Practical Approaches to the Patient with Chronic Pain

Practical Approaches to the Patient with Chronic Pain M. Jean Uy- Kroh, MD, FACOG Assistant Professor Of Surgery, CCLCM Director of Chronic Pelvic Pain Program Women s Health Institute Cleveland, Ohio

For those of you who downloaded the powerpoint to get the analgesia therapeutics please see the separate Mword Document I uploaded. I hope you find the information helpful.

CLINICAL PEARL: For patients who exhibit centralized pain features that were discussed during the talk I recommend you consider not just starting with the standard gyn meds of NSAIDS and hormones and wait for them to return to the office saying they feel no better or different. Instead, consider concomitant start of one of these central acting medications in addition to our standard gyn medications. And of course, please counsel patients on the side effects of these medications and that it will take several weeks/ months before they may experience the full pharmacologic benefit.

CLINICAL PEARL: For patients who exhibit centralized pain features that were discussed during the talk I recommend you consider not just starting with the standard gyn meds of NSAIDS and hormones and wait for them to return to the office saying they feel no better or different. Instead, consider concomitant start of one of these central acting medications in addition to our standard gyn medications. And of course, please counsel patients on the side effects of these medications and that it will take several weeks/ months before they may experience the full pharmacologic benefit.

Practical Approaches to the Patient with Chronic Pain M. Jean Uy- Kroh, MD, FACOG Assistant Professor Of Surgery, CCLCM Director of Chronic Pelvic Pain Program Women s Health Institute Cleveland, Ohio

Objectives Discuss the impact and challenges of Chronic Pelvic Pain (CPP) Provide a basic review of pain physiology and recent insights Reframe our understanding of CPP Review common causes and treatments for CPP

Impact CPP is non cyclic pelvic pain 6 months localized below the umbilicus and Severe enough to cause functional disability or leads to medical care (ACOG) $2.8 Billion/ year in medical costs + $15 Billion/ year lost productivity Gyang, Anthony et al, Musculoskeletal Causes of Chronic Pelvic Pain: What a Gynecologist Should Know. Obstet Gynecol. 2013 Mar;121(3):645-50

Impact CPP Affects 15% of women in the US annually Is multifactorial in nature which makes it difficult to evaluate and treat Often erroneously implicate endometriosis, adenomyosis, PID as etiology of pain

CPP Impact

Challenges No clear algorithm and treatment care paths Reality of time and economic constraints Emotional burden on physician/ surgeon/ PA/NP Dearth of treatment resources Paucity of pelvic pain education in our training

As a GYN please note -Estimated 70% of CPP etiology is NOT gynecologic in origin -yet it is the indication for: 10% outpatient office visits 40% diagnostic laparoscopies 12% hysterectomies Collett et al, A comparative study of women with chronic pelvic pain, chronic nonpelvic pain and those with no history of pain attending general practitioners. Br J Obstet Gynaecol. 1998 Jan;105(1):87-92

Why it matters Appropriate patient selection for surgery Surgery can amplify pain Appropriate patient with targeted medical therapy Has a tremendous positive impact on quality of life

Adapted from S. As-Sanie, MD PAIN NOCICEPTIVE NEUROPATHIC CENTRAL PERIPHERAL Peripheral inflammation or mechanical damage Osteoarthritis, Cancer Central pain processing error that is not due to painful stimuli IBS, TMJ, FM Peripheral nerve damage or entrapment Diabetic neuropathy Herpes Zoster

Adapted from S. As-Sanie, MD PAIN NOCICEPTIVE NEUROPATHIC CENTRAL PERIPHERAL Peripheral inflammation or mechanical damage Osteoarthritis, Cancer Central pain processing error that is not due to painful stimuli IBS, TMJ, FM Peripheral nerve damage or entrapment Diabetic neuropathy Herpes Zoster

What s going on? It s not always clear The case of Endometriosis I have pain it used to be cyclical but now its daily Laparoscopy à Excisional biopsies confirm endometriosis and no evidence of D.I.E. Continuous medical management, NSAIDS Ultimately she undergoes TLH BSO w/ no evidence of D.I.E STILL has pain Now what should you offer? What is one to think?

