Optimizing Non-Opioid Therapy for Chronic Pain

Optimizing Non-Opioid Therapy for Chronic Pain

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Learning Objectives Cite the available non-opioid medications available for managing pain Evaluate the potential risks and benefits of non-opioid medications

Pain Is Seen Everyday in Primary Care 1 in 5 Canadian adults suffer from chronic pain Pain is the most common reason for seeking health care Presenting complaint in up to 78% of visits to the emergency department The prevalence of pain is likely to continue to increase as our population ages The Canadian Pain Society. Pain in Canada Fact Sheet.

Management of Pain Is Evolving Manage pain with every option Less concern with opioids Emphasis was treating pain aggressively as the risk was thought to be minimal Increasing concerns about opioid use and addiction Need to manage pain, but large focus on safety Focus on non-opioid options

Each Patient With Pain Is Unique Approach to managing each case is the same: Assess Type of pain Patient characteristics Other disease states and medications Red flags What therapies can we use to treat pain?

Case #1: Mr. Jones Mr. Jones is here to see you to discuss his low back pain.

What Is the Most Important Information You Need to Determine the Treatment for Low Back Pain? a. Age of patient b. Comorbid conditions c. Current medications d. Acute or chronic e. Level of impairment f. What has been done to manage the pain g. Current imaging of his back

Mr. Jones: Low Back Pain 42 years old Low back pain Pain intensity 6 to 7 on 10-point scale Uses topical products for back pain Pain has flared over the last few days, and it is impacting his sleep and daily function No underlying medical conditions

Low Back Pain: TOP Guidelines TOP = Toward Optimized Practice Updated in December 2015 Addresses: Prevention of LBP Management of acute LBP Management of chronic LBP Patient education booklets http://www.topalbertadoctors.org /cpgs/885801

Assessment: Red Flags Alarm Feature Features of cauda equina syndrome including sudden or progressive onset of loss of bladder/bowel control, saddle anaesthesia Severe worsening pain, especially at night or when lying down Significant trauma Weight loss, history of cancer, fever Use of steroids or intravenous drugs Patient with first episode of severe back pain older than 50 years, especially older than 65 years Widespread neurological signs Referral Urgency Emergency within hours Within 24 48 hours Within 24 48 hours Within 24 48 hours Within 24 48 hours Referral within a few weeks Referral within a few weeks Toward Optimized Practice (TOP). Low Back Pain. December 2015

Assessment: Yellow Flags Yellow Flag Belief that pain and activity are harmful Sickness behaviours (like extended rest) Low or negative moods, social withdrawal Treatment beliefs do not fit best practice Problems with claim and compensation History of back pain, time off, other claims Problems at work, poor job satisfaction Heavy work, unsocial hours (shift work) Overprotective family or lack of support Intervention Educate and consider referral to active rehab including cognitive behavioural therapy (CBT) Educate and consider pain clinic referral Assess for psychopathology and treat Educate Connect with stakeholders and case manager Follow up regularly; refer if recovering slowly Engage case management through disability carrier Follow up regularly; refer if recovering slowly Educate patient and family Toward Optimized Practice (TOP). Low Back Pain. December 2015

Need to Order Images? Acute: Film imaging is indicated when compression or other fracture suspected Only order imaging to clarify anatomy where the results direct treatment Choosing Wisely: Imaging for low back pain in the first 6 weeks after pain begins should be avoided in the absence of specific clinical indications Chronic: X-rays of the lumbar spine are very poor indicators of serious pathology In the absence of clinical red flags, radiculopathy, or neurogenic claudication, spinal X-rays and MRI are of limited value Practice Tip: For most cases of low back pain, imaging is not required Toward Optimized Practice (TOP). Low Back Pain. December 2015 Choosing Wisely. American Society of Anesthesiologists Pain Medicine, 2014

If Our Patient Has Acute Low Back Pain If Mr. Jones is presenting with acute low back pain, which of the following non-opioid treatments is considered first line: a. Acetaminophen b. Ibuprofen c. Diclofenac d. Celecoxib e. Muscle relaxant

