Chronic Pain Syndromes by PAINWeek

Chronic Pain Syndromes Gary W. Jay, MD, DAAPM, FAAPM

Disclosures Consultant/Independent Contractor: INC Research, LLC President Elect: The Eastern Pain Association

Learning Objectives Review the pathophysiology and presentation of chronic pain syndrome List the differential diagnoses involved in chronic pain syndrome Identify appropriate treatment modalities and goals for chronic pain syndrome

1,2 Background

Epidemiology –35% of Americans have some element of chronic pain –50 million Americans are disabled to some degree related to chronic pain –Results in $61 billion in lost productivity –Most common symptom for which patients seek medical care

1. http://emedicine.medscape.com/article/310834-overview#a0101. accessed May 13, 2011. 2. Hardt, et.al Prevalence of Chronic Pain in a Representative Sample in the United States. Pain Medicine 9;7:803-12 2008.

Risk Factors for Development of Chronic Pain3 Duration of pain History of –Psychosocial pathology –Substance abuse/ dependence –Prolonged recovery from previous painful experience –Psychological or physical trauma or abuse

3. Warfield CA, Fausett HJ, eds. Manual of Pain Management, second Ed.. Philadelphia, PA: Lippincott Williams & Wilkins; 2002.

Risk Factors for Development of Chronic Pain3 (cont’d) Low job satisfaction Decreased activity and increased pain behaviors Negative or anxiety-producing beliefs about pain Explanatory model –How the patient relates the pain in a global perspective

Clinician Bias Misconceptions regarding chronic pain patients –Those patients have higher pain thresholds –Patients failing treatment because they don’t want to give up their pain –Opioids are not appropriate for chronic pain syndromes –Pain becomes worse when litigation is involved

Patient Bias The primary provider has “given up” when referrals to specialists are considered The primary provider will be “pleased” with less complaining of worsening pain Fear of addiction to all medications used to treat pain Changing daily activities will not improve pain

Insurance Company Bias “Psychological issues are not our problem” “Drugs are cheaper than rehabilitation” “My way or the highway”

Review the Pathophysiology and Presentation of Chronic Pain Syndrome

Comparisons Pain signal transmission

Mechanism

Duration

Management

Acute pain Nociceptive

Trauma, infection, inflammation

Limited

Well documented

Chronic pain

Peripheral and central nerve sensitization

Greater than 6 months

Neuropathic

Evolving

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Wind up secondary to continuous peripheral stimulae which changes acute pain to chronic via neuroplasticity- WDR spinal neurons stay â&#x20AC;&#x153;onâ&#x20AC;? and the CNS is continuously bombarded by stimulae which started peripherally and became central http://spinewave.co.nz/

Central Sensitization: acute pain becomes chronic

Signs and Symptoms Description is typically shooting, shock-like or burning in nature Pain that does not resolve with conventional medical management Anxiety and depression can worsen pain and worsening pain can intensify anxiety and depression Fatigue and restlessness Withdrawal from pleasurable activities

4 Assessment Algorithm

Complete history and physical –Including all previous medical history available

Psychological assessment questions –Documentation of non-physiological influences on chronic pain

Functional assessment tools –Determination of level of current disability 4. Veasey, GD. Managing chronic pain: What’s the best approach? Journal of Family Practice. 57;12: 806-11 2008.

Available Tools Pain assessment scales –Visual analog scale –Wong-Baker faces scale

Psychological assessment scales –West Haven-Yale multidimensional pain inventory –McGill pain questionnaire –Pain perception profile

Available Tools (cont’d) Psychological (cont’d) –Multidimensional pain inventory –Pain patient profile –Pain presentation inventory

Functional assessment scales –Oswestry disability index5 –Roland-Morris disability questionnaire6 5. Fairbank JCT, Couper J, Davies JB. "The Oswestry low Back Pain Questionnaire." Physiotherapy 1980; 66: 271-273 6. Stratford PW, Binkley J, Solomon P, et al. Defining the minimum level of detectable change for the Roland-Morris Questionnaire. Phys Ther. 1996;76:359-365

