Diagnosing & Treating Musculoskeletal Pain In Working-Aged Adults

The Importance of Identifying The Central Pain Phenotype

9/22/17

Presented By:Paul C. Coelho, MD

Salem Health

Objectives

• 1. Become familiar with the 'central pain' phenotype and recognize that it is opioid unresponsive.

• 2. Become familiar with the Pain Catastrophizing Scale as a screening tool for the 'central pain' phenotype.

• 3. Become familiar with the 2016 Fibromyalgia Screening Questionnaire for the central pain phenotype.

Disclosures:The presenters have no financial relationships with a commercial entity producing health care related products and/or services.

Table of Contents

Early Pain Models

Modern Pain Models

FMS, HA, and LBP

The Central Pain Phenotype

Sample Case

Evidence-Based Treatments

1980 Model of MSK Pain

Nociceptive NeuropathicPrimarily due to inflammation or tissue damage in the periphery

Damage or entrapment of peripheral nerves.

NSAID/Opioid Responsive Responds to both peripheral and central pharmacotherapy.

Responds to procedures. Does not respond to procedures.

Behavioral factors minor. Behavioral factors minor.

Examples: Osteoarthritis, Rheumatoid arthritis, cancer pain.

Examples: Diabetic peripheral neuropathy, post-herpetic neuralgia.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1829161/

1990 FMS

https://www.rheumatology.org/Portals/0/Files/1990_Criteria_for_Classification_Fibro.pdf

US Overdose Deaths1980-2014

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1829161/

0

12500

25000

37500

50000

1980 1983 1986 1989 1992 1995 1998 2001 2004 2007 2010 2013

Wolfe ACR FMS1990

FDA Approves OxyContin1995

APS Pain as a 5th Vital Sign1996

Wolfe Recants FMS2008

IOM 100M In Pain2011

Peak Incidence of Prescription OD 45-54

Portenoy Portenoy/Foley1986

Portenoy Recants2012

Variation in Opioid Rx’ing forFMS 2007-2009

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4346177/

Peak Incidence of Prescription OD 45-54

35% of FMS Pt’s Receive SSDI

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4151179/

Disabled Medicare Beneficiaries Rx’d Opioids

FMS Patients Report High PainLevels In Spite of High Dosages

https://www.ncbi.nlm.nih.gov/pubmed/24310048

N = 582

Opioids In FMS: Once StartedSeldom Stopped

https://www.ncbi.nlm.nih.gov/pubmed/26443495

N = 100K, 60% Received Opioids.

30 Day Supply & Risk of COT

https://www.cdc.gov/mmwr/volumes/66/wr/mm6610a1.htm

20% will remain on opioids at 3yrs.

FMS Is Not Opioid Responsive

https://www.ncbi.nlm.nih.gov/pubmed/26975749

Organization

American Pain Society

American Academy of Pain Medicine

American Academy of Neurology

European League Against Rheumatism

Canadian Pain Society

Canadian Rheumatology Association

British Pain Society

2017 Model of MSK PainNociceptive Neuropathic Central

Primarily due to inflammation or tissue damage in the periphery

Damage or entrapment of peripheral nerves.

Primarily due to a central disturbance in pain processing.

NSAID/Opioid Responsive Responds to both peripheral and central pharmacotherapy.

Tricyclic neuro-active compounds. Opioid unresponsive.

Responds to procedures. Does not respond to procedures.

Does not respond to procedures.

Behavioral factors minor. Behavioral factors minor. Behavioral Factors Prominent.

Examples: Osteoarthritis, Rheumatoid arthritis, cancer pain.

Examples: Diabetic peripheral neuropathy, post-herpetic neuralgia.

Examples: FMS, cLBP, cHA, IBS.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1829161/

Comorbid Pain in FMS is the Norm

https://www.ncbi.nlm.nih.gov/pubmed/22364327

Low Back Pain

“Overwhelming evidence reveals that what isoften labeled as a single chronic regional painsyndrome is, upon closer evaluation, a chronicillness beginning much earlier in life, where thepain merely occurs at different points of the bodyat different points in time and is given different labels by subspecialists focusing on “their region” of the body.”

