There are NO STUDIES on the use of opioids in chronic pain! The actual addiction rate is closer to 40-50%!

36

37

38

39 The Problem of Diversion

40 Opioid Side Effects Drowsiness Confusion Nausea/vomiting Constipation Urinary retention Itching Depression Respiratory depression Addiction Death

41 Think Twice About Using Opioids If You: Have a history of addiction of any kind Are on sedative medications, especially Valium-like drugs Use alcohol, marijuana or other illegal drugs Have sleep apnea Are obese Are a male with prostate problems Have not faithfully used all other treatment options first Are not willing to be seen in the clinic regularly Are not willing to submit to drug testing Are OK with health care professionals questioning your use of an addictive drug

42 So What Works? Physical Therapy/Physical Fitness 30-60% Behavioral Therapy/Meditation 30-50% Sleep Restoration 30-40% Opioids Less than 30% Antiepileptics Less than 30% Acupuncture 10%+ l

43 Take Home Points 1.Deal with pain early on 2.You as the patient must actively work at dealing with pain 3.Stay active and fit, unless told otherwise, even if it hurts 4.Don t count on pills to cure your pain they don t work that well 5.Avoid opioids except as a last resort

44 THANK YOU!