Opioids in chronic neuropathic pain - A systematic review ...
Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in...
Transcript of Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in...
![Page 1: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/1.jpg)
ChronicPainManagementDanielW.Odell,M.D.AssistantProfessor
DepartmentofAnesthesiology,UniversityofUtahSupportiveOncologyandSurvivorship,HuntsmanCancerHospital
![Page 2: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/2.jpg)
ChronicPain
• Affectsapproximately20%ofthepopulation• Severelyimpactsqualityoflife,sociallife,workforceactivities,overallhealth• Mostcommonpainlocations:• Lowback• Headache• Neckpain• Jointpain• Generalizedpain/fibromyalgia
![Page 3: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/3.jpg)
DiagnosticEvaluationofChronicPain
![Page 4: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/4.jpg)
PainAssessment
• History– OPQRST• Onset• Provocation/Palliation• Quality• Region/radiation• Severity• Timecourse
• History+• Medicationtrialsandresponse
• Adequatedose?• Adequatelengthofmedicationtrial?
• Relatedconditions• Sleep• Function• Mood
• SocialHistory• Substanceabuse• Socialsituation
![Page 5: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/5.jpg)
DiagnosticEvaluation
• Fullphysicalexam• Begentle!• Painbehaviorsandeffort• Neurologicandmusculoskeletalexam• Evaluationofgeneralizedtenderness• Generalizedpainsyndrome• Opioid-inducedhyperralgesia
• Palpationoftriggerpoints
![Page 6: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/6.jpg)
DiagnosticEvaluation
• Characterizetypesofpain�Myofascial� Generalized� Neuropathic� Nociceptive– visceral� Nociceptive- somatic�Mostpatientswillhavemixedpaintypes
• Trytoputitalltogether�Why dotheyhavepain?
![Page 7: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/7.jpg)
Myofascial Pain
![Page 8: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/8.jpg)
Myofascial Pain
• Extremelyunder-recognized!• NotthesameasFibromyalgia– reallyquitetheopposite!• Painresultingfromdisorganizedmusclefibers• Triggerpoints– painradiateswithpalpation• Canmimicradicular painandbeverypainful– morethan“musclepain”• Post-surgical• Deconditioning• Alteredgaitorpositioning
![Page 9: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/9.jpg)
Myofascial Pain
• Gluteusminimus andmedius triggerpointreferralpattern• LookslikeL5radiculitis
Characteristicreferralpatternsoftriggerpoints
SimonandTravells “MyofascialPainandDysfunction:theTriggerPointManual”
![Page 10: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/10.jpg)
Myofascial Pain
• SternocleidomastoidandTrapeziustriggerpoints• Looksliketensionheadache• Canmimicorprovokemigraineheadache
![Page 11: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/11.jpg)
Myofascial Pain• Verytreatable!• Physicaltherapy– morerehab-basedthanorthopedic-based• Experiencewithmyofascialrelease• Experiencewithdryneedling
• Triggerpointinjections• IncombinationwithPT
• Massage• Acupuncture• Theracane/BodyBackBuddy• “TheTriggerPointTherapyWorkbook”
![Page 12: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/12.jpg)
Theracane /BodyBackBuddy
• $35onAmazon.com oroccasionallyatRelaxtheBackstore• Holdtriggerpointwithlight-medium pressurefor10-15sec
![Page 13: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/13.jpg)
NeuropathicPain
• “Painarisingasdirectconsequenceofalesionordiseaseaffectingthesomatosensory system”• Affects3-8%ofpopulation• Characteristics• Burning• Shooting• Electric• Limitedbenefitfromopioids• Mayormaynotbeconfinedtoknownnerve/nerverootdistribution
![Page 14: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/14.jpg)
NeuropathicPain
• Peripheralneuropathy• Phantomlimbpain• Post-herpeticneuralgia• Multiplesclerosispain• Post-surgicalneuropathicpain• Post-injuryneuropathicpain• Chronicradiculopathy• Complexregionalpainsyndrome
![Page 15: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/15.jpg)
PhantomLimbPain
Painperceivedinanabsentbodypart• Variableincidence,60-80%in1st year,maydiminishovertime• ↑incidence:traumaticamputation,upperextremityamputation
Onset§ ImmediateoryearslaterDuration§ Random,recurringintervals§ Canresolvespontaneouslyorpersistforyears