List the Differential Diagnoses Involved in Chronic Pain Syndrome

Systems Affected Neurologic –Chronic headaches, central and peripheral neuropathies and spinal stenosis

Musculoskeletal –Arthropathies, myofascial, fibromyalgia and chronic back pain

Gastrointestinal/ Genitourinary –Irritable bowel syndrome, chronic visceral pain, pancreatitis, interstitial cystitis and endometriosis

Fibromyalgia Presentation includes body-wide pain specifically in tender points in muscles, joints and other soft tissue areas Pain is generally deep, aching, burning and radiates Non-pain symptoms include, irritable bowel, headaches, numbness, exercise intolerance and difficulty thinking clearly

Tender Points

Interstitial Cystitis (IC)  Inflammatory pain in the bladder thought to originate from – Lymphatic or vascular obstruction – Infection – Primary mast cell disorders

 Pain is described as pressure and aching – Lower abdomen and back – Urethra and vaginal areas

 Women are at ten times greater risk of IC development

Visceral Pain True visceral pain –Felt deep in the viscera

Referred visceral pain –Pain signals originating in the viscera and converging with nociceptive neurons from the muscle and skin –The referred pain site may also exhibit hyperalgesia

Psychological Effects Chronic pain syndromes have negative effects on –Quality of life –Social interaction

Learned pain behaviors –The patient experiences pain in different intensity based on environmental factors –Changing environments can alter response or activity

Central Pain Syndrome Develops after an acute injury to the central nervous system (CNS) –Initial injury from • Stroke • Multiple sclerosis • Spinal cord injury • Parkinson’s • Traumatic brain injury (TBI)

–Not necessarily thalamic involvement

Central Pain Syndrome (cont’d) Initial presentation as pain with sensory deficits and weakness –Sensory deficits and weakness eventually subside leaving pain

Pain descriptions are typically neuropathic in nature –Burning, ice-like or stabbing

Cardinal signs include altered sensation to temperature changes

Case 1  56 y/o male presenting to the hospital after high speed motor vehicle collision and confirmed TBI  Post stabilization and neurosurgical intervention the patient describes paresthesias on his right side and complaints of 6/10 “fire like” pain bilaterally  The patient is discharged three weeks later with improved motor function however the “fire like” feeling is becoming worse 8/10 despite oxycodone 5 mg every 4 hr prn pain and gabapentin 300 mg TID with follow up scheduled in two weeks

Case 1 (cont’d)  During a follow up appointment 6 months after the MVC the patient requests more opioids and reports pain still as 8-9/10 with the same quality  Current pain medications have been changed to gabapentin 600 mg TID, oxycodone 15 mg every 4 hrs prn pain and oxycodone ER 20 mg every 12 hrs.  There have been multiple appointments with physical therapy but the patient has not made it to any of them  The patient becomes agitated when talking about the overall condition and prognosis  What are some of the next steps?

Identify Appropriate Treatment Modalities and Goals for Chronic Pain Syndrome

Principles of Management Developing a plan of care based on a biopsychosocial model Non-pharmacologic and pharmacologic management strategies Reassessment of chronic pain using time frames based on management strategy Multidisciplinary team involvement

7 Biopsychosocial Approach

Approaches chronic pain in a strategy of management rather than searching for a “cure” The goals are improvement of –Functional capacity –Affective state

Depending on the severity will require primary, secondary and tertiary care 7. Gatchel. The Biopsychosocial Approach. Practical Pain Management. http://www.practicalpainmanagement.com/treatments/psychological/biopsychosocial-approach accessed May 30, 2011.

