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Pain Management in the Context of an Opioid Epidemic: Considerations and Tools for Success

The document outlines strategies for pain management amid the opioid epidemic, focusing on comprehensive assessments and the importance of a patient-physician partnership. It addresses the risks and benefits of opioids, non-opioid alternatives, and the need for informed consent and monitoring to mitigate potential misuse. Additionally, it provides tools such as the opioid risk tool to identify patients at higher risk for substance use disorders.

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Pain Management in the Context of an Opioid Epidemic: Considerations and Tools for Success
CME Provider Information Satisfactory Completion Learners must complete an evaluation form to receive a certificate of completion. You must participate in the entire activity as partial credit is not available. If you are seeking continuing education credit for a specialty not listed below, it is your responsibility to contact your licensing/certification board to determine course eligibility for your licensing/certification requirement. Physicians In support of improving patient care, this activity has been planned and implemented by Amedco LLC and VITAS® Healthcare. Amedco LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. Credit Designation Statement – Amedco LLC designates this live activity for a maximum of 1 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Objectives • Incorporate a comprehensive pain assessment • Describe four different types of pain • Appreciate pain physiology and how it relates to pain management • Identify non-opioid treatments as part of a comprehensive plan • Detail three tools to incorporate to help manage patients on opioids
Reductions in Prescribed Opioids Has Not Led to Reductions in Opioid-related Deaths *Provisional data for the 12-month period Jan. 2020–Jan. 2021 https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Overdose deaths: 94,134* Opioid prescriptions 143,390,9511 (44.4% decrease since 2011) 1
Opioid Deaths by Opioid Type https://www.cdc.gov/nchs/images/databriefs/401-450/db428-fig4.png, https://www.cdc.gov/nchs/products/databriefs/db428.htm Heroin Fentanyl
Benefits and Risks Associated With Opioids Benefits • Analgesia • Option for patients with contraindications for non-opioid analgesics • Relieves suffering • May improve function and quality of life Risks • Life-threatening respiratory depression/overdose • Development of SUD/OUD • Diversion • Inadvertent exposure to family and pets • Interactions with other meds and substances • Neonatal abstinence syndrome • Physiologic dependence and withdrawal
Terminology Misuse Use of a medication in a way other than how it is prescribed. Abuse Use of a substance with the intent of getting high. Tolerance Increased dosage needed to produce a specific effect. Dependence State in which an organism only functions normally in the presence of a substance. Diversion Transfer of a legally controlled substance, prescribed to one person, to another person for illicit (forbidden by law) use. Common Term Preferred Term Addiction Substance Use Disorder Drug Seeking, Aberrant, Problematic Behavior Using Medication Not as Prescribed Addict Person With Substance Use Disorder (SUD)
Important Considerations • Pain is often multifactorial and uniquely impacts individuals, and benefits from non-pharmacologic and pharmacologic approach • Establishing a positive patient- physician partnership provides an important foundation that will optimize treatment outcomes – Develop a mutual understanding of treatment goals/expectations – Build rapport and trust – Encourage patients take on an active role in managing their pain • Substantial improvement in function and quality of life can be anticipated even if pain is not eliminated • Persistent pain is treatable, but it is not curable
Multifaceted Pain Assessment Self and Proxy Report • NRS • VDS • FPS Potential Contributors • History – medical, psychological social, spiritual, and family • Physical exam Behavior Assessment • Direct observation • At rest and with activity Analgesic Trial
Acute or Chronic Pain Acute • Acute and duration of < 1 month • Sudden onset, self-limiting • Ideally resolves with healing • Triggered by tissue damage and inflammation • Has protective value • Inflammatory mediation • Subacute, pain that continues for 1-3 months, can become chronic “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.” —IASP (July 2020) Chronic • Lasting 3 months or longer • Generally steady- state or worsening • Persists beyond normal healing period • Serves no value • Peripheral and central sensitization
Pain Assessment: Self-report Heapy A, Kerns RD. Psychological and behavioral assessment. In: Raj's Practical Management of Pain. 4th ed. 2008:279-295; Zacharoff KL, et al. Managing Chronic Pain with Opioids in Primary Care. 2nd ed. Newton, MA: Inflexion, Inc.; 2010. • Description of pain PQRST= Palliative/Provocative Factors, Quality/Quantity, Region/Radiation, Severity, Temporal factors • What relieves the pain? • What causes or increases the pain Location Intensity Onset duration Variations/ patterns/rhythms Quality • Effects of pain on physical, emotional, and psychosocial function? • Patient’s current level of pain and function
