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Assessment & Management of Chronic Non-Malignant Pain

Assessment & Management of Chronic Non-Malignant Pain. Randy Brown, M.D. Assistant Professor UW Dept of Family Medicine PhD Candidate UW Dept of Population Health Sciences 6/8/06. Chronic Nonmalignant Pain (CNMP). Present ≥ 3 mos. Nociceptive, neuropathic, or mixed

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Assessment & Management of Chronic Non-Malignant Pain

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  1. Assessment & Management of Chronic Non-Malignant Pain Randy Brown, M.D. Assistant Professor UW Dept of Family Medicine PhD Candidate UW Dept of Population Health Sciences 6/8/06

  2. Chronic Nonmalignant Pain (CNMP) • Present ≥ 3 mos. • Nociceptive, neuropathic, or mixed • Continuous often w/ intermittent flare • Negative impact upon • Well-being • Level of function • Quality of life

  3. CNMP Epidemiology • Pain = most common presenting complaint • 50 million Americans • ~8% have diffuse musculoskeletal pain

  4. Common Diagnoses • Osteoarthritis • Rheumatoid arthritis • Spinal arthropathies/disc disease +/- radiculopathy • Complex regional pain (reflex sympathetic dystrophy) • Fibromyalgia • Myofascial pain • Painful peripheral neuropathies • Post-herpetic neuralgia • HIV disease • Headache syndromes

  5. CNMP Challenges • Little appropriate prospective data • Pain complaints often >> findings • Psychiatric comorbidity common • Concerns re: long-term opioids • Decrease patient function? • Unmanageable adverse effects? • Increase pain? • Cause addiction? • The State Medical Board and DEA are watching. . .

  6. Main Points • Appropriate assessment includes pain, medical, psychiatric, and substance use history • Care = multi-disciplinary • Negotiate individualized, quantifiable treatment goals • Watch the 4 A’s • Analgesia • Activity • Adherence • Adverse effects

  7. “Drug-Host Interaction” Initial Visit: Assessment • Pain complaint history • Functional impact • Medical co-morbidity • Psychiatric history • Substance use history

  8. severe mod. mild 0 1 3 4 6 7 10 No pain Worst pain Initial Visit: Assessment • Pain complaint • Onset/chronology • Characterization • Quality • Location/referral/radiation • Intensity • Visual Analog Scale

  9. Initial Visit: Assessment • Pain complaint • Onset/chronology • Characterization • Quality • Location/referral/radiation • Intensity • Aggravating/alleviating factors • Additional symptoms • Functional impact • Work • Activities of Daily Living • Sleep • Mood • Social

  10. Initial Visit: Assessment • Treatment history • Surgical/interventional • Pharmacotherapeutic • Rehabilitation/physiatry • Psychiatric • Complementary

  11. Initial Visit: Exam • Musculoskeletal • Neurological • Screening for anxiety/depression • Functional assessment • Lab/radiography—if indicated

  12. Initial Visit: Treatment Goals • Goals/expectations = negotiated, realistic, measurable • Realms to consider: • Pain relief • Function • Sleep • Coping skills • Affective distress • Work/vocational retraining

  13. Treatment Components • Physical rehabilitation • Function • Pain control • Self-management • Psychological/behavioral • Interventional/surgical • Complementary • Pharmacotherapy

  14. Treatment: Pharmacotherapy • NSAIDs • Indication: mild-mod pain • Nociceptive > neuropathic • Adverse effects (fx): GI, renal, hypertension • Acetaminophen • Indication: mild-mod pain • Dosing < 4g daily • Adverse fx: hepatotoxicity, renal insufficiency

  15. Treatment: Pharmacotherapy • Adjunctive Rx • Topicals (e.g. capsaicin) • Anticonvulsants (e.g. Tegretol, Neurontin) • Tricyclic antidepressants • Selective serotonin reuptake inhibitors (FMR, IBS) • “Muscle relaxants”

  16. Treatment: Pharmacotherapy • Opioids • Indications • Mod-severe pain • Functional impact • Failure of non-opioids • Primary agent = long-acting if used daily • ↓ withdrawal, euphoria, abuse/dependence • ↑ pain control, tolerance to adverse fx “Drug-Host Interaction”

  17. Serum level 8PM 8AM Noon 4PM MN 4AM 8AM Long- vs. Short-Acting Opioids Adverse Effects Therapeutic Window Ineffective/opioid withdrawal

  18. Serum level 8PM 8AM Noon 4PM MN 4AM 8AM Long- vs. Short-Acting Opioids

  19. Opioid Dose Titration • Opioid naïve • Scheduled + as needed short-acting preparation • When dose stable, convert to long-acting dose equivalent • http://globalrph.com/narcoticonv.htm • http://www.globalrph.com/narcotic_pda.htm • Reduce dose-equivalent by 25-50% if converting to a different opioid • Non-naïve  2 and 3 above

