CHRONIC PAIN MANAGEMENT

Michael Marschke, MD

Medical Director of Horizon Hospice

COMMON ETIOLOGIES OF CHRONIC PAIN

Episodic pain syndromes: Headaches – migraine, tension, cluster… Ischemic episodes – claudication,

angina, sickle cell disease Visceral pain – biliary colic, irritable

bowel, pre-menstrual syndrome, renal colic

Somatic pain - gout

COMMON ETIOLOGIES OF CHRONIC PAIN

Chronic pain syndromes: Somatic – degenerative and inflammatory

arthitis, trauma, vertebral compression fractures, boney metastases, fibromyalgia

Visceral – abdomenal cancers, chronic pancreatitis

Neuropathic – diabetic neuropathy, phantom limb pain, spinal stenosis/sciatica, spinal mets, HIV, drug induced

CHRONIC PAIN IS MULTI-FACTORIAL Psychologic factors – depression, anxiety,

somatization Socioeconomic factors – cultural differences,

urban poor, gender Spiritual factors – spiritual suffering,

meaning of pain Physical factors – VERY complex

neuroanatomy creating the pain sensation, from pain receptors to afferent nerves to spinothalamic tract, to thalamus to cortex with modulators all along the way

Therefore best approach is multi-disciplinary

EVALUATION OF CHRONIC PAIN

GOALS: Determine etiology to better treat

this pain Determine if correctable, intractable,

or potentially dangerous causes Determine impact on patient’s life Take a detailed pain history to aid in

controlling this pain

PAIN HISTORY

O = Other associated symptoms ( nausea with stomach cramps, swelling with somatic pain, depression, anxiety…)

P = Palliative/provocative factors (mobility, touching, eating…)

Q = QualityR = Region/radiationS = Severity ( 0 to 10 )T = Timing (when started,

continuous/intermittent, time of day…)U = Untoward effects on activity or quality of

life, including psychosocial, spiritual effects

HOW DO YOU TELL WHICH PAIN SYNDROME? – HISTORY!

Somatic – focal, ache/throb/sharp, maybe with swelling/edema/redness, tender, worse with movement, better at rest, maybe from trauma

Visceral – viscous organ – colicky, vague, diffuse, worse with meals, liver/spleen/pancreas – may be more constant, more focal, worse with eating, uterine – colicky, pelvic, maybe with discharge

Neuropathic – burning, sharp, tingling, either dermatomal or stocking-glove, worse with touch, maybe with numbness

DRUGS IN WHO STEP LADDER

Step 1: Acetomenophen, Tramadol (Ultram) plus adjuvant

Step 2: Tylenol #2/3/4, Vicoden, Darvocet, Percocet

Step 3: Morphine, Dilaudid, Fentanyl, Demerol, Methadone, Oxycodone, Levodromaran

Marschke’s Modified Pain Escalator

ADJUVANTS TO SOMATIC PAINNon-pharmacologic: Ice, heat Physical therapy Chiropractic/osteopathic

manipulations Massage Acupuncture Yoga Topical agents (Ben

Gay/Icy Hot – with menthol, salcylates, Capcaicin)

Local injections (steroids, lidocaine)

Glucosamine shown to help with osteoarthritis

Pharmacologic: NSAIDs Cox 2 inhibitors Steroids Muscle relaxants

SPECIAL SOMATIC PAIN SYNDROMES

Boney mets: Local RT Pamidronate and

other diphosphonates

Strontium 89 and other radioactive isotopes, taken up by osteoclasts

Vertebral compression fractures:

Calcitonin Pamidronate Vertebroplasty

VISCERAL PAIN Anti-cholinergics for colicky pain H2 blockers/PPIs for PUD/GERD Steroids for enlarged organs with

capsular swelling NSAIDs for uterine pain Nitrates for angina Others – celiac/pelvic plexus blocks, RT

for enlarged organs, massage, herbs, aromatherapy, acupuncture, healing touch

NEUROPATHIC PAIN Tricyclic antidepressants Anti-epileptics Anti-arrhythmics Topical agents – lidocaine, capsiacin Steroids for spinal radiculopathies Others – RT for spine mets, TENS/PENS units

and also spinal electrical stimulators CAM - Acupuncture, massage, PT, yoga,

healing touch

OTHER CAM ADJUVANTS Herbals/supplements – glucosamine shown to be

useful in osteoarthritis, certain herbs like chamomile useful for colicky pain

Homeopathies/flower essences – for relaxation, visceral pain

Healing touch/Reiki – using energy techniques, useful with emotional components

Neuro Emotional Technique – A chiropractic technique also useful with emotional components