Severity§ For3–10%ofamputees,phantompainischronic&severe
![Page 16: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/16.jpg)
PreventionofPhantomLimbPain• ReferraltospecialistweekstomonthsBEFOREamputationifpossible• InterdisciplinaryTreatmentfocusedon:• Pain:Somatic,Neuropathic,Myofascial• Psychologicalsupport• Physicaltherapy• Familysupport
• MirrorTherapy?• Linksvisualandmotorpathwaystoimagerecreatebody• Reversemaladaptivememorytraces
![Page 17: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/17.jpg)
Medical Physical Psychological Invasive
Gabapentinoids Physicaltherapy Explanation StumprevisionTCAs Mirrortherapy GuidedImagery Neuroma
resection
SNRIs Prosthesisadjustment
Relaxation Spinalcordstimulation
Anticonvulsants Stumpdesensitizing
Behavioraltherapy
Thalamic/cortexstimulation
Beta-blockers Acupuncture HypnosisKetamine Stumpmassage Biofeedback
LidocaineIV TENS Psychotherapy
TreatmentofPhantomLimbPain
![Page 18: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/18.jpg)
Post-HerpeticNeuralgia
• Painthatpersistsaftershinglesinfection• Unilateral,dermatomal
• Increaseincidencewithage• 80%inpatients80yo
• Severeburning,shootingpain+/-skinhypersensitivity• Morecommoninimmunosuppressedpatients• Earlytreatmentassociatedwithimprovedoutcomes
![Page 19: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/19.jpg)
Post-HerpeticNeuralgia
•Prevention• Antivirals infirst48hoursofshinglesoutbreak• Zostervaccineif>60yoorprioroutbreak
• Treatment• NeuropathicAgents
• InterventionalTherapies• Stellate Ganglionblock• Face/upperextremity
• Epiduralsteroidinjection• Thorax/abdomen
![Page 20: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/20.jpg)
ComplexRegionalPainSyndrome• Spectrumofdiseasebutveryspecific
• Not“PainNOS,”NotReflexSympathyDystrophy(RSD)
• Continuouspain,disproportionatetoanyincitingevent• Historyofonesymptomin3categoriesandpresenceatthetimeofevaluationofsymptomsin2categories:• Sensory– hyperesthesia,allodynia• Vasomotor– temperatureasymmetry,skincolorchanges• Sudomotor/Edema– swelling,sweating• Motor/Trophic – decreasedrangeofmotion,motordysfunction,trophic changes
• Nootherdiagnosisthatbetterexplainsthesigns/symptoms
![Page 21: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/21.jpg)
ComplexRegionalPainSyndrome
• Uncommontobepresentinmorethan1bodypart• Thereisnosuchthingas“Full-bodyCRPS”thoughCRPShassystemiceffects
• Variableprogressionovertime– overallfavorable• Returnoffunctionandreliefofpainassociatedwithearlyandaggressivecare
• Treatment• Physicaltherapywithdesensitizationfollowedbyincreasingflexibility,rangeofmotionandstrength
• Pharmacotherapywithanti-neuropathicagents• Sympatheticnerveblockstofacilitatephysicaltherapy• Moreinvasivetherapiesifneeded(spinalcordstimulator)
![Page 22: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/22.jpg)
ComplexRegionalPainSyndrome
![Page 23: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/23.jpg)
ComplexRegionalPainSyndrome
• Physicaltherapy• Experiencedprovider• Desensitizationtherapy• Mirrortherapy• Increasingrangeofmotionslowly
• Sympatheticnerveblocks• UsedtofacilitatePTandbreakcycleofpain
• Neuropathicmedications
![Page 24: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/24.jpg)
GeneralizedPain
![Page 25: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/25.jpg)
GeneralizedPainSyndromes• Widespreadpainthroughoutthebody• Notmultiplelocationsbutcontinuousinjoints,softtissue,etc
• Variablequality,usuallynoincitingevent• Diffusetendernesstopalpationthroughoutbodyonexam• Absenceofsignificanttriggerpoints
• Associatedwithdepression,poorsleep• Thoughtduetocentralsensitization
![Page 26: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/26.jpg)
Fibromyalgia
• Specificdiagnosiswithin“GeneralizedPainStates”• Specificdiagnosticcriteria• Incorporatessleep,cognitivesymptoms,othersomaticsymptomsintodiagnosis
• NOTTHESAMEASMYOFASCIALPAIN• Affects2-4%ofthepopulation,femalepredominance• Oftenbeginsinmiddleadulthood
![Page 27: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/27.jpg)
Fibromyalgia
![Page 28: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/28.jpg)
GeneralizedPainStates
• Treatment• Physicalactivity!
