Fibromyalgia & Other Pain Controversies

1. Raouf (Ron) Gharbo D.O. VOMA Spring Conference 2010 Williamsburg, Virginia Fibromyalgia & Other Pain Controversies

3. Bias • A personal and unreasoned judgment. • Merriam-Webster • One commercial break for our sponsor • Not looking for more Fibromyalgia referrals

4. Pain Management • What is your definition of Management? • Does it imply holistic approach? • Not recognized by America Board of Medical Specialties • National and individual outcomes? • Interventionalist • Isn’t Fibromyalgia a pain syndrome?

5. Pain • The American Academy of Pain Medicine– “An unpleasant sensation and emotional response to that sensation” • The real issue is anguish/emotional suffering • Barbuto; Am. J. Phys. Med. Rehab. 2008 • Anxiety is a fuel for pain • Insomnia is a fuel for anxiety and visa versa • Fear , anger, unrealistic expectations are fuels for anxiety

6. Anxiety • A painful or apprehensive uneasiness of mind usually over an impending or anticipated ill • Inconvenient to treat • Friday afternoon breakthrough anxiety-fear • Lifestyle choices • Atypical Chest Pain? • Medication efficacy • Avoidance is a coping strategy • Somatization is one avoidance strategy • Why don’t so IT pain pumps seem to work?

7. Fear • An unpleasant often strong emotion caused by anticipation or awareness of danger and accompanied by increased autonomic activity • The amygdala (emotional memory center) is activated and initiates the flight or fight response • Disabled Distressed Rats: Fear of re-injury and pain are major causes of disability

8. Anger • A strong feeling of displeasure & belligerence • Anger is a emotion when threatened • Frymoyer & Bigos Studies 1990’s • Anger towards direct supervisor • Why don’t we see many angry fibromyalgia men?

9. Fight or Flight Response • Amygdala • Pituitary – sympathetic response • HPA axis: Adrenals release of cortisol • Systemic & Cardiac Adrenaline effects • What about chronic stress

11. Secondary Gain, or is it Fear? Or both? • Chronic somatically focused LBP • Fear of Re-injury? Job loss? • Who’s fault is it if our patients are afraid of degenerative arthritis, fibromyalgia or discogenic pain?

12. Degenerative Arthritis v. Osteoarthritis • Bradykinesia & kinesophobia signs of F.O.S.? • “Your spine is going to crumble into a fine dust” • Fear of reinjury • Age appropriate changes • Wolfe’s Law and spine stability • Straightening of cervical lordosis?

13. Fibromyalgia Syndrome • Does it exist? • Syndrome: A set of symptoms occurring together; the sum of signs of any morbid state • Fibromyalgia is different from good ole American chronic low back pain • Dicle Univeristy Physiatry

14. Fibromyalgia: What are you going to do? • Oath to treat only convenient patients that keep us on schedule? • To validate or not to validate? Hamlet • Validate Pharma commercials? • Your choices: • Scoot quickly out of room & be afraid of every f/u • Dump on your colleagues • Take on their burden and risk your own survival? • Kubler-Ross 5 stages of provider grieving • Accept to take on their treatment, but not their burden

16. Stereo System Volume Dial • Hearing dial • Pain dial: elevated levels of substance P in muscle tissue • Awareness/Proprioception dial

17. Manage the Fibromyalgia Visits • Printed website handout • Second visit: 30min f/u • Listen and assess motivation by quality of Q’s • Answer questions • Validate with eye contact & limit to office, move on, in office revalidation, move on, in office revalidation, move on • Sleep habits • TPI & Nutrition covered in another lecture

18. Some Useful Home Exercises • Passive Trapezius muscle stretching • Breathing, awareness and slowing down • High stress reduces efficacy of medications • Active Cervical ROM • Sand down Ca++ deposit rough edges from lack of use

19. Medications • Rational Polypharmacy? • Muscle Relaxers?? • Dantrolene Sodium • Cyclobenzaprine & TCA’s • Gabapentin & Pregabalin(Lyrica) • SNRI’s • “what if that doesn’t work?”