Pain Intensity and Functional Interference Cleeland C and Wang S (1999) Oncology NCCN Proceedings • As pain intensity increases, so does the degree of functional interference • The figure on the right shows the relationship in persons with cancer pain • Studies of patients with AIDS and chronic non-cancer pain show similar interferences with function with increasing pain As pain intensity increases, so does the degree of functional interference relate walk sleep active mood work enjoy walk sleep active mood work enjoy sleep active mood work enjoy sleep active mood work enjoy work enjoy enjoy 3 4 5 6 7 8 Worst Pain (0-10 scale)
Proxy Pain Report • Healthcare Professionals – Physicians – APPs – Nurses – Nursing assistants • Families
Potential Contributors and Treatment • Conditions with focus on those attributable to pain – Medical: osteoarthritis, gout, spinal stenosis, post-herpetic neuralgia, cancer, etc. – Post-surgical: hip fracture with repair, joint replacement, other surgeries • Conditions that may impact metabolism or ability to tolerate analgesics – Liver, renal, pulmonary, cognitive, gastrointestinal (nausea and constipation) • Identify previous treatments, including effectiveness and adverse effects – Query the state Prescription Drug Monitoring Program (PDMP) – Corroborate patient/family report – Past medical records as appropriate • Assess barriers, such as the cost of treatment, childcare, transportation, attitudes, and health-care literacy
Prescription Drug Monitoring Program • Reports on scheduled drugs including opioids that are filled • Nearly all available 24/7/365 with 54 operational within the US – No national DPMP exists • Requirements mandating use vary by state – Know your state law • Multiple benefits have been reported – Lower rates of opioid-prescription ED visits and hospitalizations – Reduction in high-dose prescriptions and over-prescribing – Reduction in doctor shopping • Identify drugs that increase overdose risk when taken together (such as benzodiazepines, gabapentinoids, opioids, and other sedatives)
Psychological, Social, and Family History • Social history – Employment, cultural background, social network, relationship history, legal history, and other behavioral patterns • Psychological history – Mental health diagnoses, depression, anxiety, OCD, and PTSD – Alcohol, tobacco, THC, and recreational drug use • History of adverse childhood experiences (ACES) • Family history of substance use disorder and/or psychiatric disorder Depression and anxiety can be predictors of chronic pain.
Behavioral Assessment: Non-verbal Pain Indicators Changes in interpersonal interactions • Combative, disruptive, resisting care, decreased social interactions, withdrawn Changes in mental status • Confusion, irritability, agitation, crying Changes in usual activity • Refusing food/appetite change, increased wandering, change in sleep habits Facial expressions • Grimacing, slight frown, rapid blinking, sad/frightened, any distortion Vocalizations (crying, moaning, groaning) • Crying, moaning, groaning, grunting, calling out, noisy breathing, a5ng for help Body movements (guarding) • Guarding, rigid, tense posture, fidgeting, pacing, rocking, limping, resistance to moving
Types of Pain Nociceptive Pain Nociplastic Neuropathic Pain in response to an injury or stimuli; typically acute Pain that arises from altered nociceptive function; typically chronic Pain that develops when the nervous system is damaged; typically chronic Fibromyalgia, irritable bowel syndrome, non- specific low back pain Mixed pain syndromes (nociceptive and neuropathic) Postoperative pain, sports injuries, arthritis, sickle cell disease, mechanical low back pain Post-herpetic neuralgia, trigeminal neuralgia, distal polyneuropathy, CRPS, neuropathic low back pain, diabetic peripheral neuropathy
Neuropathic Pain • Neuropathic pain involves injury or alteration of the normal sensory and modulatory nervous system • Multiple processes are capable of producing sufficient neural alteration to produce neuropathic pain – Abnormal nerve regeneration – Increased expression of membrane sodium channels – Disinhibition of modulatory processes – Decreased expression of mu-opioid receptors • Pain occurs because injured nerves (CNS or periphery) react abnormally to stimuli or discharge spontaneously
Nociceptive Pain American Pain Society, Principles of Analgesic Use, 7th Ed. • Nociceptors = pain receptors in our tissues – Nerve endings that process stimuli (noxious and innocuous) – Skin, GI tract, skeletal muscle, joints, arteries, head, heart • Nociceptive pain – arises from actual or threatened damage to nonneural tissue, due to activation of nociceptors • Direction stimulation of afferent nerves due to tissue injury or tumor infiltration of skin, soft tissue, or viscera • Proportionate to the stimulation of the nociceptor – More tissue damage = more pain
Pain Pathways Dorsal Horns Brainstem Dorsal Root Ganglion Afferent Pain Fiber Thalamus
Transduction Mechanical Thermal Chemical Action Potential
Mediators of Peripheral Nociception With thanks to Allan Basbaum and David Julius, University of California, San Francisco Feeling physical pain is vital for survival; pain is the body’s early warning system.
