Alternative Treatments for Chronic Pain
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2 Alternative Treatments for Chronic Pain
3 MICIS Workshop Speakers: Peter Michaud, RN, JD Elisabeth Fowlie Mock, MD, MPH Gordon Smith, JD
4 Disclosures MICIS does not accept any money from pharmaceutical companies This presentation includes off label use of medications
5 Materials May Include: un-ad one page handout for each topic Update on ME laws slide set How to Use Naloxone (pt brochure) Chapter 21 rules DHHS prescription guide National/state numbers Resource documents at MICISMAINE.org
6 Learning Objectives Discuss alternative treatments for chronic pain management Highlight a team based approach to care for patients living with chronic pain Understand ways to reduce pain by addressing the physical, psychological, social and spiritual components of pain
7 Outline Introduction Nonpharmacological treatments Pharmacological treatments (non-opioid) Best practices
8 Chronic Pain Best Practices Multiple approaches Utilized in concert Coordinated Multidisciplinary team Medication not sole focus of treatment Set reasonable expectations Nociceptive Pain Neuropathic Pain
9 HARM REDUCTION/HEALTH PROMOTION Access to NALOXONE Avoid co-prescribing benzos and opioids Identifying OUD and referring to treatment
10 BEST PRACTICE EXAMPLES Mercy Pain Center-integrated chronic pain treatment 1/14/16 Quality Counts webinar Expanding the Team Harrington Health Center-mapping of complementary medical neighborhood
11 Brainstorming exercise & discussion NONPHARMACOLOGICAL
12 NONPHARMACOLOGICAL APPROACHES Behavioral Exercise/touch Anti-inflammatory diet Complementary practitioners Energies Interventional approaches Emerging therapies
13 BEHAVIORAL Cognitive behavioral therapy (CBT) Individual & group counselling Biofeedback Mindfulness Relaxation therapy Psychotherapy Hypnosis Meditation Guided imagery Balneotherapy
14 EXERCISE/TOUCH Aerobic Aquatic Yoga Tai Chi; QiGong Massage Reflexology Therapeutic touch Kinesiology tape
15 ANTI-INFLAMMATORY DIET Plant-based foundation Fiber rich Limited saturated fat, no trans fat Omega-3 fatty acid rich Avoid processed foods & refined sugars Nuts and seeds Avoidance of gluten and/or dairy
16 COMPLEMENTARY PRACTICES Osteopathic manipulation Acupuncture Physical therapy Occupational therapy Chiropractic Music therapy
17 ENERGIES Ultrasonic stimulation Electrical neuromodulation Transcutaneous electrical nerve stimulation (TENS) Spinal cord stimulation Thermal application (heat/cold) Reiki Whole body vibration Infrared therapy
18 INTERVENTIONAL APPROACHES Ablative techniques Botulinum toxin injections Nerve blocks Trigger point injections Epidural steroid injections Minimally invasive surgical techniques
19 EMERGING THERAPIES Virtual reality i.e. SnowWorld Acute/peri-operative pain Chronic pain
20 Understanding Pain: Brainman Chooses
21 Best Practices Calais orthopedic surgery group-taper off opioids preop for elective cases Bucksport Regional Health Center- Pain on the Brain required curriculum through behavioral health & palliative care exemption committee case review
22 Brainstorming exercise & discussion PHARMACOLOGICAL
23 PHARMACOLOGICAL APPROACHES Nonopioid Analgesics Antidepressants Anticonvulsants Adjuvants Natural medicines Anti-inflammatory Antidepressants Misc.
24 Nonopioid Analgesics Acetaminophen NSAIDs-naproxen Platelet aggregation inhibition GI: dyspepsia & gastric ulceration Nephrotoxicity Cardiovascular COX-2 inhibitors-celecoxib
25 Antidepressants Tricyclics (TCAs) Desipramine & nortriptyline Amitriptyline Serotonin norepinephrine reuptake inhibitors (SNRIs) Venlafaxine Duloxetine Selective serotonin reuptake inhibitors (SSRIs)
26 Anticonvulsants Gabapentin Pregabalin Topiramate Lamotrigine Levetiracetam Phenytoin Valproate Carbamazepine/oxcarbazepine NOT Benzodiazepines (esp clonazepam)
27 Adjuvants Topicals lidocaine, capsaicin, NSAID, doxepin Antispasmodics/muscle relaxants (not carisoprodol) Botulinum toxin Cannabis & cannabinoids
28 Natural medicines-anti-inflammatory Bromelain Cat s Claw Devil s Claw Stinging nettle Turmeric Willow bark
29 Natural medicines-antidepressants 5-HTP L-tryptophan St. John s wort Acetyl-L-carnitine Alpha-lipoic acid Counterirritants: Camphor Capsicum
30 Natural medicines-misc Arnica Avocado Cetylated fatty acids Chrondroitin sulfate Comfrey Glucosamine sulfate (+HCl) Marijuana/cannabis MSM N-acetyl glucosamine SAMe Soybean oil Many others
31 Cannabis--Benefits High-quality evidence for several conditions Possible decrease in opioid use for chronic pain (causality not shown) No respiratory depression, not lethal in overdose For some patients, financially accessible by growing own supply
32 Cannabis Side Effects Risk of use disorder 9% in general public, higher in patients prone to chemical coping Chronic bronchitis (smoking/inhaled) Psychosis and anxiety Cognitive dysfunction drop in IQ temporary in adults, can be permanent in adolescents Doubled risk of motor vehicle crashes while under the influence
33 Cannabis--Unknowns Barriers to scientific study due to Schedule 1 status Thousands of chemicals in the plants difference species and variable concentrations of THC and CBD Incentives for big tobacco, venture capitalists and state governments as of early 2018, a $7 billion industry
34 PCSS podcast fantastic overview of non-opioid treatments and studies Naltrexone at microdoses Episode 8: Non-opioid pharmacological management of chronic pain, 5/23/17
35 Reference #1-UpToDate Article (requires subscription) Overview of the treatment of chronic non-cancer pain Last update 11/30/17, literature review through Jan, 2018 Graphic 2-page 13 Neuropathic pain: Pharmacologic approach Graphic 3-page 14 Nociceptive pain: Pharmacologic approach Graphic 4 comparison on NSAIDs Graphic 6 comparison of SEs of antidepressants
36 Reference #2-Prescriber s Letter (subscription required) Multiple summaries, guidelines & charts for chronic pain tx Natural Medicines in the Clinical Management of Pain, Vol 15, No 106, Self-study course #150106
37 MICISmaine.org Chronic Pain Toolkit
38 Highlighted Resources in Toolkit CDC 2 page handout on chronic pain tx NIH Chronic Pain in Depth NIH e-book Pain: Considering Complementary Approaches
39 In Summary...
40 A multitude of nonpharmacological options can benefit patients in acute and chronic pain Management of both acute and chronic pain is most effective when done by teams Pain is complex and has multiple dimensions: physical, psychological, social and spiritual
41 other references: MICISMaine.org
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