IBS, TMJ, FM central pain syndromes Characterized by Multifocal pain Multiple somatic symptoms High rates of co-morbidities with other related syndromes 1.5 2X more common in females Strong familial/genetic underpinnings Triggered or exacerbated by stressors Pain and sensory amplification (experimental pain testing) is most reproducible pathophysiological feature Adapted from S. As-Sanie MD

Decreased Regional Gray Matter Density in Patients with IBS Medial prefrontal cortex Ventrolateral prefrontal cortex Posterior parietal cortex Ventral striatum Thalamus Seminowicz 2010

Decreased Regional Gray Matter Density in Patients with Cyclic Menstrual Pain R medial frontal gyrus R central/ventral precuneus B somatosensory cortex (posterior & mid insula) Tu et al. 2010

Decreased Regional Gray Matter Volume in Women with CPP Endo Pain vs. age-matched controls (n=17,17) B cingulate gyrus R putamen R posterior insula L thalamus Endo Pain vs. age-matched controls (n=6,12) L thalamus P<0.001, extent threshold = 200 contiguous voxels

Increased Regional Gray Matter Volume in Women with Endo Pain Endo Pain vs. age-matched controls (n=15,14) R Periaquaductal Gray P<0.001, extent threshold = 200 contiguous voxels

Correlates of regional atrophy in women with CPP & endometriosis Decrease in thalamic gray matter is associated with increased pain unpleasantness Regional atrophy NOT associated with: Depression, anxiety, hormonal contraceptive use Duration of pain As-Sanie et al, Changes in regional gray matter volume in women with chronic pelvic pain: a voxel-based morphometry study. Pain. 2012 May;153(5):1006-14.

Summary of Findings Women with CPP demonstrate higher pain sensitivity, regardless of the presence of endometriosis Women with CPP demonstrate localized decreases in brain volume in key regions of the pain matrix (e.g. thalamus) Unlike CPP patients, women with endometriosis and no CPP show localized increase in brain volume in key regions of the pain matrix known to be associated with pain inhibition 26

History it s important Given complexity of needs will refer to Dr. X for surgery THANKS! But know when it will not help the patient, and may even harm her. Consider medical therapy (antiepileptic or antidepressant therapy with analgesic properties)

History- the office visit Find a method that works for you and remember: -For the patient, talking is therapeutic Screen for abuse, current safety, safety of exam and guidelines If you don t ask who will? Explain why you are asking Avoid concluding causal relationship of pain

Essential Element of History Patient s functionality the clearest window Able to continue work? Take care of household activities? Enjoy leisure activities? Sleep and exercise regimen now v. before pain Patient s response to pain exacerbations Reactive v. proactive Introduce the exam chronic pelvic pain exam Musculoskeletal evaluation, avoidance of speculum until end if at all necessary, visual inspection, qtip vestibule/vulvar testing, single digit exam, no bimanual, pelvic floor survey

History- the office visit Also remember: You don t have to be their BFF

History- the office visit You don t have to spend hours with them (but they might require more time.) Why are you telling me this? We don t need any more information!

The office visit Also remember: They might not like what you have to say

Get me 100 mg Oxycontin and pick up something for this guy while you re at it. Opioid induced hyperalgesia

Surgical Considerations Vaginal cuff revision/ trachelectomy focal tenderness on exam, predictable and reproducible (dyspareunia) without other nociceptive pain

Surgical Considerations Hysterectomy appropriate if: all other etiologies have been excluded Urologic, GI, MSK the patient does not desire fertility the patient has been adequately counseled on surgical goals and pain expectations (reduction not elimination)

Surgical Considerations Ovarian Remnant Syndrome observe, excise if suspicious for malignancy, adhesiolysis and excision of surrounding fibrosis but often retain the ovary

Surgical Considerations Caveat for all surgeries: I cannot guarantee your pain will improve with surgery and it may even worsen

Impact

Treatment Considerations Consider central acting medications as first line therapy along with standard hormonal modulation and NSAIDs in patients with neuropathic pain features v. After using standard hormonal suppression and hormone modulation if pt is still symptomatic add central acting meds.

Medical Therapies with Analgesic Effects Drug Class Antidepressant Dosage Side effects and contraindications TCA Amitryptyline Elavil Venlafaxine Effexor 10mg & 25mg tabs If 1 tab works use as maintenance dose. If still with symptoms increase by 1 tab at night per wee

Medical Considerations

Other Therapies Physical Therapy Yoga but not pilates (too much valsalva) Electrical stimulation (TENS like device some are external others are internal devices) Pain Psychology CBT often group therapy Sleep hygiene Daily (sweaty) exercise regimen -start slow and progress toward vigorous aerobic exercise Nicotine cessation controversial