Biopsychosocial Approach (cont’d)  Primary care – Relief of symptoms of the acute pain and improvement of functional capacity – Psychological factors addressed include anxiety management and or fear associated with pain

 Secondary care – Interdisciplinary care involving avoidance of further physical deconditioning and reduction of psychological barriers interfering with recovery

Biopsychosocial Approach (cont’d)  Tertiary care – Interdisciplinary team including primary care, psychiatrist, physical therapy and a disability care manager – Goals include development of a comprehensive plan to regain mobility and teach stress management and coping skills to manage daily life stressors – Detoxification from pharmacologic treatment has also been identified as a key component at this step in patient management

Non-Pharmacologic Strategies Physical therapy –Fibromyalgia8 • Avoiding overloading in activities of daily living • Addressing postural fatigue and posturing • Conditioning weak muscles • Stretching muscles • Avoiding inactivity and establishing appropriate periods of rest

8. Offenbacher M, Physical therapy in the treatment of fibromyalgia. Scandinavian Journal of Rheumatology - Supplement. 113:78-85, 2000.

Pharmacologic Strategies Tricyclic antidepressants –Amitriptyline, nortriptyline, desipramine and doxepin –Dosing for pain management is not the same as dosing for antidepressant effects –Anticholinergic effects are common and can be dose limiting –Other concerns related to arrhythmias and sedation can limit widespread patient use

Pharmacologic Strategies (cont’d) Serotonin and norepinephrine inhibitors –Duloxetine, milnacipran and venlafaxine • Milnacipran currently has one FDA approved indication – Fibromyalgia

Serotonin selective inhibitors (SSRI) –SSRI’s in general do not have sufficient data related to effective neuropathic pain management –Currently no SSRI has an FDA approved indication for management of pain

Pharmacologic Strategies (cont’d) Antiepileptics –Carbamazepine, divalproex, gabapentin, topiramate and lamotrigine –These agents are more effective in management of lancinating and burning pain –These agents are better tolerated than tricyclic’s; having fewer anticholinergic side effects –Slow titration down is needed to avoid development of seizures

Pharmacologic Strategies (cont’d) NMDA antagonists –Ketamine9 • Twenty two trial meta analysis examined the use of oral ketamine for chronic pain • Dosing in those trials ranged from 45 mg to 1 gram in divided daily dosing • Adverse effects most documented included dizziness, sedation and somnolence • Efficacy and long term effects were insufficiently studied to provide conclusive data regarding oral ketamine for chronic pain

9. Blonk MI et al. Use of oral ketamine in chronic pain management: A review. Eur J Pain (2009), doi:10.1016/j.ejpain.2009.09.005

Topical Agents  Capsaicin – Topical cream applied to the skin in order to deplete substance-P – Patch applied every 3 months for post herpetic pain10 • Local anesthetic needed prior to application and cleansing gel applied after removal of the patch to remove residual • Skin will be more sensitive to temperature changes and sunlight for a few days post application

10. http://www.qutenza.com/_docs/qutenza_full_PI_.pdf accessed May 31, 2011

Topical Agents (cont’d)  Lidocaine – Available as topical gel, cream and patch – The 5% patch is FDA indicated for the treatment of post herpetic neuralgia; applied to intact skin – Application to the affected area is 12 hours on and 12 hours off – Two week randomized cross-over placebo controlled trial for post herpetic neuralgia patients11 • Lidocaine patch was patient preferred 78.1% v. 9.4% for placebo patch • Adverse effects were not statistically different between the two groups 11. Galer BS, Topical lidocaine patch relieves postherpetic neuralgia more effectively than a vehicle topical patch: results of an enriched enrollment study. Pain. 1999 Apr;80(3):533-8.

Opioids Opioids fell out of favor for management of chronic pain at the beginning of the 20th century Within the past 20 years opioid use has increased exponentially for chronic pain Currently there is a clear lacking of evidence for or against opioids for chronic pain

Opioids (cont’d)  Meta analysis of 26 trials comparing opioids to placebo or active control for a variety of chronic pain syndromes12  Measured pain scales from the trials revealed improvement across all studies – Most of the studies were over a period of weeks; one reached 32 weeks – Average daily dose of morphine required for improved neuropathic pain was 180 mg

 Initially opioids improve chronic pain however more data are needed in this area of long term opioids for chronic pain 12. Ballantyne JC, Efficacy of Opioids for Chronic Pain A review of the literature. Clinical Journal of Pain. 24(6):469-78, 2008.

