Chronic pain
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Chronic pain . T. www. Thepracticalnursepractitioner.com. “What do you mean my MRI is negative? My back still hurts! . “My whole body aches.”. and other statements to address in primary care pain management. Annemarie M. Kallenbach RN CNP No Disclosures. docakilah.wordpress.com.

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Chronic pain

Chronic pain


Chronic pain

T

www.Thepracticalnursepractitioner.com


My whole body aches

“What do you mean my MRI is negative?

My back still hurts!

“My whole body aches.”

and other statements to address in primary care pain management.


Chronic pain

Annemarie M. Kallenbach

RN CNP

No Disclosures


Chronic pain

docakilah.wordpress.com


Overview

Overview 

  • Fibromyalgia and chronic back pain are two time consuming and frustrating diagnoses seen frequently in clinical practice

  • Choosing to treat or transferring care to a consultant or specialist has benefits and drawbacks.

  • Understanding the use of pain contracts /partner agreements and frequent intervals of visits will improve outcomes.


Overview1

Overview

  • Chronic low back pain and fibromyalgia share two clinical features.

    • The visits are not quick

    • The visits are not easy.


Overview2

Overview

Implementing a consistent algorithm that incorporates current recommendations in today’s busy clinic will yield improved results in patient care.


Overview3

Overview

  • Chronic pain must to be addressed in a multi directive model.

  • A clear, practical chart checklist will keep treatment plan on course.


Pain response

Pain response


Personal experience

Personal experience

  • Labor

  • Stubbing toe on chair leg

  • Burning shoulder pain from too much time on computer


Provider response

Provider Response

Jot down 5 honest reactions to seeing back pain-recurrent, fibromyalgia follow up on your schedule.


Provider reactions

Provider reactions

  • Time consuming

  • Frustrated

  • Angry

  • Nervous

  • Agitated

  • Scared

  • Skeptical


Provider reactions1

Provider reactions

  • Excited for the challenge.

  • Ready to try a multiple facet approach to treatment.

  • Armed with excellent resources.


Provider reactions2

Provider reactions

  • Frustrated

  • Angry

  • Nervous

  • Agitated

  • Scared

  • Skeptical

  • Excited for the challenge

  • Ready to try a multiple approach to treatment

  • Armed with excellent resources


Bring it on

Bring it on!!


Patient questions to ponder

Patient questions to ponder

  • Does you patient have chronic pain?

  • Has a complete workup been done in the past? Labs, diagnostics


Patient questions to ponder1

Patient questions to ponder

  • Has your patient been screened for mental health problems?

  • Does your patient have a diagnosis of mental health problems?

  • Is it the correct diagnosis?

  • Is the patient adequately treated for mental health (pharmacologic agents, talk therapy, support groups, behavior modification)


Patient questions to ponder2

Patient questions to ponder

  • Do you believe you can have an honest patient provider relationship?


Kid you re asking the wrong guy

Kid, you’re asking the wrong guy.


Patient questions to ponder3

Patient questions to ponder

  • Does your patient have the ability to go to a chiropractor, PT, massage therapist, acupuncturist, etc?


Patient questions to ponder4

Patient questions to ponder

  • Is your patient already on routine opiods?

  • Is your patient willing to partner to reduce/eliminate ineffective opiods?


Provider questions beliefs

Provider questions/beliefs

  • Do you have time and interest in treating?

  • Do you have knowledge to treat?


Wasssup

Wasssup?


Provider questions beliefs1

Provider questions/beliefs

  • Can you prescribe narcotics? What classes of narcotics? Long acting narcotics, including Methodone?

  • Do you have knowledge regarding medical marijuana?

  • Do you understand parameters for prescribing opioids?


Provider questions beliefs2

Provider questions/beliefs

  • Do you have relationships with local pharmacists?


Provider questions beliefs3

Provider questions/beliefs

  • Do you have the ability to drug screen your patient?


What i was thiiiirrrsty

What? I was thiiiirrrsty


State level questions

State level questions

  • Does your state have medical marijuana?

  • Does your state have a narcotic prescription reporting mechanism?


