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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 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 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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