Chronic Pain Chronic Pain ManagementManagement

Elaine Wendt, MDElaine Wendt, MD

Pain is now “Fifth Vital Sign”Pain is now “Fifth Vital Sign”

The best way to perceive the professional burden The best way to perceive the professional burden involved in the care of patients with chronic involved in the care of patients with chronic pain is to pick your most comfortable chronic pain is to pick your most comfortable chronic medical diagnosis to manage and take out that medical diagnosis to manage and take out that diagnosis and substitute the syndrome, diagnosis and substitute the syndrome, “chronic pain.”“chronic pain.”

For ExampleFor Example My patient with diabetes will have diabetes throughout her My patient with diabetes will have diabetes throughout her

lifetime and need medical help to manage the diabetes lifetime and need medical help to manage the diabetes throughout her lifetime while I am her physician.throughout her lifetime while I am her physician.

My patient with chronic pain will have chronic pain My patient with chronic pain will have chronic pain throughout her lifetime and need medical help to manage throughout her lifetime and need medical help to manage the chronic pain throughout her lifetime while I am her the chronic pain throughout her lifetime while I am her physician.physician.

Pain management: physiologic Pain management: physiologic permanence permanence

http://www.ama-assn.org/ama/no-index/about-ama/16408.shtml

Somatic pain modelSomatic pain model Local inflammation>lowered threshold of c-fiber Local inflammation>lowered threshold of c-fiber

excitation> eventual Rexed lamina 5 wide dynamic excitation> eventual Rexed lamina 5 wide dynamic neuronal intracellular protein changes….neuronal intracellular protein changes….

Neuropathic pain model Neuropathic pain model Nerve injury> changes in location, density, number, and Nerve injury> changes in location, density, number, and

type of ion channels> altered nerve firing> eventual Rexed type of ion channels> altered nerve firing> eventual Rexed lamina 5 wide dynamic neuronal intracellular protein lamina 5 wide dynamic neuronal intracellular protein changes > altered neurotransmitter dynamics> neuronal changes > altered neurotransmitter dynamics> neuronal death/drop out> altered behavior of glial and other death/drop out> altered behavior of glial and other architectural cells (scar) architectural cells (scar)

Currently no single pain Currently no single pain medication exists that will take medication exists that will take

away more than 30 % of a away more than 30 % of a patient’s chronic pain.patient’s chronic pain.

Set Appropriate Expectations Set Appropriate Expectations EarlyEarly

Assess Pain Score and FunctionalityAssess Pain Score and Functionality

Wong Baker in EMRWong Baker in EMR ICSI Functional Ability QuestionnaireICSI Functional Ability Questionnaire

Make an Appropriate Differential Make an Appropriate Differential DiagnosisDiagnosis

Determine biological mechanisms of painDetermine biological mechanisms of pain Neuropathic painNeuropathic pain Muscle painMuscle pain Inflammatory painInflammatory pain Mechanical / Compressive painMechanical / Compressive pain

Identify and Address Identify and Address Comorbitities Early OnComorbitities Early On

Perform a Psychological Assessment, Perform a Psychological Assessment, including risk of Addictive Disordersincluding risk of Addictive Disorders

DepressionDepression AnxietyAnxiety Substance Abuse and DependenceSubstance Abuse and Dependence Sleep disordersSleep disorders Personality disordersPersonality disorders History of abuseHistory of abuse Coping patterns and resourcesCoping patterns and resources SpiritualitySpirituality Working and disability IssuesWorking and disability Issues

Make Therapy GOAL Make Therapy GOAL Oriented, Not PAIN Oriented, Not PAIN

OrientedOrientedBy Next visit, I will be able to do…By Next visit, I will be able to do…

Use a Treatment AgreementUse a Treatment Agreement

Plan of carePlan of care Set personal goalsSet personal goals Improve sleepImprove sleep Increase physical activityIncrease physical activity Manage stressManage stress Decrease painDecrease pain

Use of Controlled Substances is Use of Controlled Substances is Sometimes Appropriate. However, Sometimes Appropriate. However,

there are Associated Risks.there are Associated Risks.

DEA Practitioner’s manualDEA Practitioner’s manual ““The Drug Enforcement Administration is pleased to provide this updated edition of the 1990 The Drug Enforcement Administration is pleased to provide this updated edition of the 1990

Practitioner’s Manual to assist you in understanding your responsibilities under the Controlled Practitioner’s Manual to assist you in understanding your responsibilities under the Controlled Substances Act (CSA) and its implementing regulations. This manual will help answer questions Substances Act (CSA) and its implementing regulations. This manual will help answer questions that you may encounter in your practice and provide guidance in complying with federal that you may encounter in your practice and provide guidance in complying with federal requirements.requirements.