  20. “Special” Opioids • Codeine • Tramadol • Meperidine • Propoxyphene • Mixed agonist/antagonists (butorphanol) • Methadone

  21. Tolerance develops Long-Term Opioid Adverse Effects • No known end-organ toxicity • Sedation • Nausea • Pruritis

  22. Long-Term Opioid Adverse Effects • Constipation • Myoclonus • Hypogonadism • Pain facilitation (hyperalgesia) • Abuse/dependence

  23. Constipation • Bowel regimen • ↑ fluids/fiber • Encourage mobility • Stool softener (ducosate) +/- stimulant laxative (senna)

  24. Somnolence/Sedation • Reduce dose if analgesia adequate • Consider addition of stimulant (modafinil)

  25. Myoclonus • Reduce dose • Rotate opioids • Benzodiazepine = last resort

  26. Hypogonadism • Women • Dose ↓ • Opioid rotation • Oral contraceptive • Men • Topical or intramuscular testosterone

  27. Pain Facilitation/Hyperalgesia • If ↑↑ ing dose w/o ↑ pain relief: • Reconsider Dx/progression of disease • Rotate opioids • Taper or discontinuation • 15-25% Q 3-5 days • Slow during last ½

  28. Opioid Abuse • 1+ in 12 month period due to use: • Failure to fulfill major obligations (work, school, home) • Recurrent use in hazardous situations • Recurrent legal consequences • Continued use despite recurrent/persistent interpersonal problems • Not dependence

  29. Physical dependence ≠ opioid dependence/addiction Opioid Dependence • 3+ in 12 months: • Tolerance • Withdrawal • Larger amounts/longer periods than intended • Persistent desire/failed attempts to quit or ↓ use • Much time obtaining, using, or recovering • Important activities sacrificed • Use continues despite knowledge of adverse effects

  30. Pseudoaddiction • Aberrant behaviors surrounding opioids due to inadequately controlled pain NOT abuse/dependence

  31. Opioid Use Disorder + CNMP • AODA consultation (diagnose/treat) • Treatment program • Methadone treatment facility • Buprenorphine • Detox/taper • Opioid analgesic taper • Clonidine + adjuncts • Consider inpatient

  32. Treatment fx/risk Abuse/dep criteria Monitoring Opioid Recipients Analgesia Activity Adverse Effects Adherence

  33. Activity • Bed days in last 30 • Missed work/school • Failed social obligations • Tolerance of walking, lifting, household chores, hobbies etc.

  34. Adverse Effects: Use Disorders • Red Flag: overt focus on obtaining opioids despite adverse fx, ineffective analgesia, and/or ↓ function

  35. Adherence • Attending visits not related to opioids? • Loss of control over opioid use? • Took opioids for pain or for craving? • Took opioids for indication other than pain (anxiety, stress, depression, or non-restorative sleep)?

  36. Addicted patient Out of control of meds Meds decrease QOL Wants med increase despite side f/x In denial re: medical problems Does not follow treatment plan Pain patient Not out of control of meds Meds improve QOL Aware of side f/x Appropriate concern about medical problems Follows agreed upon treatment plan Adherence: CNMP vs. SUD

  37. Adherence: Concerning Behaviors • Out of town patient • Cash-paying patient • “No” becomes “yes” • Telephone requests for narcotics • Multiple allergies (NSAIDs, codeine. . .) • Frequent no-shows

  38. Adherence: Concerning Behaviors • Overly focused on medication rather than pain relief • Multiple Rx “losses” • Functional deterioration • Repeated resistance to changes in Rx despite clear evidence of adverse fx or lack of efficacy

  39. Pseudoaddiction vs. SUD • Name-brand requests (?) • Aggressive complaining about need for ↑ analgesia • Drug hoarding when ↓ symptoms • Openly acquiring narcotics from other medical sources • Unsanctioned dose ↑

  40. Adherence: Pain Management Agreements • One prescriber/one pharmacy • Prescriptions must last as intended • No after-hours refill requests • Lost prescriptions not replaced • Safe activities when drowsy • Additional required care • Random urine drug screens • Possible responses to violations

  41. Urine Drug Screens • Detects other substance use NOTabuse/dependence • MAY aid in detecting diversion • need to specifically order prescribed opioid testing • consider urine dip for pH, SG, plus urine Cr & temp. • results should be discussed with patient

  42. Regulatory Issues • DEA concerned with intentional diversion • State Medical Boards most often involved in MD discipline • Complaint driven

  43. Regulatory Issues • Document!! • Pain assessment/diagnosis • Function • Subst. use/Ψ hx • Exam/diagnostic testing • Follow-up (4 A’s) • Tx goals/pain mgmt agreement • Reassess pain/substance use in setting of agreement violations

  44. Summary • Appropriately assess pain & co-morbidity • CNMP care = multidisciplinary • Establish realistic goals you can measure • Watch and document 4 A’s

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