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Pain Management in Primary Care

Pain Management in Primary Care. Kimberly Zoberi, MD Saint Louis University School of Medicine. Who treats chronic pain?. Bruer B, et al, Southern Medical Journal, 2010; 103:738-747. Ways to classify pain. Acute vs. chronic Nociceptive vs. neuropathic Psychogenic vs. somatic.

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Pain Management in Primary Care

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  1. Pain Management in Primary Care Kimberly Zoberi, MD Saint Louis University School of Medicine

  2. Who treats chronic pain? BruerB, et al, Southern Medical Journal, 2010; 103:738-747

  3. Ways to classify pain • Acute vs. chronic • Nociceptive vs. neuropathic • Psychogenic vs. somatic

  4. Acute vs. Chronic

  5. Nociceptive vs. Neuropathic Nociceptive: Appropriate stimulation of nerve endings leads to signaling Neuropathic: Dysfunction of nerve

  6. Acute, nociceptive pain • Examples? • Goals of treatment • Heal the injury • Decrease acute pain • Prevent progression to chronic pain • Strategies

  7. Acute, neuropathic pain • Migraine, herniated disk

  8. Chronic, nociceptive pain • Arthritis, cancer • BOTH ongoing damage and upregulation of nerve impulses • Remodeling centrally and dorsal horn of spinal cord • Multimodal treatment

  9. Chronic, neuropathic pain • Fibromyalgia, IBS • Not much utility to anti-inflammatories • Neuromodulating agents are key

  10. Psychogenic component Insomnia Chronic pain Anxiety Depression

  11. Musculoskeletal symptoms and non-REM sleep disturbance in patients with "fibrositis syndrome" and healthy subjects. Moldofsky, et al, Psychosomatic Medicine, 1975, 37 (4): 341-351.

  12. Sleep deprivation patients looked identical to fibromyalgia patients in • mood • somatic complaints • sleep architecture

  13. Smith et al. The effects of sleep deprivation on pain inhibition and spontaneous pain in women.Sleep. 2007. Kundermannet al. The effect of sleep deprivation on pain.Pain Res Manag. 2004

  14. Source: Sleep and Pain, Lavigne (ed) 2007.

  15. How patients feel

  16. What patients want

  17. Physical therapy Behavioral activation Psychotherapy Family therapy Neuromodulators Anxiety management Sleep regulation TENS Mood regulation NSAIDS/Co-analgesics Narcotics Interventions

  18. General Treatment Strategy • Acknowledgement of patient’s pain • Nonpharmacologic treatments • Physical therapy • Exercise • Heat/ice • Coping mechanisms • CBT

  19. Pharmacologic treatment + + Acetaminophen Neuropathic Non-neuropathic NSAIDS +/- mild opioids Adjuvant pain meds Continued pain Short acting Opioids PRN Long Acting Opioids ATC +/- Adjuvant pain meds

  20. Inhibition NE/Serotonin Dopamine Opioids GABA Cannabinoids Adenosine Facilitation Substance P Glutamate NGF CCK

  21. Adjuvant Pain Meds • Neuromodulators • Calcium channel agents • Ca needed for afferent pain fibers to synapse • Gabapentin inhibits this • Sodium channel agents • Na needed for spinal cord neurons to transmit impulses • Topamax inhibits this • Serotonin/NE reuptake inhibitors

  22. Adjuvant pain meds • Side effects? • Which one has NO weight gain?

  23. 3 Circumstances to Use Opioids • Moderate to severe pain • Patient has already failed other therapies • Other therapies (NSAIDs) are contraindicated

  24. Opioids • Which patients should NOT use opioids?

  25. Informed Consent for Opioids

  26. Documentation • How NOT to get in trouble with the DEA

  27. Initial Assessment • Onset, duration • Location, distribution • Quality, character • Intensity • Aggravating and relieving factors • Associated factors • Mood and emotional distress • Functional impairment • Associated features • Neurological deficit, hyperalgesia, allodynia • Previous treatments

  28. Ongoing Assessment(Progress Note) • 4 A’s • Analgesia (use a pain scale) • ADL’s • Adverse effects • Aberrant drug related behavior • Assessment and Plan

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