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Nuts & Bolts of Outpatient Pain Management Spring NP/PA/CNM PPG Conference 4.18.13 Carr Auditorium. Kirsten Y. Day, MD Associate Professor Department of Family and Community Medicine UCSF/SFGH FHC. Nuts & Bolts of Outpatient Pain Management Objectives. Pain Physiology Evaluation of Pain

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Nuts bolts of outpatient pain management spring np pa cnm ppg conference 4 18 13 carr auditorium

Nuts & Bolts of OutpatientPain Management Spring NP/PA/CNM PPG Conference4.18.13 Carr Auditorium

Kirsten Y. Day, MD

Associate Professor

Department of Family and Community Medicine

UCSF/SFGH FHC


Nuts bolts of outpatient pain management objectives
Nuts & Bolts of OutpatientPain ManagementObjectives

  • Pain Physiology

  • Evaluation of Pain

    • History and Physical

    • Factors that Influence Pain

  • Management of Pain

    • Physical Modalities

    • Psychological Modalities

    • Pharmacologic Modalities

      • Meds commonly Used

      • How to Evaluate Effectiveness

    • Insurance Issues

    • Tolerance, Dependence, Addiction and Pseudo-Addiction

    • Chronic Narcotic Use in Substance Use Disorders


Nuts bolts of outpatient pain management physiology of pain
Nuts & Bolts of OutpatientPain Management Physiology of Pain

Who, except the gods, can live time through forever without any pain?

- Aeschylus


Nuts bolts of outpatient pain management physiology of pain1

Acute Pain is an Early Warning System

Nuts & Bolts of OutpatientPain Management Physiology of Pain


Nuts bolts of outpatient pain management physiology of pain2
Nuts & Bolts of OutpatientPain Management Physiology of Pain

  • Nociceptive Pain

    • Somatic

      • Tissue Damage - Temperature, Trauma, Chemical

      • Once Stimulated, become hyperactive

      • Localized, constant, throbbing, aching

    • Visceral

      • Stretching or Pressure

      • Referred pain

      • Generalized, less constant or colicky, cramping

  • Neuropathic Pain

    • Damage directly to neurons cause abnormal neural activity

    • Constant, frequently burning or electrical with periods of marked increases in pain


Nuts bolts of outpatient pain management physiology of pain3
Nuts & Bolts of OutpatientPain Management Physiology of Pain

  • Stress Analgesia

    Short-term intense pain controlled with short-term nervous system changes

  • Hyperalgesia

    Lowered pain threshold produces pain with less stimulation

  • Allodynia

    Previously non-painful stimuli are now painful


Nuts bolts of outpatient pain management physiology of pain4
Nuts & Bolts of OutpatientPain Management Physiology of Pain

Normal

Hyperalgesia

Allodynia

Pain Tolerance

Response

Pain Threshold

Stimulus Intensity


Nuts bolts of outpatient pain management evaluation of pain
Nuts & Bolts of OutpatientPain Management Evaluation of Pain

  • Pain is real when you get other people to believe in it. If no one believes in it but you, your pain is madness or hysteria.

    - Naomi Wolf


Nuts bolts of outpatient pain management evaluation of pain1
Nuts & Bolts of OutpatientPain Management Evaluation of Pain

  • Subjective - NOT a vital sign

  • History is the foundation for evaluation

    • PQRST - Provocation, Quality, Radiation, Severity, Time

    • Location QuEST - Location, Quality, Exacerbating/relieving, Severity, Temporal profile

    • Functionality


Nuts bolts of outpatient pain management evaluation of pain2
Nuts & Bolts of OutpatientPain Management Evaluation of Pain

  • Physical Examination

    • General

      • Movement

        • Gait

        • Positioning

      • Affect

      • Vital Signs in acute setting


Nuts bolts of outpatient pain management evaluation of pain3
Nuts & Bolts of OutpatientPain Management Evaluationof Pain

  • Physical Examination

    • Focused System Exam

    • Musculoskeletal

      • Palpation

      • Range of Motion

      • Strength and Laxity

    • Neurologic

      • Determine distribution of symptoms

      • Sources of Referred Pain


Nuts bolts of outpatient pain management evaluation of pain4
Nuts & Bolts of OutpatientPain Management Evaluation of Pain