13 Reassessment

 Regular reassessment should focus on the four A’s + 1 – Analgesia – Activity – Adverse effects – Aberrant behavior – Affect

 Any changes in treatment should accompany sufficient documentation indicating the changes made to the plan 13. Gourlay DL. Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Medicine. 6(2):107-12, 2005.

Multidisciplinary (MDP) Team Approach14 ď&#x201A;§ Meta-analysis of ten randomized trials of chronic low back pain patients comparing MDP teams to a control group not receiving MDP therapy ď&#x201A;§ Many of the MDP programs had a standard duration of interventions and individualized exercise, psychological, social and occupational counseling

14. Guzman J, Multidisciplinary rehabilitation for chronic low back pain: systematic review. BMJ. 322; 7301:1511-6, 2001 .

Multidisciplinary (MDP) Team Approach (cont’d) Patients involved with the intensive MDP’s with functional restoration approaches had decreased pain and improved function Patients involved with the less intensive programs had little to no change compared to a non-MDP approach The intensive MDP’s with treatment times > 100 hours of therapy had more benefit based on this meta analysis

Case 1 (cont’d) Current therapy: oxycodone immediate and extended release and gabapentin. Has never received physical therapy What other non-pharmacologic therapy could be trialed? What modifications could be made to his current pharmacotherapy regimen? Would this patient be a good candidate for interdisciplinary care?

Summary  Chronic pain syndromes develop over weeks to months from acute injury  Assessment must include both physiological and psychological metrics  Non-pharmacologic and pharmacologic options should be explored in concert  Management, not curative, strategies are key to effective and long lasting positive outcomes

References              

http://emedicine.medscape.com/article/310834-overview#a0101. accessed May 13, 2011. Hardt, et.al Prevalence of Chronic Pain in a Representative Sample in the United States. Pain Medicine 9;7:803-12 2008. Warfield CA, Fausett HJ, eds. Manual of Pain Management, second Ed.. Philadelphia, PA: Lippincott Williams & Wilkins; 2002. Veasey, GD. Managing chronic pain: What’s the best approach? Journal of Family Practice. 57;12: 806-11 2008. Fairbank JCT, Couper J, Davies JB. "The Oswestry low Back Pain Questionnaire." Physiotherapy 1980; 66: 271-273. Stratford PW, Binkley J, Solomon P, et al. Defining the minimum level of detectable change for the Roland-Morris Questionnaire. Phys Ther. 1996;76:359-365. Gatchel, The Biopsychosocial Approach. Practical Pain Management. http://www.practicalpainmanagement.com/treatments/psychological/biopsychosocial-approach accessed May 30, 2011. Offenbacher M, Physical therapy in the treatment of fibromyalgia. Scandinavian Journal of Rheumatology - Supplement. 113:78-85, 2000. Blonk MI et al. Use of oral ketamine in chronic pain management: A review. Eur J Pain (2009), doi:10.1016/j.ejpain.2009.09.005 http://www.qutenza.com/_docs/qutenza_full_PI_.pdf accessed May 31, 2011 Galer BS, Topical lidocaine patch relieves postherpetic neuralgia more effectively than a vehicle topical patch: results of an enriched enrollment study. Pain. 80;3:533-8 1999. Ballantyne JC, Efficacy of Opioids for Chronic Pain A review of the literature. Clinical Journal of Pain. 24(6):469-78, 2008. Gourlay DL. Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Medicine. 6(2):107-12, 2005. Guzman J, Multidisciplinary rehabilitation for chronic low back pain: systematic review. BMJ. 322; 7301:1511-6, 2001 .