DEA remains committed to the 2001 Balanced Policy of promoting pain relief and preventing abuse DEA remains committed to the 2001 Balanced Policy of promoting pain relief and preventing abuse of pain medications. In enforcing the CSA, it is DEA’s responsibility to ensure drugs are not of pain medications. In enforcing the CSA, it is DEA’s responsibility to ensure drugs are not diverted for illicit purposes. Unfortunately, this country is now experiencing an alarming diverted for illicit purposes. Unfortunately, this country is now experiencing an alarming prescription drug abuse problem:prescription drug abuse problem:

Today, more than 6 million Americans are abusing prescription drugs—that is more than the Today, more than 6 million Americans are abusing prescription drugs—that is more than the number of Americans abusing cocaine, heroin, hallucinogens, and inhalants, combined. number of Americans abusing cocaine, heroin, hallucinogens, and inhalants, combined.

Researchers from the Centers for Disease Control and Prevention report that opioid Researchers from the Centers for Disease Control and Prevention report that opioid prescription painkillers now cause more drug overdose deaths than cocaine and heroin prescription painkillers now cause more drug overdose deaths than cocaine and heroin combined. combined.

Today more new drug users have begun abusing pain relievers (2.4 million) than marijuana Today more new drug users have begun abusing pain relievers (2.4 million) than marijuana (2.1 million) or cocaine (1.0 million). (2.1 million) or cocaine (1.0 million).

It is more important now than ever to be vigilant in preventing the diversion and abuse of controlled It is more important now than ever to be vigilant in preventing the diversion and abuse of controlled substances. This manual will help you do that by listing some safeguards you can take to prevent substances. This manual will help you do that by listing some safeguards you can take to prevent such diversion. It also explains registration, recordkeeping, and valid prescription requirements.such diversion. It also explains registration, recordkeeping, and valid prescription requirements.

As a practitioner, your role in the proper prescribing, administering, and dispensing of controlled As a practitioner, your role in the proper prescribing, administering, and dispensing of controlled substances is critical to patients’ health and to safeguarding society against the diversion of substances is critical to patients’ health and to safeguarding society against the diversion of controlled substances. DEA is committed to working jointly with the medical community to ensure controlled substances. DEA is committed to working jointly with the medical community to ensure that those in need are cared for and that legitimate controlled substances are not being diverted for that those in need are cared for and that legitimate controlled substances are not being diverted for illegal use.”illegal use.”

Document Informed ConsentDocument Informed Consent

Informed consent for chronic opioid therapyInformed consent for chronic opioid therapy(HCHD has bilingual forms)(HCHD has bilingual forms) Side effects of medicationSide effects of medication Monitoring of medication useMonitoring of medication use Refill policyRefill policy

Assess Pain Level and Function Assess Pain Level and Function before and during Therapybefore and during Therapy

Wong Baker ScoresWong Baker Scores Attainment of GoalsAttainment of Goals

Regularly Assess the 4 “A’s”Regularly Assess the 4 “A’s”

AnalgesiaAnalgesia ActivityActivity Adverse effectsAdverse effects Aberrant behaviorAberrant behavior

Document all Assessments and Care Document all Assessments and Care PlansPlans

Texas Medical Board Rules, Ch.170Texas Medical Board Rules, Ch.170 http://www.tmb.state.tx.us/rules/docs/Current

RulesRevised09-20-07.pdf

Texas Medical Board Rules, Texas Medical Board Rules, Ch.170Ch.170

The Shalls:The Shalls: ““the medical recordthe medical record shall document the medical history shall document the medical history

and a physical examination that includes a problem-and a physical examination that includes a problem-focused exam specific to the chief presenting complaint focused exam specific to the chief presenting complaint of the patient.” of the patient.”

““The medical record shall document the physician’s The medical record shall document the physician’s rationale for the treatment plan and the prescription of rationale for the treatment plan and the prescription of drugs for the chief complaint of chronic pain and show drugs for the chief complaint of chronic pain and show that the physician has followed these guidelines” that the physician has followed these guidelines”

““Each periodic review shall be documented in the Each periodic review shall be documented in the medical record”medical record”

SummarySummary

Chronic pain is a chronic illnessChronic pain is a chronic illness Assess comorbidities early onAssess comorbidities early on Create goals for therapyCreate goals for therapy Use formal contracts for controlled substancesUse formal contracts for controlled substances Reassess and documentReassess and document