21. *A Word From our Sponsor on SNRI’s • Two SNRI’s have been shown to reduce pain in Fibromyalgia • -Duloxetine-Cymbalta 1 to 0.2 S:N affects • -Milnacipran-Savella - 1 to 3 S:N affects • Only medication to increase function(SF36) at 3 & 6 months is Milnacipran • Mease 2009 N=888 & Clauw 2008 N=1196 • Renal excretion • >10 years of safety • Weight neutral at worst

22. New Topic: Somatization • Somatizing patients without comorbid depression or anxiety disorder. N=290 • Results extrapolated to national level 256 billion/yr in medical care costs are attributable to the incremental effect of somatization alone. • Approximately 2x the annual medical care costs of nonsomatizing patients. • Barsky; Arch of Gen Psychiatry 2005 • Remember costs come with procedure and medication risks

23. Avoidance Behavior • Psychiatry DSM criteria and definitions • Somatically Preoccupied • Spitzer JAMA 1991 • The real issue is anguish/emotional suffering • Barbuto Commentary: Am. J. Phys. Med. Rehab. 2008

24. Somatically Focused (LBP) • Maladaptive avoidance behavior that results in a disparity between physical impairment and function regardless of organic pathology

25. Somatization Enablers • Entities that validate or magnify minimal organic impairments reinforcing maladaptive avoidance behavior

26. Examples of Somatization Enablers • Opioids • Monthly vicodin merry go round • Discogenic pain • Discograms • 5th vital sign • Lumbar scars • Interventionalists • (Myopic ones)

27. Discogenic Pain Controversy • Pain is not a diagnosis • Low back pain with or without leg pain • Characteristics of a good screening test • No false negatives • Reliable outcome measures (pain?) • Inexpensive • Noninvasive • Well defined condition • Treatment has good outcomes

28. 2000 Volvo Award Winner • 45 asymptomatic patients with normal psychometric testing • 143 discs evaluated by MRI • 13 discs showed HIZ on lumbar MRI • 9 abnormal on discography • Carragee, Spine 2000 • Please don’t ever send any of my family members for a discogram

29. What are the Rules? • Primum non nocere: Do No Harm • Beneficence vs. Do No Harm? • “I believe my patients” • “They came to me to do something” • Acute pain model simply doesn’t work for chronic somatically focused low back pain patients • Protect your patients against willful myopia

30. Holistic Care for “Drug Seekers” • Intelligent disciplined diverters -criminal act worthy of discharge • Substance abuse -medical condition with specific patterns worthy of medical treatment, appropriate opioid weaning, and a measure of empathy • Anxiety/Somatization-worthy of greater time & attention, rational opioids and protect from unnecessary risk

31. My Painful Principles:To stay out of trouble • No dumping • “I do not prescribe” is not acceptable if you maintain a DEA# • Lying is just a symptom of abuse • Baseball rule • One Mulligan • Maintain good habits without escalation (be effective, not right) • No gotcha • Pseudoaddiction • “Not all pain can be relieved” • Some patients not ready change • Pain and suffering often look the same-Barbuto • Opioids can validate and enable • A single provider can’t….

32. What’s Reasonable? • Legitimate diagnosis documented and communicated • Stable dose and mood • No major workup or decline of condition expected • Documented functional gains for nonmalignant pain • May follow up prn for dose escalation

33. Chronic Stress Response… Cycle?

34. VagalNerve Afferents

35. Heart Rate Variability BiofeedbackMcCraty: American Journal of Cardiology 1995 • Slight increase HR with inspiration & slight decrease with expiration • Habituate gratitude • Less hopelessness then less helplessness

36. Summary • Do No Harm • Protect your patients • Don’t be right and escalate, be effective • Listening is counseling • Validate Fibromyalgia with eye contact and move on • Don’t validate avoidance behavior