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When Chronic Pain Comes Knocking

When Chronic Pain Comes Knocking. Kenneth R. Goldschneider, MD, FAAP Director, Division of Pain Management Cincinnati Children’s Hospital Medical Center. The Chronic Pain Patient Arrives…. Disclosure. 2006 Pfizer Pain Visiting professorship No promotional activity. Case #1.

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When Chronic Pain Comes Knocking

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  1. When Chronic Pain Comes Knocking Kenneth R. Goldschneider, MD, FAAP Director, Division of Pain Management Cincinnati Children’s Hospital Medical Center

  2. The Chronic Pain Patient Arrives…

  3. Disclosure • 2006 Pfizer Pain Visiting professorship • No promotional activity

  4. Case #1 • 12y.o. female presents with 3 months of severe, constant abdominal pain, epigastric, sometimes wakes her, interferes with school. Looks a little uncomfortable. VSS, abd diffusely tender, o/w (-) • PMHx: headaches 1-2/week, o/w (-) • Meds: PPI, MVits; NKA • FHx: Aunt with “spastic colon”

  5. Functional Gastrointestinal Disorders (FGIDs) • Pain anywhere in abdomen • Usually constant or frequent, may waken from sleep. Many descriptors. • Exam non-focal • Often start with infectious or stressful event • Stress exacerbates

  6. Alarm Symptoms • Weight loss, vomiting, focal exam or complaint, decelerating growth curve, GI blood loss, dysphagia, fever, arthritis, delayed puberty, perirectal disease; FHx of IBD, Celiac Dz; Eosinophilic Dz

  7. Pediatric FGIDs • Functional Dyspepsia • Irritable Bowel Syndrome • Abdominal Migraine • Childhood Functional Abdominal Pain+/- Syndrome • Functional Constipation • Nonretentive Fecal Incontinence • Gastroenterology 2006; Vol 130:1537

  8. They’ll fool ya’ • Myofascial pain • Intercostal neuralgia • Slipping rib syndrome • Umbilical hernia • Xyphoidalgia

  9. Treatment of FGIDs • Behavioral Medicine • Biofeedback, coping, lifestyle adaptations, parental coaching • Avoid obvious triggers • Fatty foods, NSAIDs, prolonged NPO • Medication • TCAs, antispasmodics, PPIs, anticonvulsants, peppermint oil

  10. Case #2 • 14 y.o. WF presents with a two week history of burning foot pain that started after twisting her ankle playing soccer. The foot is cyanotic, a bit puffy, and she won’t let you near it. Straight-A student, good family. • PMHx (-); Meds (-); NKA; FHx (-)

  11. CRPS Type I Formerly: Reflex Sympathetic Dystrophy Algodystrophy Algoneurodystrophy Sudek’s Atrophy Reflex Neurovascular Dystrophy Osteodystrophy

  12. CRPS Type I: Diagnosis 1. Develops after initiating noxious event 2. Spontaneous pain or allodynia occurs • not necessarily dermatomal • disproportionate to inciting event 3. Evidence or history of: • edema • sudomotor abnormality • skin blood flow abnormality 4. Excluded by existence of conditions otherwise accounting for degree of pain and dysfunction

  13. 1. Acute: weeks to months warm, dry, most responsive to treatment 2. Dystrophic: months cool, cyanosis/mottling, sudomotor changes 3. Atrophic: years cool, white, atrophy of muscle/skin Traditional sequential stages may not exist May be subtypes: Limited vasomotor predominant Limited neuropathic pain/sensorimotor abnormalities predominant Florid presentation “Classic RSD” Bruehle, et al 2002 RSD: Stages (?)

  14. Presentation Age range: 3 years and up Female:Males = 5:1 Lower:Upper extremity ~5:1 Sports-related injury: ~50% ~85% involved in sports or dance Spontaneous pain Mechanical allodynia, edema, cold extremity, cyanosis

  15. CRPS

  16. Ancillary Findings CRPS Bone scan: mixed results, not useful Radiography: non-specific demineralization Psychological profile: stress seems to exacerbate Wilder, et al, 1992

  17. Recommendations Central theme: functional restoration Objective and Reachable rehab goals essential PT is key Psychological treatment essential Neuropathic meds and occasional block All components subserve the central theme Self-management is emphasized

  18. Younger patients have milder course less pain, higher function, fewer remaining autonomic signs on follow-up, shorter duration, more likely to return to sports School days missed in first year after injury No effect: Duration of symptoms Gender Relation to sports Immobilization Number of SNS Outcome Wilder, et al, 1992

  19. Figure from Reg Anes 23(3)

  20. Case #2 again • Your CRPS patient returns a couple weeks later complaining of sleepiness, dizziness, dry mouth, and (per her mom) significant mood swings. Her pain is a little better. HR: 115; mucous membranes dry, cerebellar signs OK; no SI. • Rx: PT; Bmed; gabapentin; amitriptyline; TENS unit

