CHRONIC PAIN MANAGEMENT

1. CHRONIC PAIN MANAGEMENT Michael Marschke, MD Medical Director of Horizon Hospice

2. COMMON ETIOLOGIES OF CHRONIC PAIN Episodic pain syndromes: • Headaches – migraine, tension, cluster… • Ischemic episodes – claudication, angina, sickle cell disease • Visceral pain – biliary colic, irritable bowel, pre-menstrual syndrome, renal colic • Somatic pain - gout

3. COMMON ETIOLOGIES OF CHRONIC PAIN Chronic pain syndromes: • Somatic – degenerative and inflammatory arthitis, trauma, vertebral compression fractures, boney metastases, fibromyalgia • Visceral – abdomenal cancers, chronic pancreatitis • Neuropathic – diabetic neuropathy, phantom limb pain, spinal stenosis/sciatica, spinal mets, HIV, drug induced

4. CHRONIC PAIN IS MULTI-FACTORIAL • Psychologic factors – depression, anxiety, somatization • Socioeconomic factors – cultural differences, urban poor, gender • Spiritual factors – spiritual suffering, meaning of pain • Physical factors – VERY complex neuroanatomy creating the pain sensation, from pain receptors to afferent nerves to spinothalamic tract, to thalamus to cortex with modulators all along the way • Therefore best approach is multi-disciplinary

5. EVALUATION OF CHRONIC PAIN GOALS: • Determine etiology to better treat this pain • Determine if correctable, intractable, or potentially dangerous causes • Determine impact on patient’s life • Take a detailed pain history to aid in controlling this pain

6. PAIN HISTORY O = Other associated symptoms ( nausea with stomach cramps, swelling with somatic pain, depression, anxiety…) P = Palliative/provocative factors (mobility, touching, eating…) Q = Quality R = Region/radiation S = Severity ( 0 to 10 ) T = Timing (when started, continuous/intermittent, time of day…) U = Untoward effects on activity or quality of life, including psychosocial, spiritual effects

7. HOW DO YOU TELL WHICH PAIN SYNDROME? – HISTORY! • Somatic – focal, ache/throb/sharp, maybe with swelling/edema/redness, tender, worse with movement, better at rest, maybe from trauma • Visceral – viscous organ – colicky, vague, diffuse, worse with meals, liver/spleen/pancreas – may be more constant, more focal, worse with eating, uterine – colicky, pelvic, maybe with discharge • Neuropathic – burning, sharp, tingling, either dermatomal or stocking-glove, worse with touch, maybe with numbness

9. DRUGS IN WHO STEP LADDER • Step 1: Acetomenophen, Tramadol (Ultram) plus adjuvant • Step 2: Tylenol #2/3/4, Vicoden, Darvocet, Percocet • Step 3: Morphine, Dilaudid, Fentanyl, Demerol, Methadone, Oxycodone, Levodromaran

10. Marschke’s Modified Pain Escalator

11. Non-pharmacologic: Ice, heat Physical therapy Chiropractic/osteopathic manipulations Massage Acupuncture Yoga Topical agents (Ben Gay/Icy Hot – with menthol, salcylates, Capcaicin) Local injections (steroids, lidocaine) Glucosamine shown to help with osteoarthritis Pharmacologic: NSAIDs Cox 2 inhibitors Steroids Muscle relaxants ADJUVANTS TO SOMATIC PAIN

12. Boney mets: Local RT Pamidronate and other diphosphonates Strontium 89 and other radioactive isotopes, taken up by osteoclasts Vertebral compression fractures: Calcitonin Pamidronate Vertebroplasty SPECIAL SOMATIC PAIN SYNDROMES

13. VISCERAL PAIN • Anti-cholinergics for colicky pain • H2 blockers/PPIs for PUD/GERD • Steroids for enlarged organs with capsular swelling • NSAIDs for uterine pain • Nitrates for angina • Others – celiac/pelvic plexus blocks, RT for enlarged organs, massage, herbs, aromatherapy, acupuncture, healing touch

14. NEUROPATHIC PAIN • Tricyclic antidepressants • Anti-epileptics • Anti-arrhythmics • Topical agents – lidocaine, capsiacin • Steroids for spinal radiculopathies • Others – RT for spine mets, TENS/PENS units and also spinal electrical stimulators • CAM - Acupuncture, massage, PT, yoga, healing touch