• Startat5min/day,workupto30min/dayaerobicactivity
• Verygradual• Sleephygiene• Treatmentofconcurrentmooddisorders• Gabapentin/Pregabalin,Duloxetine,?TCA,NSAIDs,tylenol• Opioidsnotindicated!
• Noteffectiveandmaycontributetohyperalgesia
![Page 29: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/29.jpg)
NociceptiveVisceralPain
![Page 30: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/30.jpg)
NociceptiveVisceralPain
• Painresultingfromthoracic,abdominalorpelvicviscera• Distension,ischemia,inflammation
• Poorlylocalized• Dull,aching,pressure,squeezing• Notparticularlymovement-related
![Page 31: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/31.jpg)
VisceralPain
• Referredtosuperficialstructures• Diaphragmà Shoulder• Anginaà Leftneck/arm
• Chronicabdominalandpelvicpain• Cancerpain
![Page 32: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/32.jpg)
NociceptiveSomaticPain
![Page 33: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/33.jpg)
NociceptiveSomaticPain• Arisesfromdamageorinjurytobone,joint,muscle,skinorconnectivetissue• “Mechanical”pain
• Well-localized• Intenseache,throbbing,sharp,stabbing,pinprick• Bonypain
• Metastases,fractures• Degenerativespinedisease
• Jointpain• Osteoarthritis
![Page 34: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/34.jpg)
TreatmentApproachtoChronicPain
![Page 35: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/35.jpg)
TreatmentAlgorithm• Conservativetreatment• Physicaltherapy,Pooltherapy• Behavioraltherapy• Complementarymedicine– acupuncture,massage,acupressure• Tylenol,NSAIDs
• Adjunctmedications• Neuropathicagents,antidepressants,topicalagents,musclerelaxants
• Injections/Procedures• InvasiveProcedures/ImplantedDevices
![Page 36: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/36.jpg)
ConservativeTreatment
![Page 37: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/37.jpg)
ConservativeTreatment
• PhysicalTherapy• Onesizedoesnotfitall!• Earlyinstitution• Experiencedproviders• Tailoredtreatment
• PoolTherapy
![Page 38: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/38.jpg)
ConservativeTreatment• BehavioralMedicine• RelaxationTherapy• BehaviorModification• Education• Biofeedback• Counseling/Therapy– CBT• Hypnosis
• Beneficialforall!• Recognizetheimpactofmoodonpainandvisaversa• Centralsensitization
![Page 39: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/39.jpg)
ConservativeTreatment
• Complementarymedicine• Acupuncture• Acupuncture• Massagetherapy• TaiChi• Mindfulnessmeditation
![Page 40: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/40.jpg)
Acetaminophen
• Analgesicandantipyretic•Mechanismofactionpoorlyunderstood
• Blocksprostaglandinsynthetase inCNS,notperipherally• Lacksperipheralanti-inflammatoryeffects• Lacksplatelet,GI,bone,renaleffects
First-linetreatmentforpainintheelderlyMaximum3000-4000mg/day
• Beawareofothertylenol-containingproducts• 2000mg/daywithhepaticdisease
![Page 41: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/41.jpg)
NSAIDsCOXInhibitors:Preventinflammatorycascade
NSAIDs
![Page 42: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/42.jpg)
NSAIDsTwoisoformsofCOXenzymeCOX-1◦ Constitutive◦ “Housekeepingenzyme”◦ GItract◦ Kidneys◦ Platelets
COX-2◦ Induciblewithinflammatorystimulus
![Page 43: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/43.jpg)
NSAIDs
• Aspirin• Ibuprofen• Ketorolac• Naproxen• Indomethacin• Diclofenac• Meloxicam• Etodolac• Celecoxib
Non-Selective,TemporaryCOX-Inhibitors
Selective,TemporaryCOX-2Inhibitors
Non-Selective,PermanentCOX-Inhibitor
![Page 44: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/44.jpg)
NSAIDs AdverseEffects
GI- Gastritis,gastric/pepticulcersHematologic– IncreasedriskofbleedingOrthopedic– Impairedbonehealing?Renal- AcutekidneyinsufficencyCardiovascular- IncreasedriskofMI
DecreasedincidencewithCOX-2Inhibitor
![Page 45: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/45.jpg)
NSAIDs
• ALWAYSTAKEWITHFOOD• ConsiderconcurrentPPIuse• Naproxen375- 550mgbid• Meloxicam7.5-15mgdaily
• 7.5mgdoseisCOX-2selective
• Celebrex100-200mgbid– easiestonGIsystem,saferwithanticoagulants,expensive• Ibuprofen600-800mgtid• IncreasedriskofAKI
![Page 46: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/46.jpg)
HotOffthePress!