Pharmacologic Therapies • Corticosteroids – Dexamethasone has least mineralocorticoid effect – All can produce glucocorticoid effects – Substantial side effects with ongoing term use (psychosis, proximal muscle wasting, and bone loss) • Nonsteroidal Anti-inflammatory Drugs (NSAIDS) – Analgesic, antipyretic, anti-inflammatory – GI bleeding, bleeding, renal dysfunction, cardiovascular effects • Capsaicin
+ + + + + - - - - - + + + + + + - - - - - + + + + + - - - - - - + + + + + - - - - - + + + + + + - - - - - + + + + + - - - - - - Action Potential Na+ Na+ Na+ K+ Na+ Na+ Na+ K+ Neuron Conduction
Conduction • C-fibers: small, unmyelinated, slow-conducting – Transmits: dull, poorly localized, diffuse, burning, aching pain – Sensitive to: mechanical, thermal, or chemical stimuli • A-delta fibers: large, myelinated, fast-conducting – Transmits: well-localized, sharp pain – Sensitive to: mechanical and thermal stimuli Impulse sent along nociceptor C fibers A delta fibers Spinal Cord
+ + + + + + + + + + + + + + + + - - - - - - - - - - - - - - - - Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ K+ + + + + + + + + + + + + + + + + - - - - - - - - - - - - - - - - r r r r r r r r r r r K+ r K+ r K+ r Action Potential Blocked r r r r r r r r r r r Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Neuron Anticonvulsants/Anesthetics
Pharmacologic Therapies • Lidocaine – PHN and diverse group peripheral NP conditions – Mild skin reactions – rash and erythema – Blood level minimal up to 4 patches/day – Caution in hepatic failure and other class I antiarrhythmics – 12 hours on and 12 hours off • Antiepileptic – Carbamazepine/oxcarbazepine efficacy in trigeminal neuralgia – Lamotrigine, topiramate, valproic acid, and phenytoin positive and negative trials, more negative than positive – None considered first line except carbamazepine and trigeminal neuralgia
Dorsal Horn Afferent Pain Fiber Spinothalamic Tract Transmission
Substance P Spinothalamic Tract Neuron Primary Afferent Neuron
Opiate Binding Spinothalamic Tract Neuron Primary Afferent Neuron Action of Opiate Binding
Opioid Receptor Location
Opioids • Potential benefits outweigh risks • Patient has failed to adequately respond to non-opioid and non- pharmacological interventions • Patient has moderate to severe nociceptive or neuropathic pain • Initiate a therapeutic trial • Morphine • Oxycodone • Hydromorphone • Fentanyl • Oxymorphone • Hydrocodone • Codeine • Oral • Rectal • Intravenous - PCA • Subcutaneous • Epidural - PCEA • Intrathecal • Transdermal • Buccal • Intramuscular
2022 CDC Guideline • Clinician recommendations for patients aged ≥18 years • Summary of current research • Flexible; encourages patient- centered decision-making • Emphasizes the importance of the individual and clinical judgement • This is a clinical tool, not a law, regulation, or policy https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm
Opioid Side Effect and Adverse Effects Side Effects Adverse Events Respiratory depression Death Opiod-induced constipation (OIC) (most common) Addiction Myoclonus (twitching or jerking) Overdose Sedation, cognitive impairment Hospitalization Sweating, miosis, urinary retention Disability or permanent damage Allergic reactions Falls or fractures Hypogonadism Tolerance, physical dependence, hyperalgesia
Opioid Risk Tool • Opioid Risk Tool identifies persons at higher risk of substance use disorder and may be used to identify patients that necessitate additional monitoring Scoring: • ≤ 2: low risk • ≥ 3: high risk Opioid Risk Tool – OUD (ORT-OUD) This tool should be administered to patients upon an initial visit prior to beginning or continuing opioid therapy for pain management. A score of 2 or lower indicates low risk for future opioid use discover; a score of >/= 3 indicates high risk for opioid use disorder. Mark each box that applies YES NO Family history of substance abuse Alcohol 1 0 Illegal drugs 1 0 Rx drugs 1 0 Personal history of substance abuse Alcohol 1 0 Illegal drugs 1 0 Rx drugs 1 0 Age between 16-45 years 1 0 Psychological disease ADD, OCD, bipolar, schizophrenia 1 0 Depression 1 0 Scoring totals
Informed Consent • When initiating a pain treatment plan, confirm patient understanding of informed consent to establish: – Analgesic and functional goals of treatments • Expectations • Potential risks • Alternatives • Patient understanding • Patient’s decision
Patient Provider Agreement Reinforce Expectations for Appropriate and Safe Opioid Use • Clarify treatment plans and goals • One prescriber • Consider one pharmacy • Safeguards – Do not store in medicine cabinet – Keep locked (medication safe) – Do not share or sell • Prescriber notification for any event resulting in a pain medication prescription • Follow-up plan • Monitoring – Pill counts • Refill procedure • Identify behaviors indicating need for discontinuation • Exit strategy • Signed by patient, clinician who goes over the form, and the physician
Opioid Use Disorder DSM-5 1. Tolerance* 2. Withdrawal* Loss Of Control 3. Using larger amounts and/ or for longer periods 4. Inability to cut down on or control use 5. Increased time spent obtaining, using, or recovering 6. Craving/compulsion Use Despite Negative Consequences 7. Role failure at work, home, school 8. Social, interpersonal problems 9. Reducing social, work, recreational activity 10. Physical hazards 11. Physical or psychological harm 2 – 3 = mild | 4 – 5 = moderate | ≥ 6 = severe
Opioid Receptors in the Brain: Relationship to Analgesia, OUD, and Withdrawal
The Cycle Of Substance Use Disorder Neurotransmitters •Dopamine •Opioid peptides •Corticotropin- releasing factor •Dynorphin •Glutamate Rewarding euphoric effect; limbic system Continue to take drug; avoid withdrawal OUD Established, preoccupation, and craving; prefrontal cortex impaired- impulsive Binge/ Intoxication P r e o c c u p a t i o n / A n t i c i p a t i o n W i t h d r a w a l / N e g a t i v e A f f e c t
Everyone Is Vulnerable, But Who Is MOST Vulnerable to Opioid Misuse or OUD? • Those with low hedonic tone — reduced capacity experience pleasure • Those with psychiatric comorbidities • Those with a genetic predisposition to substance abuse (family history) • The probability of long-term opioid use increases most sharply in the first days of therapy, particularly after 5 days or 1 month of opioids prescribed 19% of people with mental health disorders in the US receive 51% of the prescribed opioids.