Mind – focusing therapies:• Meditation, yoga, guided-imagery, hypnosis, biofeedback• Art/music/humor therapy, pet therapy• By distraction, found to lower HR/RR and decrease pain up

to 10-20%

ADDING AN OPIOID

To achieve quick pain relief: (LOAD)1. Start low dose, short-acting2. Dose q peak3. P.C.A. not “prn” (Patient controls it)4. Re-eval in 4 hrs. to figure out what dose is needed

“prn” dosing

Low-dose, short-acting opioids Tylenol #3, 1-2 tabs Vicoden, Norco,

Lortab 1-2 tabs Darvocet N-100, 1-2

tabs Percocet, 1-2 tabs Vicuprofen, 1-2 tabs

DOSING LIMITED BY ATTACHED DRUG (max Tylenol a day is 4000mg)

MSIR/Roxanol,5-10mg PO, 1-3MG IV/SQ

Dilaudid, 1-2mg PO, 0.25-0.5 IV/SQ

OxyIR, 5-10mg PO

NEVER USE DEMEROL IN CHRONIC PAIN!!!

MAINTAINING AN OPIOIDFor constant pain:

(MAINTENANCE)1. Go long (convert 24hr total of short acting directly to long acting)2. REM breakthru = 10-20% of total daily dose, as short-acting, immediate release3. Re-eval, if 4+ breakthru/d, increase maintainance dose

LONG-ACTING OPIOIDS MS Contin, Oramorph, q12hr, in 15,30,60,

100, and 200mg tabs Kadian, Avinza, q24hr, in 20,50, 100mg

time-release capsules (can be opened to ease swallowing or put thru gastric tubes)

OxyContin, q12hrs, in 10,20,40,80, and 100mg tabs

Duragesic (Fentanyl) patches in 25,50,75, and 100 ug/hr q48-72hrs.

Palladone (Dilaudid) q24hr, in time released capsules

CAVEATS IN OPIOID USE With pure agonists, the sky is the limit 80% of the time dose needs to be increased because the

disease is advancing; 20% because of tolerance. Mixed or partial agonists (Stadol, Talacen, Talwin) have a

ceiling, neurotoxicity, and can induce withdrawal if on other opioids

Methadone – q8-24hr drug, may be better with neuropathies & addiction because inhibits the NMDA receptor in the brain, though half-life 6-100hrs so watch for accumulation

Demerol – neurotoxic metabolite can build up in 1 wk, in 1 day with renal failure

Oral, sublingual, rectal short acting meds peak within 1 hr., IV/SQ peak within 10 minutes. Choose oral if they can do it.

Use conversion tables to switch narcotics, start at 50-100% of equivalent dose

To taper drug, decrease by 25% a day.

OPIOID SIDE EFFECTS Constipation is a given, no tolerance develops,

use stimulants (Senokot, Bisocodyl, Pericolace) Nausea/vomiting – tolerance can occur in 2-5

days, compazine/reglan can help Sedation – tolerance can occur in 2-3 days,

changing drug or Ritalin can help if persists Clonic jerks – usually hi doses, can change drug

or benzodiazepam can help Respiratory suppression in toxic doses, never

see it if have pain or use the drugs the right way

PHYSICAL vs. PSYCHOLOGIC DEPENDENCEPHYSICAL DEPENDENCE: Tolerance (20-40%) – up-regulate opioid receptors

to need higher dose for sustained effect Withdrawal (20-40%) – after 2 wks, withdrawing

drug leads to adrenaline response (sweating, tachycardia, tachypnea, cramps, diarrhea, hypertension); avoid by decreasing drug 25% a day.

PSYCHOLOGIC DEPENDENCE: Addiction (0.1% in CA pain) – a need to get “high”

where drug controls your life, compulsive uncontrolled behavior to get the drug; lie, cheat, steal.

PSEUDO-ADDICTION: Physical dependence confused with

psychologic dependence Pain-relief seeking, not drug-seeking When right dose used, patient

functions better in life, whereas opposite true with the true addict

To help diffentiate: one MD controls the drug under a specific contract with pt., one pharmacy, frequent visits, pill counts