• “TakinganydoseofNSAIDsforoneweek,onemonth,ormorethanamonthwasassociatedwithanincreasedriskofmyocardialinfarction.”
![Page 47: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/47.jpg)
AdjunctMedications
![Page 48: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/48.jpg)
AdjunctMedications
•Gabapentinoids• Gabapentin• Calciumchannelblocker• 300mgqhs withtitrationtototaldailydose1800-3600mg(startwith100mgqhs withtitrationto300mgtid inelderly)
• Neuropathicpain,generalizedpain,opioid-sparing• Pregabalin• Calciumchannelblocker• 50mgqhs withtitrationtototaldailydose300-600mg• Neuropathicpain,generalizedpain,opioid-sparing
![Page 49: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/49.jpg)
AdjunctMedications
• Antidepressants• Tricyclic antidepressants
• Amitriptyline andImipramine – tertiaryamines,moresideeffects
• Nortriptyline andDesipramine – secondaryamines,lesssideeffects• Desipramine causesleastamountofsleepiness
• Startat25mgqhs,titrateto100mgqhs astolerated(lessinelderly)
• Cautionwithotherseratonergicmedications,elderlypatients• SNRIs• Duloxetine(60-120mg/day)• Venlafaxine?• Evidenceisunderwhelming
![Page 50: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/50.jpg)
AdjunctMedications
•Anticonvulsants• Topiramate• Sodiumchannelblocker• Poorevidenceinpainotherthanmigraineprophylaxis
• Carbamazepine/Oxcarbazepine• Sodiumchannelblockers• Trigeminalneuralgia
![Page 51: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/51.jpg)
AdjunctMedications
•MuscleRelaxants• Workbestwithshort-termuse(10days),tolerancedevelopsquickly• Cyclobenzaprine5-10mgtid• TCA-like,cautionwithotherseratonergicmedsandintheelderly
• Tizanidine2-8mgtid• Valium,Soma(carisoprodol),Robaxin (methocarbamol),Skelaxin(metaxaolone)• CNSsedatives– notmusclerelaxants.Avoid.• SomaisadangerousCNS-depressantandimplicatedinmanymultidrugunintentionaloverdosedeaths
![Page 52: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/52.jpg)
AdjunctMedications•TopicalAgents•Voltaren gelorFlector patch• Diclofenacpreparations– gelnowgeneric• Applytoaffectedarea• Greatforpatientsonoralanticoagulation• Worksbestwhenpainfulareaisclosetotheskin• Knees,finger/toes,etc
•Compoundedcreams• Expensiveandineffective• Exceptionmaybeketamine creamforallodynia
![Page 53: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/53.jpg)
OpioidMedications
![Page 54: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/54.jpg)
PainandAddiction
• Chronicpainiscommon• Occursin33%ofthepopulation,severein10%
• Opioidsarefrequentlyprescribedforpain• 16%ofpatientsinprimarycaresettingin2002
• Opioidmisuseandaddictionarecommon• Fishbain 2007
• 11.5%ofchronicpainpatientsmisuseopioids• 3.5%ofchronicpainpatientshavedevelopopioidaddiction• 14.5%ofchronicpainpatientsuseillicitdrugs
![Page 55: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/55.jpg)
Whentoconsideropioids• Appropriatetypeofpain
• Notmyofascial pain• Notgeneralized/fibromyalgiapain
• NEVERfirstline• Conservativetreatment• Adjunctmedications• Physical,behavioral,complementarytherapies
• Failureofmultiplepasttrialsofmedication/therapies• Willitimprovefunction??