Differential Considerations • Under-treated pain, including disease progression, sometimes termed “pseudoaddiction” – Often benefit from co-analgesics • Opioid induced hyperalgesia • Paradoxical response where increased opioids for pain treatment actually creates increased pain sensitivity/increase pain report • Typically diffuse and less defined quality • Non-medical use of opioids sometimes termed “chemical coping” • Used to treat anxiety, insomnia, and existential suffering • Misuse, abuse, or diversion
Opioid Misuse, Abuse, and Diversion • Incorporate as part of the initial and subsequent assessments – Include patient, family caregivers, frequent visitors • Ongoing evaluation process by IDG • Regularly consider especially when “red flag” situations arise: – Pill counts “off” – Repeated requests for early refills including after-hours – Repeated requests for dosing adjustments because “it isn’t working” – Conversations are focused on opioids – Caregivers are never the same and/or won’t identify themselves
Glutamate Primary Afferent Neuron ­ NMDA Receptor Activation ­ Excitotoxicity ­ Ca++
Glutamate NMDA Receptor Antagonist Spinothalamic Tract Neuron Primary Afferent Neuron
NMDA Receptor Antagonists • Methadone – Opioid receptor agonist and NMDA receptor antagonist • Ketamine – Opioid sparing and deceases pain intensity – Side effects include nausea, sedation, delirium, hallucinations, psychotomimetic phenomena, hypersalivation, and tachycardia • Urinary and hepatobiliary toxicity – Oral test dose (20mg po) – Frequency every 6 to 8 hours – Usually administer 100mg over course of day and can increase 100mg daily to 800mg
Gabapentinoids • Gabapentin and pregabalin • Voltage-gated calcium channel binder, decreases glutamate, norepinephrine, and substance leading to decreased presynaptic release of excitatory neurotransmitters • Increased descending inhibition • Efficacy in a variety of peripheral nerve conditions and fibromyalgia • Often used to be opioid sparing • Generally well tolerated – dizziness, sedation, and peripheral edema • Increased risk respiratory depression and death with concomitant use opioids • Renal dosing
Anti-Spasm Drugs • Baclofen – 5-20 mg po TID – Drowsiness, dizziness, hallucinations • Tizanidine – 2 mg po TID – Drowsiness • Clonazepam – 0.5 mg po BID – QID – Sedating
Perception Thalamus Somatosensory Cortex Associative Cortex
Cognitive and Behavioral Interventions • Relaxation • Guided imagery • Distraction • Cognitive reframing • Support groups • Pastoral counseling/prayer
Modulation Serotonin (5HT) Norephrinephrin (NE) Brainstem x
5HT + NE Antidepressants Mechanism of Action of Antidepressants
Antidepressants: Tricyclics • Central and peripheral neuropathic pain • Most studied agent, amitriptyline, has substantial anticholinergic effects • Alternate agents: nortriptyline, desipramine • Usually sedating, administer at night • Start low, 10mg at night titrate gradually every 2 or 3 days, max dose 150mg (cardiac) • Cardiac toxicity (sinus tach and vent ectopy)
Antidepressants: SNRI • Venlafaxine – Peripheral neuropathic pain – Start low 37.5–75 po qd; titrate gradually every 3-4 days; 150-225 mg/day – Nausea (take with food) – Cardiac disease (EKG changes) and HTN • Duloxetine – Peripheral neuropathic pain – FDA Approval fibromyalgia and chronic musculoskeletal pain (arthritis and low back pain) – Reduce dose with renal disorder, may be contraindicated with hepatic impairment – Nausea, dry mouth, drowsiness, and dizziness
Afferent Pain Fiber Brainstem Cognitive Behavior Therapy NSAIDs/DEX LA/Anticonvulsants Opioids/NMDA/α 2-δ Ca Channel TCA/SNRIs
Pharmacologic Management by Pain Etiology Nociceptive Pain Nociplastic Neuropathic Antihistamine Acetaminophen Opioids and NMDA blockers Nerve blocks NSAIDs Topical/transdermal treatments Anticholinergic Anticonvulsants TCAs and SNRIs Other serotonin agents Anticonvulsants Opioids and NMDA blockers Nerve blocks TCAs and SNRIs Generally not opioid responsive
Important Considerations • Pain is often multifactorial and uniquely impacts each individual, and benefits from non-pharmacologic and pharmacologic approach. • Establishing a positive patient- physician partnership provides an important foundation that will optimize treatment outcomes. – Develop a mutual understanding of treatment goals/expectations. – Build rapport and trust. – Encourage patients take on an active role in managing their pain. • Substantial improvement in function and quality of life can be anticipated even if pain is not eliminated. • Persistent pain is treatable, but it is not curable.