Https sso state mi us

https://sso.state.mi.us


Elements of a pain history

Elements of a Pain History

Taking a Pain History

• Location

• Radiation

• Onset: sudden or insidious

• Duration

• Frequency: continuous

or intermittent

• Description

• Intensity

• Alleviating factors

• Exacerbating factors


Chronic pain site

Chronic pain site

  • Lumbar

  • Knee

  • Neck

  • Shoulder

  • Total body


Current previous medication r egimen

Current (Previous) Medication Regimen

  • Anti inflamatory

  • Elavil/Pamelor

  • Neurontin

  • Lyrica

  • Antidepressent

  • SSRI

  • SNRI

  • Mood stabilizer

  • Anxiolytic

  • Opiod

  • Tramadol

  • Sleep agent

  • SUBOXONE, METHADONE


Diagnostic work up

Diagnostic work up

  • Was it complete?

  • Exam findings

    • X-ray

    • MRI

    • Consult notes


Referrals

Referrals

  • Orthopedic

  • Pain management

  • Neurosurgeon

  • Injection therapy

  • Psychologist


Physical therapy chiropractic care massage therapy accupuncture

Physical therapy,Chiropractic care, massage therapy, Accupuncture

  • Dates

  • Goals

  • Patient’s adherence to sessions and to home exercises

  • Trial of TENS


Additive disorder

Additive disorder

  • Tobacco smoker

  • Drug dependence

  • Alcoholic


Collaboration

Collaboration

  • Partner agreement

  • Pain contract signed


American pain foundation

American Pain Foundation

Treatment Options:

A Guide for People Living with Pain


American pain foundation1

American Pain Foundation

Dedicated to eliminating the under treatment of pain in America.


American pain foundation2

American Pain Foundation

www.painknowledge.org/opioidtoolkit/docs/Treatment%20Options.pdf


American pain foundation3

American Pain Foundation

The following organizations are represented by those who helped

create this publication:

American Academy of Pain Management

American Academy of Pain Medicine

American Alliance of Cancer Pain Initiatives

American Board of Hospice and Palliative Medicine

American Holistic Nursing Association

American Pain Society

American Society for Pain Management Nursing

American Society of Regional Anesthesiologists

Association of Oncology Social Work

Healing Touch International

Intercultural Cancer Council

International Association for the Study of Pain

Midwest Nursing Research Society

National Association of Social Workers

Oncology Nursing Society


Chronic pain

HELPFUL HINTS ON YOUR ROAD TO PAIN RELIEF

Keep the following tips in mind as you seek treatment for your pain:

• Chronic pain can result in physical and psychological challenges. It is important to accept support from loved ones—you need and deserve all the help you can get.

• Be sure to seek treatment as early as possible to avoid further problems.

• Do not allow your physical illness or pain to take over your life. Pain is a part of

you, but it should not define who you are.

• Try not to let past frustrations of failed treatments stand in your way; there are a wide range of treatments available as detailed in this guide. While your pain might not go away completely, there are ways to reduce it so that it is bearable and you can reclaim parts of your life.


Chronic pain

HELPFUL HINTS ON YOUR ROAD TO PAIN RELIEF

Keep the following tips in mind as you seek treatment for your pain:

• Chronic pain can result in physical and psychological challenges. It is important to accept support from loved ones—you need and deserve all the help you can get.

• Be sure to seek treatment as early as possible to avoid further problems.

• Do not allow your physical illness or pain to take over your life. Pain is a part of

you, but it should not define who you are.

• Try not to let past frustrations of failed treatments stand in your way; there are a wide range of treatments available as detailed in this guide. While your pain might not go away completely, there are ways to reduce it so that it is bearable and you can reclaim parts of your life.


Chronic pain

  • COMMON FEATURES OF AN OPIOID AGREEMENT

  • Sign an opioid agreement to be kept in your medical file (ask for your own copy)

  • Obtain prescriptions from only one doctor

  • Have your prescriptions filled at one pharmacy

  • Come in for regular office visits (every 2-4 weeks or so)

  • Agree to have periodic urine drug screening

  • Bring your pills in to be counted during visits

  • Follow any additional rules not listed above

  • http://www.painknowledge.org/opioidtoolkit/docs/Treatment%20Options.pdf


Additive disorder1

Additive disorder

  • Tobacco smoker

  • Drug dependence

  • Alcoholic


Disability issues

Disability issues

  • In process

  • Resolved


Mental health

Mental health

  • Concern for metal illness

  • Past history of mental illness

  • Family history of mental illness

  • Bipolar depression Yes/No

  • Treated satisfactorily Yes/No

  • DepressionYes/No

  • Treated satisfactorily Yes/No


Disability issues1

Disability issues

  • In process

  • Resolved


Stable on current program

Stable on current program

  • Mental health

  • Addictive disorder

  • Chronic pain


Chronic pain

NOT!