  • Diagnosis

    • Chronic Pain is not a diagnosis

    • LBP is a symptom, not a diagnosis

      DJD Radiculopathy Disk Disease

      Spinal StenosisMyofascial dysfunction

      Sacroiliac dysfunction

    • Fibromyalgia - Tender points in specific patterns

    • Myofascial Pain - Trigger points with twitch response and specific referred pain patterns


Nuts bolts of outpatient pain management evaluation of pain5
Nuts & Bolts of OutpatientPain Management Evaluation of Pain

Factors that Influence Pain

  • Cognitive, Emotional factors

  • Environmental Factors

    • repeated injury

    • lack of healing

  • Timing - duration of pain experience


Nuts bolts of outpatient pain management management of pain
Nuts & Bolts of OutpatientPain Management Management of Pain

  • Physical Modalities

  • Psychological Modalities

  • Pharmacologic Modalities

  • Insurance Issues


Nuts bolts of outpatient pain management management of pain1
Nuts & Bolts of OutpatientPain Management Management of Pain

  • Physical Modalities

    • Exercise

    • Thermal Therapy

    • Manual Medicine Disciplines

      • Physical Therapy

      • Chiropractic

      • Osteopathy

      • Acupuncture

      • Trigger Point Injection

    • The only treatments that can “Cure”

      • Myofascial Pain

      • Joint dysfunction


Nuts bolts of outpatient pain management management of pain2
Nuts & Bolts of OutpatientPain Management Management of Pain

  • Psychological Modalities

    • Cognitive Behavioral Therapy

    • Biofeedback

    • Stress Reduction Techniques


Nuts bolts of outpatient pain management management of pain3
Nuts & Bolts of OutpatientPain Management Management of Pain

  • Pharmacologic Modalities

    • Step Therapy

      • Mild pain - Acetaminophen and NSAIDs

      • Moderate Pain - Combination Analgesics

        • APAP/Codeine (Tylenol #3), APAP/Hydrocodone (Vicodin), APAP-Oxycodone (Percocet)

      • Severe or Refractory Pain - Opiates

        • Morphine

        • Methadone

        • Oxycodone

        • Fentanyl


Nuts bolts of outpatient pain management management of pain4
Nuts & Bolts of OutpatientPain Management Management of Pain


Nuts bolts of outpatient pain management management of pain5
Nuts & Bolts of OutpatientPain Management Management of Pain

  • Pharmacologic Modalities

    • Targeted Treatment

      • NSAIDS - Inflammatory and Prostaglandin mediated processes

      • Lidocaine - Myofascial Pain by Trigger Point Injection or Topical Patches

      • Antiepileptics - Neuropathic pain

        • Tegretol

        • Depakote

        • Gabapentin

      • Tricyclic Antidepressants - Neuropathic pain


Nuts bolts of outpatient pain management management of pain6
Nuts & Bolts of OutpatientPain Management Management of Pain

  • Clonidine - augmentative pain relief

  • SSRI’s - somatic symptoms with or without depressed mood

  • “Muscle Relaxants”

    • Centrally acting

    • Only helpful in Acute injury or Exacerbations


Nuts bolts of outpatient pain management management of pain7
Nuts & Bolts of OutpatientPain Management Management of Pain

  • Pharmacokinetics of Opiates

    • Duration of Action -

      • 4-6 hrs for almost all orals (fentanyl 1-2 hrs.)

      • Controlled Release (CR) or Sustained Release (SR) 8-12 hours

    • Onset of Action -

      • Accelerated with IV dosing versus PO or IM (max effect at 10-20 min for morphine IV)

      • CR or SR have delayed onset and maximum effect

    • Steady state

      • 12-24 hrs with short acting

      • 48-72 hrs with long acting.

    • Metabolism and drug interactions.


Nuts bolts of outpatient pain management management of pain8
Nuts & Bolts of OutpatientPain Management Management of Pain

  • Titrating doses

    • Choose medications based on type and severity of pain

    • Give initial doses in short acting agents, assess and titrate at 12 hrs.

      • With mild to mod pain increase by 25-50% of dose

      • With mod to severe increase by 50-100% of dose

    • Convert to long acting agents

      • Inpatients - within 24 hrs.