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Pain Management in the Context of an Opioid Epidemic: Considerations and Tools for Success

  • 1.
    Pain Management inthe Context of an Opioid Epidemic: Considerations and Tools for Success
  • 2.
    CME Provider Information SatisfactoryCompletion Learners must complete an evaluation form to receive a certificate of completion. You must participate in the entire activity as partial credit is not available. If you are seeking continuing education credit for a specialty not listed below, it is your responsibility to contact your licensing/certification board to determine course eligibility for your licensing/certification requirement. Physicians In support of improving patient care, this activity has been planned and implemented by Amedco LLC and VITAS® Healthcare. Amedco LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. Credit Designation Statement – Amedco LLC designates this live activity for a maximum of 1 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
  • 3.
    Objectives • Incorporate acomprehensive pain assessment • Describe four different types of pain • Appreciate pain physiology and how it relates to pain management • Identify non-opioid treatments as part of a comprehensive plan • Detail three tools to incorporate to help manage patients on opioids
  • 4.
    Reductions in PrescribedOpioids Has Not Led to Reductions in Opioid-related Deaths *Provisional data for the 12-month period Jan. 2020–Jan. 2021 https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Overdose deaths: 94,134* Opioid prescriptions 143,390,9511 (44.4% decrease since 2011) 1
  • 5.
    Opioid Deaths byOpioid Type https://www.cdc.gov/nchs/images/databriefs/401-450/db428-fig4.png, https://www.cdc.gov/nchs/products/databriefs/db428.htm Heroin Fentanyl
  • 6.
    Benefits and RisksAssociated With Opioids Benefits • Analgesia • Option for patients with contraindications for non-opioid analgesics • Relieves suffering • May improve function and quality of life Risks • Life-threatening respiratory depression/overdose • Development of SUD/OUD • Diversion • Inadvertent exposure to family and pets • Interactions with other meds and substances • Neonatal abstinence syndrome • Physiologic dependence and withdrawal
  • 7.
    Terminology Misuse Use ofa medication in a way other than how it is prescribed. Abuse Use of a substance with the intent of getting high. Tolerance Increased dosage needed to produce a specific effect. Dependence State in which an organism only functions normally in the presence of a substance. Diversion Transfer of a legally controlled substance, prescribed to one person, to another person for illicit (forbidden by law) use. Common Term Preferred Term Addiction Substance Use Disorder Drug Seeking, Aberrant, Problematic Behavior Using Medication Not as Prescribed Addict Person With Substance Use Disorder (SUD)
  • 8.
    Important Considerations • Painis often multifactorial and uniquely impacts individuals, and benefits from non-pharmacologic and pharmacologic approach • Establishing a positive patient- physician partnership provides an important foundation that will optimize treatment outcomes – Develop a mutual understanding of treatment goals/expectations – Build rapport and trust – Encourage patients take on an active role in managing their pain • Substantial improvement in function and quality of life can be anticipated even if pain is not eliminated • Persistent pain is treatable, but it is not curable
  • 9.
    Multifaceted Pain Assessment Selfand Proxy Report • NRS • VDS • FPS Potential Contributors • History – medical, psychological social, spiritual, and family • Physical exam Behavior Assessment • Direct observation • At rest and with activity Analgesic Trial
  • 10.
    Acute or ChronicPain Acute • Acute and duration of < 1 month • Sudden onset, self-limiting • Ideally resolves with healing • Triggered by tissue damage and inflammation • Has protective value • Inflammatory mediation • Subacute, pain that continues for 1-3 months, can become chronic “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.” —IASP (July 2020) Chronic • Lasting 3 months or longer • Generally steady- state or worsening • Persists beyond normal healing period • Serves no value • Peripheral and central sensitization
  • 11.
    Pain Assessment: Self-report HeapyA, Kerns RD. Psychological and behavioral assessment. In: Raj's Practical Management of Pain. 4th ed. 2008:279-295; Zacharoff KL, et al. Managing Chronic Pain with Opioids in Primary Care. 2nd ed. Newton, MA: Inflexion, Inc.; 2010. • Description of pain PQRST= Palliative/Provocative Factors, Quality/Quantity, Region/Radiation, Severity, Temporal factors • What relieves the pain? • What causes or increases the pain Location Intensity Onset duration Variations/ patterns/rhythms Quality • Effects of pain on physical, emotional, and psychosocial function? • Patient’s current level of pain and function
  • 12.
    Pain Intensity andFunctional Interference Cleeland C and Wang S (1999) Oncology NCCN Proceedings • As pain intensity increases, so does the degree of functional interference • The figure on the right shows the relationship in persons with cancer pain • Studies of patients with AIDS and chronic non-cancer pain show similar interferences with function with increasing pain As pain intensity increases, so does the degree of functional interference relate walk sleep active mood work enjoy walk sleep active mood work enjoy sleep active mood work enjoy sleep active mood work enjoy work enjoy enjoy 3 4 5 6 7 8 Worst Pain (0-10 scale)
  • 13.
