New Diagnosing & Treating Musculoskeletal Pain In Working-Aged...

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Diagnosing & Treating Musculoskeletal

Pain In Working-Aged Adults

The Importance of Identifying The Central Pain

Phenotype3/21/17

Presented By:

Paul C. Coelho, MD

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Disclosures:Dr. Coelho has no disclosures. He will not be discussing any off-

label uses of medications or devices.

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Table of Contents

Early Pain Models

Modern Pain Models

FMS, HA, and LBP

The Central Pain Phenotype

Sample Case

Evidence-Based Treatments

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1980 Model of MSK Pain

Nociceptive Neuropathic

Primarily 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/

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1990 FMS

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

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US Overdose Deaths

1980-2014


0

12500

25000

37500

50000

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

Wolfe ACR FMS

1990

FDA Approves OxyContin

1995

APS Pain as a 5th Vital Sign

1996

Wolfe Recants FMS

2008

IOM 100M In Pain

2011

Peak Incidence of Prescription OD 45-54

Portenoy Portenoy/Foley

1986

Portenoy Recants

2012

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Variation in Opioid Rx’ing for

FMS 2007-2009


Peak Incidence of Prescription OD 45-54

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35% of FMS Pt’s Receive

SSDI

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

Disabled Medicare Beneficiaries Rx’d Opioids

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FMS Patients Report High Pain

Levels In Spite of High Dosages

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

N = 582

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Opioids In FMS: Once Started

Seldom Stopped


N = 100K, 60% Received Opioids.

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Opioids In FMS: Once Started

Seldom Stopped


N = 64K, 44% Received Opioids.

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30 Day Supply & Risk of COT

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

20% will remain on opioids at 3yrs.

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FMS Is Not Opioid Responsive


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

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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.


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Comorbid Pain in FMS is the

Norm


Low Back Pain

“Overwhelming evidence reveals that what is

often labeled as a single chronic regional pain

syndrome is, upon closer evaluation, a chronic

illness beginning much earlier in life, where the

pain merely occurs at different points of the body

at different points in time and is given different

labels by subspecialists focusing on “their region”

of the body.”

Daniel Clauw, MD

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Prevalence of LBP & HA in

FMS


2007 Internet Survey of 2596 FMS Pts

Ave Age = 47

If due to chance alone

LBP .3 x .05 =1.5%

HA: .2 x .05 =1%

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Prevalence of FMS in cLBP

42%


Chance Alone: .3 x .05 = 1.5%

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Prevalence of FMS in Migraineurs

56%

Chance Alone:

.2 x .05 += 1%


N = 1,730

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Head Ache & LBP Predict FMS


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Comorbid Pain in FMS is the

Norm


Fibromyalgia

Low Back Pain

Fibromyalgia Fibromyalgia

Head AcheLow Back Pain

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Central Sensitivity Spectrum

Disorders


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Overlapping Chronic Pain

Conditions


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Prescribers are Poor at

Diagnosing

Central Pain Syndromes


23% Sensitivity

N = 312, 240 FMS+

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Diagnosing



27% Specificity

N = 4M

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Diagnosing



“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

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Diagnosing Central Sensitivity

Spectrum Disorders


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.

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2016 FMS Survey Questionnaire96% Sensitivity, 92% Specificity

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Pain Catastrophizing ScaleModerate Risk 20-29

High Risk > 30

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Elevated PCS Predicts Abuse


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Why Is Dx’ing FMS/CSS

Important?


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.

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FMS Is Opioid Unresponsive


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Natural Hx of FMS


N = 1,555

11yr f/u

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Natural Hx of FMS


N = 76

2yr f/u

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FMS is the Primary Source of

Morbidity in Mixed Pain States


N = 383, 76 FMS+

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Morbidity in Mixed-Pain States


N = 156, 25 FMS+

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Morbidity in Mixed Pain States


N = 172

38 + FMS

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Sample Case

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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.

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>13 = FMS

7

10

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Joyce

>13 = FMS

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Joyce

>30 Abnl

443

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3

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344

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48/52

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Evidence-Based Treatments of

FMS


Treatment Evidence Level

Patient Education 1A

Graded Exercise 1A

CBT 1A

Tricyclics 1A

SNRI’s 1A

Gabapentenoids 1A

NSAIDS 5D

Opioids 5D

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Centralized Pain Pt Handout

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

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Evidence-Based Treatments for

FMS

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

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FMS

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

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Pain Catastrophizing

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Resources

Fibromyalgia Screening Questionnaire

http://www.slideshare.net/101N/pcp-pain-screening-tool

Evidence-Based Treatments for FMS, Dr. Clauw JAMA

http://www.slideshare.net/101N/fibromyalgia-clinical-review

Daniel Clauw, MD Youtube Video for patients

https://www.youtube.com/watch?v=pgCfkA9RLrM&t=6s

Sample Centralized Pain Patient Handout

http://www.slideshare.net/101N/central-sensitization-70569194

List of non-opioid alternatives for chronic non-cancer pain

http://www.slideshare.net/101N/nonopioid-alternatives-for-chronic-

noncancer-pain

http://www.slideshare.net/101N/pcp-pain-screening-tool

http://www.slideshare.net/101N/fibromyalgia-clinical-review

https://www.youtube.com/watch?v=pgCfkA9RLrM&t=6s

http://www.slideshare.net/101N/central-sensitization-70569194

http://www.slideshare.net/101N/nonopioid-alternatives-for-chronic-noncancer-pain

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