![Page 56: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/56.jpg)
InitiationofOpioids• Documentationofpainandpriorinterventions,therapiesandmedicationtrials• Psychologicalassessment• Substanceabuseassessment
• Risk/benefitdiscussionwiththepatient• Medicationagreement• Specifywhocanprescribeopioids• Whocanprescribeothercontrolledmedications• Managementofacutepain
• Considerbaselineurinedrugscreen
![Page 57: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/57.jpg)
InitiationofOpioids
• Trialofopioids• Lowdose(Hydrocodone 5/325bid-tid)• Mildescalationreasonable(approaching30-50mgOME?)
• Assessmentofimprovement• Pain• FUNCTION!
• Routinely assess4A’s• Analgesia• Activity• AdverseEffects• AberrantBehavior
![Page 58: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/58.jpg)
CasualPrescribingofOpioids
• Ifyoustartopioidsyouhavebecomethatpatient’sopioidprescriber• Maybereasonableforacuteissues• Importantforpatienttohaveappropriateexpectations• Duediligence
• ControlledSubstanceDatabasereport• Knowledgeofothersedatingmedications• Healthhistory
• Donotgiveopioidsandtellapatientanotherprovider(PainSpecialist,Surgeon,Dentist)willgivethemmore
![Page 59: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/59.jpg)
Pre-ExistingOpioids• Managementofpatientsalreadyonopioids• Sameconsiderations
• Appropriatetypeofpain• Failureofmultipletherapiesandnon-opioidmedications• Psychologicalassessment• Substanceabuseassessment• Risk/benefitdiscussionwiththepatient• Medicationagreement
• Ifnotappropriateinformthepatientanddevelopplanforopioidtaperwithinitiationofothertreatment• Youarenotbeholdentoprescribeopioidsjustbecauseanotherpractitionerhasdoneso• Howevertaperingovertimecanpromotetherapeuticrelationshipwithpatient
![Page 60: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/60.jpg)
Preventionofopioidmisuse/abuse
•Prescriberfactors• Dose• Risksincreaseabove100mgOME,skyrocketover200mgOME
• Concurrentcontrolledsubstances• Risksincreasewithconcurrentbenzodiazepinesorhypnotics
• “Musclerelaxants”otherthantizandine/cyclobenzaprine• Sleepaids:Ambien/Lunesta/Sonata,temazepam• Onlyone?Onlytwo?
![Page 61: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/61.jpg)
CDC.CDCgrandrounds:prescriptiondrugoverdoses-aU.S.epidemic.MMWRMorb MortalWkly Rep2012;61:10-3.
![Page 62: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/62.jpg)
Detectionofaberrantopioid-relatedbehaviors
![Page 63: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/63.jpg)
AberrantBehavior
• Lostopioid prescriptions• Outofopioids early• InappropriateDOPL• InappropriateUDS• Failuretoparticipateinnon-opioid treatment• Concernforopioid diversion• Overtsedation
![Page 64: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/64.jpg)
AberrantBehavior
• Safetyofpatientandcommunityisfirstconsideration• Verifythefacts• Controlledsubstancedatabasereport• Callpatient’spharmacyorotherproviders• RequestrecordsfromED/Hospital
• Basedecisiononcontinuedprescribingonsafety,factualinformation,painissueandinformthepatient• Provideresourcesforopioidwithdrawal
![Page 65: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/65.jpg)
Detectionofaberrantopioidbehaviors• UrineDrugScreening• Presenceofexpectedmedicationsandmetabolites• Absenceofillicitsubstancesorotheropioids• Onlyasgoodasyourtest!
• Falsepositivesandnegativesexist– knowyourpatientandtest• High-resolutiontestinEPIC• ARUPpathologistsoncalltotroubleshoot/answerquestions
• Howoften?• PRIORtoinitialprescribing• Q3-12months• Witnessed?• Orjustmakesuretheydon’ttakeanythingintothebathroom?