    Proxy Pain Report •Healthcare Professionals – Physicians – APPs – Nurses – Nursing assistants • Families
  • 14.
    Potential Contributors andTreatment • Conditions with focus on those attributable to pain – Medical: osteoarthritis, gout, spinal stenosis, post-herpetic neuralgia, cancer, etc. – Post-surgical: hip fracture with repair, joint replacement, other surgeries • Conditions that may impact metabolism or ability to tolerate analgesics – Liver, renal, pulmonary, cognitive, gastrointestinal (nausea and constipation) • Identify previous treatments, including effectiveness and adverse effects – Query the state Prescription Drug Monitoring Program (PDMP) – Corroborate patient/family report – Past medical records as appropriate • Assess barriers, such as the cost of treatment, childcare, transportation, attitudes, and health-care literacy
  • 15.
    Prescription Drug MonitoringProgram • Reports on scheduled drugs including opioids that are filled • Nearly all available 24/7/365 with 54 operational within the US – No national DPMP exists • Requirements mandating use vary by state – Know your state law • Multiple benefits have been reported – Lower rates of opioid-prescription ED visits and hospitalizations – Reduction in high-dose prescriptions and over-prescribing – Reduction in doctor shopping • Identify drugs that increase overdose risk when taken together (such as benzodiazepines, gabapentinoids, opioids, and other sedatives)
  • 16.
    Psychological, Social, andFamily History • Social history – Employment, cultural background, social network, relationship history, legal history, and other behavioral patterns • Psychological history – Mental health diagnoses, depression, anxiety, OCD, and PTSD – Alcohol, tobacco, THC, and recreational drug use • History of adverse childhood experiences (ACES) • Family history of substance use disorder and/or psychiatric disorder Depression and anxiety can be predictors of chronic pain.
  • 17.
    Behavioral Assessment: Non-verbalPain Indicators Changes in interpersonal interactions • Combative, disruptive, resisting care, decreased social interactions, withdrawn Changes in mental status • Confusion, irritability, agitation, crying Changes in usual activity • Refusing food/appetite change, increased wandering, change in sleep habits Facial expressions • Grimacing, slight frown, rapid blinking, sad/frightened, any distortion Vocalizations (crying, moaning, groaning) • Crying, moaning, groaning, grunting, calling out, noisy breathing, a5ng for help Body movements (guarding) • Guarding, rigid, tense posture, fidgeting, pacing, rocking, limping, resistance to moving
  • 18.
    Types of Pain NociceptivePain Nociplastic Neuropathic Pain in response to an injury or stimuli; typically acute Pain that arises from altered nociceptive function; typically chronic Pain that develops when the nervous system is damaged; typically chronic Fibromyalgia, irritable bowel syndrome, non- specific low back pain Mixed pain syndromes (nociceptive and neuropathic) Postoperative pain, sports injuries, arthritis, sickle cell disease, mechanical low back pain Post-herpetic neuralgia, trigeminal neuralgia, distal polyneuropathy, CRPS, neuropathic low back pain, diabetic peripheral neuropathy
  • 19.
    Neuropathic Pain • Neuropathicpain involves injury or alteration of the normal sensory and modulatory nervous system • Multiple processes are capable of producing sufficient neural alteration to produce neuropathic pain – Abnormal nerve regeneration – Increased expression of membrane sodium channels – Disinhibition of modulatory processes – Decreased expression of mu-opioid receptors • Pain occurs because injured nerves (CNS or periphery) react abnormally to stimuli or discharge spontaneously
  • 20.
    Nociceptive Pain American PainSociety, Principles of Analgesic Use, 7th Ed. • Nociceptors = pain receptors in our tissues – Nerve endings that process stimuli (noxious and innocuous) – Skin, GI tract, skeletal muscle, joints, arteries, head, heart • Nociceptive pain – arises from actual or threatened damage to nonneural tissue, due to activation of nociceptors • Direction stimulation of afferent nerves due to tissue injury or tumor infiltration of skin, soft tissue, or viscera • Proportionate to the stimulation of the nociceptor – More tissue damage = more pain
  • 21.
    Pain Pathways Dorsal Horns BrainstemDorsal Root Ganglion Afferent Pain Fiber Thalamus
  • 22.
  • 23.
    Mediators of PeripheralNociception With thanks to Allan Basbaum and David Julius, University of California, San Francisco Feeling physical pain is vital for survival; pain is the body’s early warning system.
  • 24.
    Pharmacologic Therapies • Corticosteroids –Dexamethasone has least mineralocorticoid effect – All can produce glucocorticoid effects – Substantial side effects with ongoing term use (psychosis, proximal muscle wasting, and bone loss) • Nonsteroidal Anti-inflammatory Drugs (NSAIDS) – Analgesic, antipyretic, anti-inflammatory – GI bleeding, bleeding, renal dysfunction, cardiovascular effects • Capsaicin
  • 25.
    + + ++ + - - - - - + + + + + + - - - - - + + + + + - - - - - - + + + + + - - - - - + + + + + + - - - - - + + + + + - - - - - - Action Potential Na+ Na+ Na+ K+ Na+ Na+ Na+ K+ Neuron Conduction
  • 26.