TOP Medication Recommendations for Acute Low Back Pain Medication Dose Adverse Effects Considerations First-line acetaminophen Second-line NSAIDs Add muscle relaxant if muscle spasm Up to 1,000 mg qid Negligible Primarily liver toxicity with long-term and highdose consumption Ibuprofen up to 800 mg tid Diclofenac up to 50 mg bid Cyclobenzaprine 10 mg to 30 mg per day up to 2 weeks Primarily gastrointestinal (GI), possible fluid retention, or CNS effects such as dizziness or fatigue at higher doses Sedation, dry mouth Caution over long-term use in patients > 45 years and those with cardiovascular (CV) risk factors and renal function Not robust evidence for long-term use Methocarbamol 800 1,000 mg qid prn Sedation, better tolerated than cyclobenzaprine Toward Optimized Practice (TOP). Low Back Pain. December 2015; See S, Ginzburg R. Am Fam Physician 2008;78:365

Acetaminophen Summary Factor Dosage Safety Liver toxicity Commentary 500 1,000 mg q4 6h prn (max 4 g / 24 h) regular, extra-strength 1,300 mg q8h (max 4 g / 24 h) timed-release arthritis formulation No dosage adjustments are required in elderly No safety concerns in patients with coronary heart disease, peptic ulcer disease, type 2 diabetes Top cause of drug-induced hepatotoxicity Vast majority of cases occur due to exceeding 4 g per day dose (1/2 intentional) Concern with unintentional is the use of multiple products with acetaminophen 5% of all patients exceed acetaminophen maximal dose Risk increases with chronic alcohol use, liver disease, dehydration, and antiepileptics Can be used in hepatic disease experts recommend dose reduction to 2 3 grams per day Imani F, et. Hepat Mon 2014;14(10); Canadian Pharmacists Association. Tylenol Product Monograph etherapeutics. Available at: https://www.e-therapeutics.ca. Kaufman DW, et al. Pharmacoepidemiol Drug Saf 2012;21:1280

NSAID Summary Factor Commentary Efficacy All NSAIDs are equally effective at reducing pain and improving function 70% 80% will respond to one NSAID, so if not responding, can try other NSAID Coxib efficacy = traditional NSAID efficacy Adverse effects Can occur at therapeutic doses of NSAIDs CVD Renal GI NSAIDs and coxibs increase blood pressure by 2 5 mm Hg, decrease efficacy of angiotensin converting enzyme inhibitors (ACEIs,) angiotensin II receptor blockers (ARBs), beta-blockers, and diuretics Coxibs and diclofenac increase risk of vascular events and death (not naproxen) All NSAIDs increase the risk of hospitalization due to heart failure 1% 5% of NSAID users may develop renal adverse effects No NSAID is free of renal issues Chronic NSAID use: > 37% had significant GI lesions and 24% had ulcers 4-fold increase in upper GI tract bleeding or perforation Proton-pump inhibitors (PPIs) and coxib reduce risk but do not eliminate it Rostom A, et al. Aliment Pharmacol & Ther 2009;29:481; CNT Collaboration, et al. Lancet 2013;382:769; Harirforoosh S, et al. J Pharm Pharm Sci 2013;16:821; Cheatum DE, et al. Clinic Ther 1999;21:992

What About Muscle Relaxants? Meta-analysis of 30 trials for acute low back pain Muscle relaxants plus acetaminophen or NSAID were more effective than analgesic alone The combination of muscle relaxant with analgesic improves and accelerates recovery Concern is drowsiness, dizziness, and clumsiness Practice Tip: Recommended for short-term use with analgesic if muscle spasms present van Tulder MW, et al. Spine 2003:28;1978

Muscle Relaxant Summary Factor Dosage Adverse effects Dosing recommendations Commentary Cyclobenzaprine: 5 10 mg tid Methocarbamol: 800 1,000 mg qid Drowsiness, dry mouth, dizziness, fatigue, nausea, constipation Cyclobenzaprine is similar in structure to tricyclic antidepressants (TCAs) Short-term use Avoid in elderly Many times added at nighttime to help for sleep Use prn; discontinue if spasms are relieved Turks E, Stacey P. Low Back Pain

Other Recommendations for Acute Low Back Pain Keep active Slowly return to normal activity as quickly as possible Most people recover in 4 to 6 weeks with no treatment Hot and cold pads may help AVOID bed rest! Follow up if pain worsens or does not improve in 6 weeks Only consider opioids in select patients with pain not managed by first and second line Toward Optimized Practice (TOP). Low Back Pain. December 2015