Daniel Clauw, MD

Prevalence of LBP & HA in FMS

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1829161/

2007 Internet Survey of 2596 FMS Pts

Ave Age = 47If due to chance aloneLBP .3 x .05 =1.5% HA: .2 x .05 =1%

Prevalence of FMS in cLBP 42%

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1829161/

Chance Alone: .3 x .05 = 1.5%

Prevalence of FMS in Migraineurs 56%

Chance Alone:.2 x .05 += 1%

https://www.ncbi.nlm.nih.gov/pubmed/25994041

N = 1,730

Head Ache & LBP Predict FMS

https://www.ncbi.nlm.nih.gov/pubmed/26772544

Comorbid Pain in FMS is the Norm

https://www.ncbi.nlm.nih.gov/pubmed/22364327

Fibromyalgia

Low Back Pain

Fibromyalgia Fibromyalgia

Head AcheLow Back Pain

Central Sensitivity Spectrum Disorders

https://www.ncbi.nlm.nih.gov/pubmed/17350675

Overlapping Chronic Pain Conditions

https://www.ncbi.nlm.nih.gov/pubmed/27586833

Prescribers are Poor at DiagnosingCentral Pain Syndromes

https://www.ncbi.nlm.nih.gov/pubmed/23071343

23% Sensitivity

N = 312, 240 FMS+

Prescribers are Poor at DiagnosingCentral Pain Syndromes

https://www.ncbi.nlm.nih.gov/pubmed/23071343

27% Specificity

N = 4M

Prescribers are Poor at DiagnosingCentral Pain Syndromes

https://www.ncbi.nlm.nih.gov/pubmed/20461781

“You cannot guess at the extent of fatigue, unrefreshed sleep, cognitive problems, multiplicity of symptoms, and extent of pain without a detailed interview. The new criteria obligate you to pay careful attention to the patient if you want to diagnose fibromyalgia.”

Fredrick Wolfe

Diagnosing Central Sensitivity Spectrum Disorders

https://www.ncbi.nlm.nih.gov/pubmed/26266995

1. Pain in many body regions. 2. Higher current and lifetime history of chronic pain in several

body regions.3. Multiple somatic symptoms (e.g., fatigue, memory difficulties,

sleep problems, mood disturbance)4. Negative Affect, dispositional pessimism, pain catastrophizing.5. More sensitive to other sensory stimuli (e.g., bright light, loud noises,

odors, other sensations in internal organs)6. 1.5 to 2x more common in women.7. Strong family history of chronic pain.8. High self-reported pain & distress (VAS/NPS/PSD/PCS)9. Pain triggered or exacerbated by stressors.10. Peak prevalence of FMS age 30-59 (working-age).*11. Essentially normal physical examination +/- diffuse tenderness.

2016 FMS Survey Questionnaire96% Sensitivity, 92% Specificity

Pain Catastrophizing ScaleModerate Risk 20-29

High Risk > 30

Elevated PCS Predicts Abuse

https://www.ncbi.nlm.nih.gov/pubmed/23618767

Elevated PCS Predicts Abuse

https://www.ncbi.nlm.nih.gov/pubmed/24612286

Elevated PCS Predicts Abuse

https://www.ncbi.nlm.nih.gov/pubmed/23809983

Why Is Dx’ing FMS/CSS Important?

https://www.ncbi.nlm.nih.gov/pubmed/26266995

1. It is opioid unresponsive.2. Prognosis: It does not improve with time.3. When present amid other CNP conditions – HA, LBP,

etc. – it is likely to be the primary source of morbidity.

FMS Is Opioid Unresponsive

https://www.ncbi.nlm.nih.gov/pubmed/26975749

Natural Hx of FMS

https://www.ncbi.nlm.nih.gov/pubmed/21765102

N = 1,55511yr f/u

Natural Hx of FMS

https://www.ncbi.nlm.nih.gov/pubmed/28077978

N = 762yr f/u

FMS is the Primary Source of Morbidity in Mixed Pain States

https://www.ncbi.nlm.nih.gov/pubmed/27049402

N = 383, 76 FMS+

FMS is the Primary Source of Morbidity in Mixed-Pain States

https://www.ncbi.nlm.nih.gov/pubmed/28182837

N = 156, 25 FMS+

Sample Case

Joyce

Joyce is a 45y/o woman who recently moved from CA to Douglas, County to retire. Her past medical history is significant for a work related back injury for which she was medically retired. She now receives SSD and seeks to establish care with you for primary care needs as well as pain management. Her medication regimen consists of Lisinopril for HTN. She is requesting “Percocet” for pain.

>13 = FMS

7

10

17

Joyce

>13 = FMS

Joyce

>30 Abnl

443

44

3

43

344

44

48/52

Evidence-Based Treatments of FMS

https://www.ncbi.nlm.nih.gov/pubmed/28077978

Treatment Evidence Level

Patient Education 1A

Graded Exercise 1A

CBT 1A

Tricyclics 1A

SNRI’s 1A

Gabapentenoids 1A

NSAIDS 5D

Opioids 5D

Centralized Pain Pt Handout

https://www.painscience.com/articles/central-sensitization.php

Evidence-Based Treatments for FMS

https://www.youtube.com/watch?v=pgCfkA9RLrM

Evidence-Based Treatments for FMS

https://fibroguide.med.umich.edu/

Evidence-Based Treatments for Pain Catastrophizing

Resources

Fibromyalgia Screening Questionnairehttp://www.slideshare.net/101N/pcp-pain-screening-tool

Evidence-Based Treatments for FMS, Dr. Clauw JAMAhttp://www.slideshare.net/101N/fibromyalgia-clinical-review

Daniel Clauw, MD Youtube Video for patientshttps://www.youtube.com/watch?v=pgCfkA9RLrM&t=6s

Sample Centralized Pain Patient Handouthttp://www.slideshare.net/101N/central-sensitization-70569194

List of non-opioid alternatives for chronic non-cancer painhttp://www.slideshare.net/101N/nonopioid-alternatives-for-chronic-noncancer-pain

paul.coelho@salemhealth.org

Thank you!