    Conduction • C-fibers: small,unmyelinated, slow-conducting – Transmits: dull, poorly localized, diffuse, burning, aching pain – Sensitive to: mechanical, thermal, or chemical stimuli • A-delta fibers: large, myelinated, fast-conducting – Transmits: well-localized, sharp pain – Sensitive to: mechanical and thermal stimuli Impulse sent along nociceptor C fibers A delta fibers Spinal Cord
  • 27.
    + + ++ + + + + + + + + + + + + - - - - - - - - - - - - - - - - Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ K+ + + + + + + + + + + + + + + + + - - - - - - - - - - - - - - - - r r r r r r r r r r r K+ r K+ r K+ r Action Potential Blocked r r r r r r r r r r r Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Na+ Neuron Anticonvulsants/Anesthetics
  • 28.
    Pharmacologic Therapies • Lidocaine –PHN and diverse group peripheral NP conditions – Mild skin reactions – rash and erythema – Blood level minimal up to 4 patches/day – Caution in hepatic failure and other class I antiarrhythmics – 12 hours on and 12 hours off • Antiepileptic – Carbamazepine/oxcarbazepine efficacy in trigeminal neuralgia – Lamotrigine, topiramate, valproic acid, and phenytoin positive and negative trials, more negative than positive – None considered first line except carbamazepine and trigeminal neuralgia
  • 29.
  • 30.
  • 31.
  • 32.
  • 33.
    Opioids • Potential benefitsoutweigh risks • Patient has failed to adequately respond to non-opioid and non- pharmacological interventions • Patient has moderate to severe nociceptive or neuropathic pain • Initiate a therapeutic trial • Morphine • Oxycodone • Hydromorphone • Fentanyl • Oxymorphone • Hydrocodone • Codeine • Oral • Rectal • Intravenous - PCA • Subcutaneous • Epidural - PCEA • Intrathecal • Transdermal • Buccal • Intramuscular
  • 34.
    2022 CDC Guideline •Clinician recommendations for patients aged ≥18 years • Summary of current research • Flexible; encourages patient- centered decision-making • Emphasizes the importance of the individual and clinical judgement • This is a clinical tool, not a law, regulation, or policy https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm
  • 35.
    Opioid Side Effectand Adverse Effects Side Effects Adverse Events Respiratory depression Death Opiod-induced constipation (OIC) (most common) Addiction Myoclonus (twitching or jerking) Overdose Sedation, cognitive impairment Hospitalization Sweating, miosis, urinary retention Disability or permanent damage Allergic reactions Falls or fractures Hypogonadism Tolerance, physical dependence, hyperalgesia
  • 36.
    Opioid Risk Tool •Opioid Risk Tool identifies persons at higher risk of substance use disorder and may be used to identify patients that necessitate additional monitoring Scoring: • ≤ 2: low risk • ≥ 3: high risk Opioid Risk Tool – OUD (ORT-OUD) This tool should be administered to patients upon an initial visit prior to beginning or continuing opioid therapy for pain management. A score of 2 or lower indicates low risk for future opioid use discover; a score of >/= 3 indicates high risk for opioid use disorder. Mark each box that applies YES NO Family history of substance abuse Alcohol 1 0 Illegal drugs 1 0 Rx drugs 1 0 Personal history of substance abuse Alcohol 1 0 Illegal drugs 1 0 Rx drugs 1 0 Age between 16-45 years 1 0 Psychological disease ADD, OCD, bipolar, schizophrenia 1 0 Depression 1 0 Scoring totals
  • 37.
    Informed Consent • Wheninitiating a pain treatment plan, confirm patient understanding of informed consent to establish: – Analgesic and functional goals of treatments • Expectations • Potential risks • Alternatives • Patient understanding • Patient’s decision
  • 38.
    Patient Provider Agreement ReinforceExpectations for Appropriate and Safe Opioid Use • Clarify treatment plans and goals • One prescriber • Consider one pharmacy • Safeguards – Do not store in medicine cabinet – Keep locked (medication safe) – Do not share or sell • Prescriber notification for any event resulting in a pain medication prescription • Follow-up plan • Monitoring – Pill counts • Refill procedure • Identify behaviors indicating need for discontinuation • Exit strategy • Signed by patient, clinician who goes over the form, and the physician
  • 39.
    Opioid Use DisorderDSM-5 1. Tolerance* 2. Withdrawal* Loss Of Control 3. Using larger amounts and/ or for longer periods 4. Inability to cut down on or control use 5. Increased time spent obtaining, using, or recovering 6. Craving/compulsion Use Despite Negative Consequences 7. Role failure at work, home, school 8. Social, interpersonal problems 9. Reducing social, work, recreational activity 10. Physical hazards 11. Physical or psychological harm 2 – 3 = mild | 4 – 5 = moderate | ≥ 6 = severe
  • 40.
    Opioid Receptors inthe Brain: Relationship to Analgesia, OUD, and Withdrawal
  • 41.