If Our Patient Has Chronic Low Back Pain If Mr. Jones is presenting with chronic low back pain, which of the following non-opioid treatments is considered first line: a. Acetaminophen b. Ibuprofen c. Diclofenac d. Celecoxib e. Muscle relaxant

Administer opioids with caution TOP Medication Recommendations for Chronic Low Back Pain Medication Dose Adverse Effects Considerations Third line: TCAs Third line: codeine Fourth line: tramadol Fifth line: strong opioids Amitriptyline/Nortriptyline 10 100 mg hs Codeine 30 60 mg q3 4h Tramadol (slow titration); max of 400 mg/day First Line: Acetaminophen Second Line: NSAIDs Drowsiness, anticholinergic Constipation, nausea, CNS Dizziness, drowsiness, asthenia, GI, hypoglycemia Start low and go slow; can help to improve sleep Up to 30% of patients do not respond to codeine Slow titration, caution if adding to SSRI or TCA Administer with caution Morphine, hydromorphone, oxycodone, fentanyl patch Guidelines now state restricting dose to < 50 mg morphine equivalents daily SSRI = selective serotonin reuptake inhibitor Toward Optimized Practice (TOP). Low Back Pain. December 2015; Draft Recommendations & Rationales for the 2017 Canadian Opioid Guideline

Other Recommendations for Chronic LBP Exercise: walking and group exercise, therapeutic aquatic exercise, yoga Education: pamphlets on TOP website Self-management programs Massage therapy as adjunct Acupuncture as adjunct Cognitive behavioural therapy Respondent behavioural therapies Toward Optimized Practice (TOP). Low Back Pain. December 2015

When to Refer for Surgery Optimal care including combined physical and psychological treatment (6 months of care) AND Have severe LBP for which the patient would consider surgery (spinal stenosis with leg pain or claudication, LBP with leg predominant pain) Address significant psychological distress before surgery Toward Optimized Practice (TOP). Low Back Pain. December 2015

Summary of Low Back Pain Management Assess for red and yellow flags No need for imaging for most patients (in the absence of flags) Acetaminophen and NSAIDs are recommended first line and second line For both acute and chronic LBP Muscle relaxants can be recommended prn for spasms and to reduce discomfort Nonpharmacological recommendations are important Some patients are candidates for surgery for chronic severe pain

Case #2: Mrs. Chen Mrs. Chen is here to see you to discuss her fibromyalgia.

What Is the Most Important Information You Need to Determine the Treatment? a. Age of patient b. Comorbid conditions c. Current medications d. Mental health concerns e. Description of pain f. Location of pain g. Level of impairment h. What has been done to manage fibromyalgia

Mrs. Chen: Fibromyalgia 32 years old Presenting with diffuse body pain, fatigue, sleep issues, cognitive change, mood disturbance Using ibuprofen to help for pain but not experiencing significant relief Willing to try anything as she is not able to function well

Fibromyalgia Therapies Which of the following treatments is recommended by fibromyalgia guidelines: a. Topical NSAIDs b. Opioids c. Amitriptyline d. Ibuprofen e. All of the above

Fibromyalgia Guidelines 2012: http://fmguidelines.ca/ 2016: http://ard.bmj.com/content/earl y/2016/07/04/annrheumdis- 2016-209724.full

Is it Fibromyalgia? Pain Predominant feature and should be present for 3 months Felt in muscle and joint tissue Neuropathic origin to pain Fatigue Up to 90% of patients and may be more disabling than pain Nonrestorative sleep impacts fatigue, affect, pain Cognitive dysfunction poor working memory, free recall, verbal fluency Mood disorder depression and anxiety in up to 75% of patients All patients with a symptom complaint suggesting a diagnosis of fibromyalgia should undergo a physical examination which should be within normal limits except for tenderness on pressure of soft tissues (ie, hyperalgesia which is increased pain response following a painful stimulus) Fitzcharles MA, et al. Pain Res Manag 2013;18:119