![Page 66: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/66.jpg)
Detectionofaberrantopioidbehaviors
• PrescriptionDrugMonitoringPrograms(DOPL)• Everytimeyouseeapatientorrefillamedication• Hopefullyeventuallynationwide• CansetsurrogatestoaccessthisunderyourlicenseinUT
• 3RNsorMas
• PillCounts• Requirecoordinationofstaffandpatient
• Requestsforearlymedicationrefills• Reportsfromfamily/friends
• Canlistentoanyinformation,maynotdiscloseany• Finelinetowalk
![Page 67: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/67.jpg)
ManagementofaberrantopioidrelatedbehaviorThehardstuff
![Page 68: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/68.jpg)
Managementofaberrantbehavior• Safetyofpatientandcommunityisfirstconsideration• Verifythefacts• Controlledsubstancedatabasereport• Callpatient’spharmacyorotherproviders• RequestrecordsfromED/Hospital
• Basedecisiononcontinuedprescribingonsafety,factualinformation,painissueandinformthepatient• Provideresourcesforopioidwithdrawal
• Youmustcontinuetocareforpatientsfor30daysafterclinicdischarge– thisdoesnotimplyprescribingopioids
![Page 69: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/69.jpg)
• Dependsonseverity• “Common”- Earlyrefills,inappropriateUDS/DOPL/PillCount
• Verifythefacts,givethepatientanopportunitytoexplain• Reasonablepractice
• Firststrikeincursawarning– documentit!• Secondstrike=nocontinuedopioidprescribing
• Concurrentillicitdruguse• Nofurtheropioidprescribing(marijuana?)
• Confirmedoverdose• Nofurtheropioidprescribing
• Confirmeddiversion• Dischargepatient
• Youmustcontinuetocareforpatientsfor30daysafterclinicdischarge– thisdoesnotimplyprescribingopioids
Managementofaberrantbehavior
![Page 70: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/70.jpg)
InjectionProcedures
![Page 71: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/71.jpg)
ChronicSpinePain•Mechanical• Scoliosis,arthritis,stenosis,degenerative• Facetarthropathy,sacroiliacjointarthropathy• Failedback/necksurgerysyndrome
![Page 72: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/72.jpg)
EpiduralInjections• Epiduralinjections• Localanesthetic+steroidinjectedintoepiduralspacesurroundingnerveroots• Clearsinflammatorymediatorsandreducesinflammation/compression
• Indicatedforradicular upperextremityorlowerextremitypain• Burning,shootingpaininspecificdistributiontodistalareaoflimb• Neurologicdeficitsà radiculopathy,“just”pain– radiculitis
• Alsoindicatedforspinalstenosis andpostherpeticneuralgia• Differentapproachesdependingonnatureandlocationofpain• Relieflasts2-4monthsonaverage
![Page 73: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/73.jpg)
![Page 74: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/74.jpg)
FacetArthropathy• Painjustoffmidline,worsewithextension/rotation• Doesnotcauseradicular painbutpaincanradiatelocally• Candevelopduetoarthritis,misalignment• Injections:• Thermalablationofnervebranchthatinnervatesthejoint(older)• Lasts6-9months,canberepeated
• Intra-articularsteroidinjections(younger)• Lesseffective
![Page 75: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/75.jpg)
SacroiliacJointInjection
• Jointatintersectionofspineandpelvis• Significantmovementandweightloading
• Candeveloppainduetoarthritisormisalignment
• PainoverSIjointwithradiationintobuttockandposteriorthigh• “FABER”provokespain
• flexion,abductionandexternalrotationofhip• Localanesthetic+steroid,lasts3-4months
![Page 76: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/76.jpg)
SacroiliacJointDysfunction
![Page 77: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/77.jpg)
PeripheralNerveInjections
• Ilioninguinal NerveBlock:• Indications:Ilioinguinalneuralgia(groinpainafteringuinalsurgery/tumor)• Steroid+localanesthetic–lastsapprox3months
![Page 78: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/78.jpg)
PeripheralNerveInjections
nOccipitalNerveBlock:n Indications:Occipitalneuralgia(occipitalpain/HAaftersurgeryortumor)
n Steroid+localanesthetic–lastsapprox3months
![Page 79: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/79.jpg)
PeripheralNerveInjections
•Genicular NerveBlock• Indications:Chronickneepain,notoperativecandidate• Diagnosticnerveblockwiththermalablationifsuccessful• Success50/50
![Page 80: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/80.jpg)
PeripheralNerveInjections
IntercostalNerveBlock◦ Indications:Intercostalneuralgia,Chronicribpain(post-thoracotomy)
◦ Localanesthetic+steroid
![Page 81: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/81.jpg)
JointInjections
•Hip,Knee,Shouldermostcommon• Painfulosteoarthritisofjoint• Dx withx-ray
• Steroid+localanesthetic– lastsapprox3months• Hyaluronate viscosupplementationforkneesmaylast6-12months• Ultrasound,fluoroscopy,“blind”
![Page 82: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/82.jpg)
InvasiveInjectionsandImplantedDevices
![Page 83: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/83.jpg)
SympatheticBlocks
• Diagnostic• Isthepainsympatheticallymediated?