      • Outpatients - Once dosing is stable

      • Provide short acting agents of 10-15% of long acting dose for breakthrough pain.


Nuts bolts of outpatient pain management management of pain9
Nuts & Bolts of OutpatientPain Management Management of Pain

Evaluation

  • Function

    • Activities

      • What

      • How Long

      • How Often

    • Sleep

    • Mood

  • Side Effects of Opiates

    • Constipation, nausea, histamine release, urinary urgency/retention

    • Evaluate promptly and frequently for side effects and treat as indicated


Nuts bolts of outpatient pain management management of pain10
Nuts & Bolts of OutpatientPain Management Management of Pain

  • Insurance Issues

    • Psychological - CBT, Chronic Pain Groups

    • Physical Modalities

      • Medicare - Chiropractic and Physical Therapy

      • Medicaid and SFHP/Slid Scale - Physical Therapy

    • Pharmacologic Treatments

      • Formulary Restrictions

        • Medicare D

        • Medicaid

        • SFHP/Slid Scale, HSF

      • Formulary Overrides

        • TAR, PAR, PA

        • Diagnosis and failure of formulary options or medical reason formulary options are contraindicated


Nuts bolts of outpatient pain management tolerance dependence addiction and pseudo addiction
Nuts & Bolts of OutpatientPain Management Tolerance, Dependence, Addiction and Pseudo-Addiction

  • Tolerance

    • Normal Physiologic Response to be expected with long-term use.

    • Expect to have to adjust doses over time.

  • Physical Dependence

    • Normal Physiologic Response to be expected with long-term use.

    • Physical withdrawal with abrupt cessation or reduction

  • Addiction

    • Neurobiological disorder

    • Compulsive use despite harm, impaired control.

  • Pseudo-Addiction

    • Patient behaviors that mimic addiction, caused by provider’s failure to treat pain either adequately or timely

    • Some patients are drug-seeking because they're in pain. . .


Nuts bolts of outpatient pain management chronic pain and substance use disorders
Nuts & Bolts of OutpatientPain Management Chronic Pain and Substance Use Disorders

  • Prevalence of Chronic Pain high amongst Substance Abusing Patients

    • 37-61% of patients on Methadone Maintenance

    • HMO patients entering drug/alcohol treatment OR 2-3 versus controls for HA, LBP, and arthritis

  • Other Considerations

    • Stimulant and opiate abuse result in increased pain sensitivity

    • Relapse

      • 30% in recovery relapse on Rx opiates

      • Untreated pain is a frequent trigger for relapse


Nuts bolts of outpatient pain management chronic pain and substance use disorders1
Nuts & Bolts of OutpatientPain Management Chronic Pain and Substance Use Disorders

  • When to use Opioids for patients with Addictive Disorders

    • Pain is moderate to severe

    • Pain has a significant impact on function and quality of life

    • Non-opioids have been tried and failed

    • The patient agrees to have opioid use closely monitored


Nuts bolts of outpatient pain management objectives1
Nuts & Bolts of OutpatientPain Management Objectives

  • Pain Physiology

  • Evaluation of Pain

    • History and Physical

    • Factors that Influence Pain

  • Management of Pain

    • Physical Modalities

    • Psychological Modalities

    • Pharmacologic Modalities

      • Meds commonly Used

      • How to Evaluate Effectiveness

    • Insurance Issues

    • Tolerance, Dependence, Addiction and Pseudo-Addiction

    • Chronic Narcotic Use in Substance Use Disorders


Nuts bolts of outpatient pain management remember
Nuts & Bolts of OutpatientPain Management Remember. . .

  • Pain is Subjective

  • Evaluate and determine a Diagnosis

  • Aim treatment at Diagnosis

  • Provide timely follow-up, evaluation and treatment

  • Communication with Pharmacist and know your formulary


Nuts bolts of outpatient pain management spring np pa cnm ppg conference 4 18 13 carr auditorium1

Nuts & Bolts of OutpatientPain Management Spring NP/PA/CNM PPG Conference4.18.13 Carr Auditorium

Kirsten Y. Day, MD

Associate Professor

Department of Family and Community Medicine

UCSF/SFGH FHC


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