15. OTHER CAM ADJUVANTS • Herbals/supplements – glucosamine shown to be useful in osteoarthritis, certain herbs like chamomile useful for colicky pain • Homeopathies/flower essences – for relaxation, visceral pain • Healing touch/Reiki – using energy techniques, useful with emotional components • Neuro Emotional Technique – A chiropractic technique also useful with emotional components • Mind – focusing therapies: • Meditation, yoga, guided-imagery, hypnosis, biofeedback • Art/music/humor therapy, pet therapy • By distraction, found to lower HR/RR and decrease pain up to 10-20%

16. ADDING AN OPIOID To achieve quick pain relief: (LOAD) 1. Start low dose, short-acting 2. Dose q peak 3. P.C.A. not “prn” (Patient controls it) 4. Re-eval in 4 hrs. to figure out what dose is needed

17. “prn” dosing

18. Tylenol #3, 1-2 tabs Vicoden, Norco, Lortab 1-2 tabs Darvocet N-100, 1-2 tabs Percocet, 1-2 tabs Vicuprofen, 1-2 tabs DOSING LIMITED BY ATTACHED DRUG (max Tylenol a day is 4000mg) MSIR/Roxanol,5-10mg PO, 1-3MG IV/SQ Dilaudid, 1-2mg PO, 0.25-0.5 IV/SQ OxyIR, 5-10mg PO NEVER USE DEMEROL IN CHRONIC PAIN!!! Low-dose, short-acting opioids

19. MAINTAINING AN OPIOID For constant pain: (MAINTENANCE) 1. Go long (convert 24hr total of short acting directly to long acting) 2. REM breakthru = 10-20% of total daily dose, as short-acting, immediate release 3. Re-eval, if 4+ breakthru/d, increase maintainance dose

20. LONG-ACTING OPIOIDS • MS Contin, Oramorph, q12hr, in 15,30,60, 100, and 200mg tabs • Kadian, Avinza, q24hr, in 20,50, 100mg time-release capsules (can be opened to ease swallowing or put thru gastric tubes) • OxyContin, q12hrs, in 10,20,40,80, and 100mg tabs • Duragesic (Fentanyl) patches in 25,50,75, and 100 ug/hr q48-72hrs. • Palladone (Dilaudid) q24hr, in time released capsules

21. CAVEATS IN OPIOID USE • With pure agonists, the sky is the limit • 80% of the time dose needs to be increased because the disease is advancing; 20% because of tolerance. • Mixed or partial agonists (Stadol, Talacen, Talwin) have a ceiling, neurotoxicity, and can induce withdrawal if on other opioids • Methadone – q8-24hr drug, may be better with neuropathies & addiction because inhibits the NMDA receptor in the brain, though half-life 6-100hrs so watch for accumulation • Demerol – neurotoxic metabolite can build up in 1 wk, in 1 day with renal failure • Oral, sublingual, rectal short acting meds peak within 1 hr., IV/SQ peak within 10 minutes. Choose oral if they can do it. • Use conversion tables to switch narcotics, start at 50-100% of equivalent dose • To taper drug, decrease by 25% a day.

22. OPIOID SIDE EFFECTS • Constipation is a given, no tolerance develops, use stimulants (Senokot, Bisocodyl, Pericolace) • Nausea/vomiting – tolerance can occur in 2-5 days, compazine/reglan can help • Sedation – tolerance can occur in 2-3 days, changing drug or Ritalin can help if persists • Clonic jerks – usually hi doses, can change drug or benzodiazepam can help • Respiratory suppression in toxic doses, never see it if have pain or use the drugs the right way

23. PHYSICAL vs. PSYCHOLOGIC DEPENDENCE PHYSICAL DEPENDENCE: • Tolerance (20-40%) – up-regulate opioid receptors to need higher dose for sustained effect • Withdrawal (20-40%) – after 2 wks, withdrawing drug leads to adrenaline response (sweating, tachycardia, tachypnea, cramps, diarrhea, hypertension); avoid by decreasing drug 25% a day. PSYCHOLOGIC DEPENDENCE: • Addiction (0.1% in CA pain) – a need to get “high” where drug controls your life, compulsive uncontrolled behavior to get the drug; lie, cheat, steal.

24. PSEUDO-ADDICTION: • Physical dependence confused with psychologic dependence • Pain-relief seeking, not drug-seeking • When right dose used, patient functions better in life, whereas opposite true with the true addict • To help diffentiate: one MD controls the drug under a specific contract with pt., one pharmacy, frequent visits, pill counts