• Therapeutic• Localanesthetic– breakthecycle• Seriesofsympatheticblocks+PTforCRPS
• Steroid– littleevidence• Chemicalneurolysis– denaturethenerves
• TerminalCancer
![Page 84: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/84.jpg)
SympatheticBlocks
• Stellate Ganglion• Neuropathicpainoftheface,neck,shoulderorupperextremity• CRPS,PhantomLimb,PHN
LumbarSympatheticBlock• Neuropathic,suspectedsympathetically-mediatedpaininthelowerextremity• CRPS,Phantomlimbpain,Ischemicpain/vascularinsufficiency
![Page 85: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/85.jpg)
SpinalCordStimulationNeuromodulation:providealternateinputtospinalcordto“coverup”pain• Leadsimplantedinepiduralspaceconnectedtoanimplantedbatterysource
• Patientsundergo“Trial”firstwithtemporarypercutaneousleadsfor3-7days• Multipledevicecompanies,stimulationmethods/parameters• InternationalNeuromodulation Society:http://www.neuromodulation.com/spinal-cord-stimulation
![Page 86: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/86.jpg)
SpinalCordStimulation
• Indications:• Neuropathicpaininlimbs
• Persistentradicularpain,phantomlimbpain,postherpetic neuralgia,brachialplexusinjury
• Failedback/necksurgerysyndromeRapidlyChanging• High-frequencySCS:Effectiveforaxiallowbackorneckpain?• DorsalRootGanglionSCS:Groinpain,ilioinguinal pain,intercostalpain,radiculopathy?
• Newwaveforms/programmingtechniques:Burst,high-density,etc.
![Page 87: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/87.jpg)
SpinalCordStimulation
•Downsides:• Invasive• Complications• Infectionrate5-10%
• Diminishedeffectovertime(5+years)• Maybelesswithnewerwaveforms
• Doesnottreatmyofascial ormechanicalpain• NotallsystemsareMRI-compatible
![Page 88: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/88.jpg)
PeripheralNerveStimulation
• Similartospinalcordstimulation• Indicatedforspecificnerves• Occipitalneuralgia• Ilioinguinal neuralgia
• Mayhavearoleinchronicmigraine• Emergingfield• Insurancecoveragechallenging
![Page 89: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/89.jpg)
Conclusion• Diagnosis:history,physicalexamandcharacterizationofpaintypes• Myofascial,Generalized,Neuropathic,Nociceptivevisceral,Nociceptivesomatic
• TreatmentAlgorithmtailoredtopaintypes• Conservativetreatment• Adjunctmedications• Injections/Procedures• InvasiveProcedures/ImplantedDevices
![Page 90: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/90.jpg)
Thanksforyourattention!
![Page 91: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/91.jpg)
Acknowledgements- JillSindt,M.D.- PerryFine,M.D.- PainManagementCenter,UniversityofUtah- SupportiveOncologyandSurvivorship,HuntsmanCancerHospital
![Page 92: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/92.jpg)
References• JohannesCBetal.TheprevalenceofchronicpaininUnitedStatesadults:Resultsofaninternet-basedsurvey.Pain2010;11(11):1230-39.
• ClarkJD.ChronicPainPrevalenceandAnalgesicPrescribinginaGeneralMedicalPopulation.JPainSymp Manage2002;23(2):131-37
• Fishbain,DAetal.2007.Whatpercentageofchronicnonmalignantpainpatientsexposedtochronicopioid analgesictherapydevelopabuse/addictionand/oraberrantdrug-relatedbehaviors?Astructuredevidence-basedreview.PainMed.9,444–459.
• WilliamC.Beckeretal.Non-medicaluse,abuseanddependenceonprescriptionopioidsamongU.S.adults:Psychiatric,medicalandsubstanceusecorrelates.DrugAlcoholDepend2008:94:37-47.
• Okie,Susan.Afloodofopioids,arisingtideofdeath.NEngl JMed2010;363:1981-1985
![Page 93: Chronic Pain Management - University of Utah Health ... · • Chronic pain is common • Occurs in 33% of the population, severe in 10% • Opioids are frequently prescribed for](https://reader033.fdocuments.us/reader033/viewer/2022042317/5f0657c57e708231d4178431/html5/thumbnails/93.jpg)
ThankYou!