Dad left when he found out about mom and panda

Dad left when he found out about Mom and Panda.


Screening for depression and bipolar disease

Screening for depression and bipolar disease

  • Depression screen

    • Becks inventory

    • PHQ-9

  • Bipolar screen – Mood disorder questionnaire (MDQ)


Beck s inventory

Beck’s Inventory

http://www.fehb.org/CSE/CCSEConference2012/BeckDepressionInventory.pdf

http://www.nhlbi.nih.gov/meetings/workshops/depression/instruments.htm


Phq 9

PHQ-9

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495268/


Mood disorder questionnaire

Mood disorder questionnaire

www.ncbi.nlm.nih.gov/pubmed/12505821


Referral to psychiatrist

Referral to psychiatrist


Evidence know it

EVIDENCE – Know it!


Early mri

Early MRI

  • The rate of lumbar spine magnetic resonance imaging in the USisgrowing at an alarming rate.

  • Evidence that it is not accompanied by improved patient outcomes.

  • Overutilization correlates with, and likely contributes to, a 2- to 3-fold increase in surgical rates over the last 10 years.

  • Knowledge of imaging abnormalities can actually decrease self-perception of health and may lead to fear-avoidance and catastrophizing behaviors that may predispose people to chronicity.

  • LEVEL OF EVIDENCE: Diagnosis/prognosis/therapy, level 5.

    Flynn TW, Smith B, Chou R. Appropriate use of diagnostic imaging in low back pain: a reminder that unnecessary imaging may do as much harm as good. J Orthop Sports Phys Ther. 2011 Nov;41(11):838-46. Epub 2011 Jun 3.


Reason s to do mri

Reason’s to do MRI

  • Suspect caudaequina

  • Longer pain than 6-12 weeks

  • Patient is amenable to injection therapy

  • Directed care to PT


Ya gonna get a snot bath

Yagonna get a snot bath!!


Referall to pain psychotherapist

Referall to pain psychotherapist


Pain management 4 legs of treatment w psychologist

Pain management 4 legs of treatment w/ psychologist

Borrie, RA. (2001). Thinking About Pain Psychologically based pain management can provide relief for pain patients. http://www.practicalpainmanagement.com/treatments/psychological/thinking-about-pain


Got milk nope

Got MILK? Nope.


Clinical guidelines

Clinical guidelines

  • NSAIDs, acetaminophen, skeletal muscle relaxants (for acute low back pain), and tricyclic antidepressants (for chronic low back pain) are effective for pain relief.

  • Opioids, tramadol, benzodiazepines, and gabapentin (for radiculopathy) are effective for pain relief.

  • Systemic corticosteroids are ineffective .

  • Adverse events, such as sedation, varied by medication, although reliable data on serious and long-term harms are sparse.

  • Most trials were short term (< or =4 weeks).

  • Few data address efficacy of dual-medication therapy compared with monotherapy, or beneficial effects on functional outcomes.

    Chou R, Huffman LH; American Pain Society; American College of Physicians. (2007). Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007 Oct 2;147(7):505-14. 


Selected nonpharmacologic treatment options from practice guidelines

Selected Nonpharmacologic Treatment Options from Practice Guidelines

Osteoarthritis

(AC R 2000)

• Self-management programs

• Weight loss

• Aerobic exercise

• Range-of-motion exercises

• Muscle-strengthening exercises

• Assistive devices

• Occupational/physical therapy

• Joint protection/energy conservation

Low Back Pain

(Chou 2007)

Acupressure/acupuncture

• Functional restoration

• Interdisciplinary rehabilitation

• Interferential therapy

• Massage

• Transcutaneous/percutaneous

electrical nerve stimulation

• Spinal manipulation


Invasive interventions

Invasive interventions


Sciatica or prolapsed lumbar disc with radiculopathy level of evidence

Sciatica or prolapsed lumbar disc with radiculopathy (level of evidence)

  • Chemonucleolysisis moderately superior to placebo injection but inferior to surgery. (good)

  • Epidural steroid injection is moderately effective for short-term (but not long-term) symptom relief. (fair)

  • Spinal cord stimulation is moderately effective for failed back surgery syndrome with persistent radiculopathy, though device-related complications are common. (fair)

  • Prolotherapy, facet joint injection, intradiscal steroid injection, and percutaneousintradiscal radiofrequency thermocoagulation are not effective. (good)

  • Insufficient evidence exists to reliably evaluate other interventional therapies.