Fibromyalgia Treatment Recommendations Nonpharmacological Graduated aerobic and strengthening exercise Cognitive behavioural therapy Psychological evaluation Meditative movement therapies (qigong, yoga, tai chi) and mindfulness-based stress reduction Defined physical therapies: acupuncture or hydrotherapy Pharmacological Acetaminophen Amitriptyline (at low dose) Duloxetine Pregabalin Cyclobenzaprine With NSAIDs acting mainly in the periphery, there is little rationale for their use Direct treatment at most troublesome symptoms to improve outcomes Fitzcharles MA, et al. Pain Res Manag 2013;18:119 Macfarlane GJ, et al. Ann Rheum Dis 2017;76:318

Neuropathic Pain Medication Summary Commentary Medications and usual maintenance dose Adverse effects Goals of therapy Place in therapy Amitriptyline, desipramine, and nortriptyline: 10 100 mg/day Gabapentin: 300 1,200 mg tid Pregabalin: 150 300 mg bid Duloxetine: 60 120 mg/day Vary based on the agent With fibromyalgia, important to start low and go slow As completely eliminating pain is not usually achievable, the goal for neuropathic pain is to make the pain tolerable Gabapentinoids (pregabalin, gabapentin), TCA, and serotoninnorepinephrine reuptake inhibitor (SNRI; duloxetine) are first line Moulin D, et al. Pain Res Manag 2014;19:328

Fibromyalgia Management Summary Important to assess symptoms besides pain Comorbid conditions and treatments can impact the management of fibromyalgia Acetaminophen is recommended first line for patients with fibromyalgia NSAIDs have limited role for patients with fibromyalgia Neuropathic pain treatment can help for pain as well as other symptoms Customize based on the patient s clinical presentation

Case #3: Mr. Tate Mr. Tate is here to see you to discuss his foot pain.

What Is the Most Important Information You Need to Determine the Treatment? a. Age of patient b. Comorbid conditions c. Current medications d. Description of pain e. Onset of foot pain f. Level of impairment g. What has been done to manage the foot pain

Mr. Tate: Diabetic Peripheral Neuropathy 52 years old Diabetes for 5 years Developed painful diabetic peripheral neuropathy Impairing his ability to exercise Tried acetaminophen and it is not helping for pain

Neuropathic Pain Guidelines Cover the pharmacological management of neuropathic pain Updated in 2014 Provide first-, second-, third-, and fourth-line recommendations Treatment is similar for diabetic peripheral neuropathy, postherpetic neuralgia, poststroke pain, multiple sclerosis pain, etc https://www.ncbi.nlm.nih.gov/p mc/articles/pmc4273712/ Moulin D, et al. Pain Res Manag 2014;19:328

Canadian Neuropathic Pain Guideline Recommendations Gabapentinoids TCA SNRI Tramadol Opioid Analgesic Cannabinoids Fourth-line agents (topical lidocaine, methadone, lamotrigine, tapentadol, botulinum toxin) Consider adding additional agents sequentially if partial but inadequate pain relief Moulin D, et al. Pain Res Manag 2014;19:328

Tailoring Treatment for Neuropathic Pain Pharmacological recommendations: First line: pregabalin/gabapentin, SNRI, TCA Tailor treatment based on patient: Avoid TCA in patients with glaucoma, orthostatic hypotension, CVD, worried about falls and weight gain Avoid duloxetine in patients with hepatic disease Avoid pregabalin and gabapentin in patients with edema and concerned about weight gain Tesfaye S, et al. Diabetes Metab Res Rev 2011;27:629

Diabetic Neuropathy: New 2017 ADA Position Statement Tight glycemic control Recommend duloxetine or pregabalin as initial approach Gabapentin may also be used as an effective initial approach Tricyclic antidepressants are also effective for neuropathic pain in diabetes (used with caution) Position paper has a summary of all treatments http://care.diabetesjournals.org/content/40/1/136 Pop-Busui R, et al. Diabetes Care 2017;40:136

Neuropathic Pain Summary Treatment of neuropathic pain is to address central pain sensitization Important to tailor treatment based on the patient s comorbid conditions Provide realistic treatment goals making the pain manageable versus completely eliminating the pain Important for painful diabetic neuropathy to address all aspects of patient s overall diabetes management Glycemic control Blood pressure control Dyslipidemia control

Key Learning Points Many different treatment options for the management of mild to moderate pain Crucial to customize based on the: Patient s medical conditions Type of pain Patient s current medications Many painful conditions can be managed with OTC analgesics By implementing guideline recommendations into practice we can optimally manage many patients in primary care without opioids