  21. Pain Meds? • Anticonvulsants • Neuropathic, abdominal pain, headache • Antidepressants • Neuopathic, headache, abdominal pain • Antihypertensives • Neuropathic pain, headache • Local Anesthetics • Neuropathic, back pain

  22. AnaesthesiaUK

  23. Adjunct Meds

  24. Anticonvulsant Side Effects • Minor: • Sedation, dizziness, trouble with memory or concentration, extremity swelling • Major: • Renal stones (Topiramate) • Rash, Stevens-Johnson Syndrome (any) • Liver dysfunction (valproate, carbamazepine) • Pancreatitis (valproate) • Mood swings (gabapentin)

  25. Antidepressant Side effects • Minor: • Sedation, mood swings, weight gain/loss, insomnia, dry mouth • Major: • Suicidal ideation (any, more prominent in SSRIs) • Prolonged QT, Torsades de Pointe (tricyclics) • SSRI interactions (CYP 2D6)

  26. Topical Treatments • Lidocaine patch (Lidoderm) • Approved for PHN • Used for back pain, localized neuropathic pain • Systemic toxicity unlikely • Clonidine patch • Capsaicin

  27. TENS Transcutaneous Electrical Nerve Stimulation

  28. Descending Inhibition Cognitive Control Large Fibers Action SG Small Fibers

  29. Herbs Not your Parents’ Nuts and Berries

  30. Dietary Supplement and Health Education Act, 1994 Created the dietary supplement category Herbs may claim effect but not promise cure No standard for quality No proof needed of efficacy or safety

  31. DSHEA: Implications Potency can vary Contaminants may exist Additives can be used • No mention needed on the label • Active ingredient need not be contained • One preparation may be vastly more or less potent than another

  32. May apple (podophyllum): recommended for pediatric constipation relief Library of Health, 1920 VP-16 (etoposide) Foxglove As a poultice over the kidneys to induce urination, over the joints for inflammation, and as a tea, for heart failure Digitalis Herbs

  33. Nicotinaea tabacum: touted for medicinal purposes Tobacco Indian Hemp: “used with benefit in neuralgia” “for medicinal purposes cannabis is used to quiet spasms and produce mental quietude” Library of Health, 1920 Herbs

  34. So, what’s popular at the herb shops?

  35. Chamomile (Chamaemelum nobile) Mild sedative effect, antispasmodic Works Cross-allergenic with ragweed Contains coumarin Garlic (Allium sativum) Treatment of familial hyperlipidemia in children (8-18 years) Garlic oil or placebo TID x 8 weeks No effect May increase bleeding risk (PT/INR/platelet effects) Herbs

  36. Ginger (Zingiber officinale) Anti-nauseant and antispasmodic Effective May inhibit platelet function May be mutagenic Echinacea (Echinacea purpurea) Immuno-stimulant Appears to work Hepatotoxic in long term use? Tachyphylaxis may develop 3 different species, effect? Herbs

  37. St. John’s Wort(Hyperecium perforatum) Uses: depression, anxiety, sleep disorders Adverse effects: Photosensitivity, dry mouth, fatigue, dizziness, nausea, constipation Drug interactions: Other photo-sensitizers, SSRIs, pseudoephedrine, MAOIs Feverfew (Tanecetum parthenium) Uses: migraine headaches Adverse effects: apthous ulcers, rebound headaches, GI irritability, increased bleeding risk Drug interactions: NSAIDs, heparin, warfarin, inhibits Fe+++ uptake Herbs

  38. Bleeding Chamomile Feverfew Garlic Ginkgo Ginseng Sedation Valerian Kava kava GE Reflux Peppermint Herb: risks and interactions

  39. Case #3 • 17 y.o. with spondylolysis-based back pain presents with increased pain, sweating, tachycardia. He is noted to be unpleasant to the RNs. He says he ran out of methadone a few days ago, and ran out of Percocet yesterday.

  40. Opioids in Pediatric Chronic Pain • Few patients • Organic diagnoses • Stable regimens, once titrated • Dx: Cancer, Ehlers-Danlos, JRA, EBD, CF, Sickle Cell,

  41. Withdrawal • Usually a “red flag” • Lost/stolen Rx, misuse, not following directions, • Sx: same as for adults • Increased pain, tremors, sweating, tachycardia, irritability, yawning, diarrhea

  42. Withdrawal • Need to contact Pain Clinic • Usually, a bolus dose, then a few days of the prior dosing until they can get to clinic • If history of abuse is known, referral to detox is appropriate • 3 day grace period

  43. Opioid Contracts • Between Chronic doc and patient/family • Defines rules of engagement • All opioids to come from Pain Clinic • Usually requires pt to contact Clinic of need to go to ED/Urgent Care Clinic

  44. Interacting with Pain Teams • Referrals • Pt should return to PMD for referral to Clinic • Feedback • Note or call to Pain Clinic helpful • Admissions • Should not be done for a chronic pain condition without consultation with Clinic (for established patients)

  45. Thank You Kenneth.goldschneider@cchmc.org

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