    Chou R, Atlas SJ, Stanos SP, RosenquistRW.Nonsurgicalinterventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine (Phila Pa 1976). 2009 May 1;34(10):1078-93


Case studies

Case studies


Arthritis on nsaids and hs opioids

Arthritis on NSAIDS and HS opioids


Methadone endometriosis

Methadone endometriosis


High dose narcotics for chronic low back pain

High dose narcotics for chronic low back pain


Overview of some of the more commonly used nonopioid and ajuvant analgesics

Overview of some of the more commonly used nonopioid and ajuvant analgesics.

used to treat chronic pain, including salicylates, acetaminophen, nonsteroidal anti-inflammatory drugs, tricyclic antidepressants, anticonvulsants, N-Methyl-D-Aspartate receptor antagonists, lidocaine, skeletal muscle relaxants, and topical analgesics.

http://www.ncbi.nlm.nih.gov/pubmed/14567202

Gordon, DB, (2003). Nonopioid and adjuvant analgesics in chronic pain management: strategies for effective use. HYPERLINK North Am. 2003 Sep;38(3):447-64,vi.


Chronic pain

http://www.ncbi.nlm.nih.gov/pubmed/21176430

Mease, PJ. (2009). Further strategies for treating fibromyalgia: the role of serotonin and norepinephrine reuptake inhibitors. Am J Med. Dec;122(12 Suppl):S44-55


Chronic pain

Franco M, Iannuccelli C, Atzeni F, Cazzola M, Salaffi F, Valesini G, Sarzi-Puttini P. Pharmacological treatment of fibromyalgia.Clin Exp Rheumatol. 2010 Nov-Dec;28(6 Suppl 63):S110-6. Epub 2010.

  • 11/18 painful tender points

  • Multimodal pharmacological treatment also combined with non-pharmacological therapy.

  • Only three drugs (duloxetine, milnacipram, pregabalin) are approved by the American Food and Drug Administration (FDA) and none by the European Medicines Agency (EMEA

  • Most of the drugs improve only one or two symptoms; no drug capable of overall symptom control is yet available.

    Tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), opioids, non-steroidal anti-inflammatory drugs (NSAIDs), growth hormone, corticosteroids and sedative hypnotics.

  • As no single drug fully manages FM symptoms, multicomponent therapy should be used from the beginning.

  • Gradually increasing low doses is suggested in order to maximize efficacy.

  • The best treatment should be individualized and combined with patient education and non-pharmacological therapy.


Chronic pain

CME: Help Your Patients Break Free Assessing and Managing Chronic Pain in Primary Care: Applying Evidence to Practice

http://www.omniaeducation.com/emails/2012images/echo_pain/ECHO_Pain_web.pdf?utm_source=Omnia+Education&utm_campaign=43b013690c-Pain_Echo1_4_2012&utm_medium=email

  • CME


Bibliography

Bibliography

Borrie, RA. (2001). Thinking About Pain Psychologically based pain management can provide relief for pain patients. http://www.practicalpainmanagement.com/treatments/psychological/thinking-about-pain

Chou R, Qaseem A, Snow V, et al; for the Clinical Efficacy Assessment Subcommittee of the American

College of Physicians and the American College of Physicians/American Pain Society Low Back Pain

Guidelines Panel. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478-491.

Chou R, Fanciullo GJ, Fine PG, et al; for the American Pain Society-American Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2):113-130.

Chou R, Atlas SJ, Stanos SP, RosenquistRW.Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine (Phila Pa 1976). 2009 May 1;34(10):1078-93


Bibliography1

Bibliography

Flynn TW, Smith B, Chou R. Appropriate use of diagnostic imaging in low back pain: a reminder that unnecessary imaging may do as much harm as good. J Orthop Sports Phys Ther. 2011 Nov;41(11):838-46. Epub 2011 Jun 3.

Franco M, Iannuccelli C, Atzeni F, Cazzola M, Salaffi F, Valesini G, Sarzi-Puttini P. Pharmacological treatment of fibromyalgia. Clin Exp Rheumatol. 2010 Nov-Dec;28(6 Suppl 63):S110-6. Epub 2010.


Chronic pain

Each king in a deck of playing cards represents a great king from history.Hearts - CharlemagneDiamonds - Julius Caesar.

Clubs - Alexander the Great

Spades= King David


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