    The Cycle OfSubstance Use Disorder Neurotransmitters •Dopamine •Opioid peptides •Corticotropin- releasing factor •Dynorphin •Glutamate Rewarding euphoric effect; limbic system Continue to take drug; avoid withdrawal OUD Established, preoccupation, and craving; prefrontal cortex impaired- impulsive Binge/ Intoxication P r e o c c u p a t i o n / A n t i c i p a t i o n W i t h d r a w a l / N e g a t i v e A f f e c t
  • 42.
    Everyone Is Vulnerable,But Who Is MOST Vulnerable to Opioid Misuse or OUD? • Those with low hedonic tone — reduced capacity experience pleasure • Those with psychiatric comorbidities • Those with a genetic predisposition to substance abuse (family history) • The probability of long-term opioid use increases most sharply in the first days of therapy, particularly after 5 days or 1 month of opioids prescribed 19% of people with mental health disorders in the US receive 51% of the prescribed opioids.
  • 43.
    Differential Considerations • Under-treatedpain, including disease progression, sometimes termed “pseudoaddiction” – Often benefit from co-analgesics • Opioid induced hyperalgesia • Paradoxical response where increased opioids for pain treatment actually creates increased pain sensitivity/increase pain report • Typically diffuse and less defined quality • Non-medical use of opioids sometimes termed “chemical coping” • Used to treat anxiety, insomnia, and existential suffering • Misuse, abuse, or diversion
  • 44.
    Opioid Misuse, Abuse,and Diversion • Incorporate as part of the initial and subsequent assessments – Include patient, family caregivers, frequent visitors • Ongoing evaluation process by IDG • Regularly consider especially when “red flag” situations arise: – Pill counts “off” – Repeated requests for early refills including after-hours – Repeated requests for dosing adjustments because “it isn’t working” – Conversations are focused on opioids – Caregivers are never the same and/or won’t identify themselves
  • 45.
    Glutamate Primary Afferent Neuron ­ NMDA ReceptorActivation ­ Excitotoxicity ­ Ca++
  • 46.
  • 47.
    NMDA Receptor Antagonists •Methadone – Opioid receptor agonist and NMDA receptor antagonist • Ketamine – Opioid sparing and deceases pain intensity – Side effects include nausea, sedation, delirium, hallucinations, psychotomimetic phenomena, hypersalivation, and tachycardia • Urinary and hepatobiliary toxicity – Oral test dose (20mg po) – Frequency every 6 to 8 hours – Usually administer 100mg over course of day and can increase 100mg daily to 800mg
  • 48.
    Gabapentinoids • Gabapentin andpregabalin • Voltage-gated calcium channel binder, decreases glutamate, norepinephrine, and substance leading to decreased presynaptic release of excitatory neurotransmitters • Increased descending inhibition • Efficacy in a variety of peripheral nerve conditions and fibromyalgia • Often used to be opioid sparing • Generally well tolerated – dizziness, sedation, and peripheral edema • Increased risk respiratory depression and death with concomitant use opioids • Renal dosing
  • 49.
    Anti-Spasm Drugs • Baclofen –5-20 mg po TID – Drowsiness, dizziness, hallucinations • Tizanidine – 2 mg po TID – Drowsiness • Clonazepam – 0.5 mg po BID – QID – Sedating
  • 50.
  • 51.
    Cognitive and BehavioralInterventions • Relaxation • Guided imagery • Distraction • Cognitive reframing • Support groups • Pastoral counseling/prayer
  • 52.
  • 53.
  • 54.
    Antidepressants: Tricyclics • Centraland peripheral neuropathic pain • Most studied agent, amitriptyline, has substantial anticholinergic effects • Alternate agents: nortriptyline, desipramine • Usually sedating, administer at night • Start low, 10mg at night titrate gradually every 2 or 3 days, max dose 150mg (cardiac) • Cardiac toxicity (sinus tach and vent ectopy)
  • 55.
    Antidepressants: SNRI • Venlafaxine –Peripheral neuropathic pain – Start low 37.5–75 po qd; titrate gradually every 3-4 days; 150-225 mg/day – Nausea (take with food) – Cardiac disease (EKG changes) and HTN • Duloxetine – Peripheral neuropathic pain – FDA Approval fibromyalgia and chronic musculoskeletal pain (arthritis and low back pain) – Reduce dose with renal disorder, may be contraindicated with hepatic impairment – Nausea, dry mouth, drowsiness, and dizziness
  • 56.
  • 57.
    Pharmacologic Management byPain Etiology Nociceptive Pain Nociplastic Neuropathic Antihistamine Acetaminophen Opioids and NMDA blockers Nerve blocks NSAIDs Topical/transdermal treatments Anticholinergic Anticonvulsants TCAs and SNRIs Other serotonin agents Anticonvulsants Opioids and NMDA blockers Nerve blocks TCAs and SNRIs Generally not opioid responsive
  • 58.
    Important Considerations • Painis often multifactorial and uniquely impacts each individual, and benefits from non-pharmacologic and pharmacologic approach. • Establishing a positive patient- physician partnership provides an important foundation that will optimize treatment outcomes. – Develop a mutual understanding of treatment goals/expectations. – Build rapport and trust. – Encourage patients take on an active role in managing their pain. • Substantial improvement in function and quality of life can be anticipated even if pain is not eliminated. • Persistent pain is treatable, but it is not curable.