Pain Management- It’s Everyone’s Business!

Dr. Joel Loiselle BSc. MD FRCPCStaff Anesthesiologist SBGH (General OR and OBS.)

Director Acute Pain Service (SBGH)

Palliative Care Consultant

Chronic Pain Consultant

Assistant Professor U of M

April 12, 2010.

CPG- opioids are only one part of a multi-modal/multi-disciplinary pain

approach.

…although I am going to talk

about opioids a fair bit today!

Objectives

Discuss some general pain definitions.

Why pain is like an onion! Some short case vignettes- why pain is important to _______.

Take home pearls- look for the important concept slides.

Definition of Pain

“…an unpleasant sensory and emotional experience associated with actual or potential tissue

damage or described in terms of such damage.”

Merskey H, Bogduk N. 2nd ed Seattle, WA: IASP Press; 1994.

Acute Pain: Adverse Consequences

“Stress hormone response” Suffering Neuronal remodeling Chronic Pain

Peripheral and central sensitization

De-conditioning: excessive bed rest

Associated behaviors

Prevention and aggressive treatment of acute pain may help prevent the development of

chronic pain

Chronic Pain

Definition: pain that lasts beyond the period of healing or is associated with chronic disease (arbitrarily 2-6 months).

Ceases to serve protective function or adaptive purpose.

Identified pathology may not explain the presence and/or severity of pain.

May be perpetuated by factors unrelated to the cause.

Associated with irritability, social withdrawal, depressed affect and vegetative symptoms.

Symptoms of catecholamine hyperactivity (tachycardia and sweating) less common.

Jacobsen L.. Bonica’s Management of Pain, 3rd ed. Baltimore, MD, Lippincott Williams & Wilkins; 2001;241-254.

Injury-induced Pain: Patient Factors

McQuay H. BMJ 1997;314:1531.

Individual variation in

response to injury:physiological,behavioural,and cultural

Individual variation in

response to treatment

Context:battlefield orlonely bed

Injury

Pain improveswith time

Complaint of pain

Pain Management: Pathophysiology of Pain and Pain Assessment. AMA, December, 2003

Three Hierarchical Levels of Pain

Sensory-Discriminatory ComponentsLocation, intensity, quality

Motivational-Affective ComponentDepression, anxiety

Cognitive-Evaluation ComponentThoughts concerning the cause

and significance of the pain

Pain Pathways

SUFFERINGSUFFERINGEMOTIONALPSYCHOSOCIAL

PHYSICAL

SPIRITUAL

A not so pretty picture

The steps:-GLU excess-NMDA receptor loses Mg2+

-Ca2+ moves in and stimul. PKC-NO is produced and stimul. guanyl syn. (K+ conduc. decreased) and Sub. P is released-Sub. P stimul. NK-1 receptor which causes c-fos activation-c-fos activation signals pain is entrenched

Chronic pain as a disease?

Pain has outlived its utility. It is typically much more difficult to identify the source of ongoing pain

The earlier chronic pain is treated, the less likely the physiological changes that occur will become firmly entrenched.

It is no longer the symptom but the disease…

Important concept #1

Pain is not a diagnosis but it may be a disease.

How common is Chronic Pain

in our society?

29%

22%

29%

39%

27%

31%

75%

59%

69%

66%

3%

3%

4%

3%

4%

3%

67%

67%Total (n=2012)

18-34 yrs (n=620)

35-54 yrs (n=890)

55+ yrs (n=473)

Male (n=1005)

Female (n=1007)

6 Months or more Less than 6 Months No Chronic Pain

Canadian National Pain Study, 2002Prevalence of Chronic Pain – (>6 Months) (n=2012)

Moulin D., PR&M, 2002

20%

10%

3%

12%

5%

3%

2%

2%

2%

2%

34%

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

ALL ARTHRITIS

Osteoarthritis

Rheumatoid arthritis

Arthritis (other mentions)

Migraines/headaches

Fibromyalgia

Degenerative discs

Angina

Osteoporosis

Sciatica

MS

Those over 55 years of age are significantly more likely to cite arthritis and osteoarthritis particularly

Canadian National Pain Study, 2002Condition Causing The Most Pain (n=340)

Moulin D., PR&M, 2002

Canadian Survey of

Post-surgical Pain 305 Canadian patients – surgery in past 3 years Both inpatient and day surgery Severe or extreme pain – 47% inpts; 15% outpts Still in pain 2 wks afterwards – 79% inpts; 74%

outpts Good relief from pain medications in 54 - 72%

Conclusion: improvements could be made

Rocchi A. Can J Anaesth, 2002

Canadian Pain SocietyPosition Statement on Pain Relief

“Almost all acute and cancer pain

can be relieved, and many people

with nonmalignant pain can be helped.”

Patients have the right to the best pain relief possible.

1. Unrelieved acute pain complicates recovery.

2. Routine assessment is essential for effective management.

3. The best pain management involves patients, families, and health professionals.

Canadian Pain Society, Patient Pain Manifesto, 2001

Treatment options for pain

Many more options outside of drug choices!!!

Opioids are accepted therapy for….

Acute Pain But for how long should you treat?Cancer PainAddiction/diversion is still a concern in this population.Chronic Non Cancer Pain

(CNCP)Most controversial area!

Case vignette # 1 Why pain is important to the surgeon… 50 y/o female

Cholecystectomy (Day surgery) for biliary colic.

Healthy. Previous surgery: ACL repair- was given Acetaminophen/Codeine Tabs and states they did not help to relieve her pain at all. She asks for Oxycodone specifically. Is this a problem?

Case vignette #2Why pain is important to the nurse/ward staff… 38 y/o female

Post op TAH for menorrhagia (endometriosis)

Chronic Pelvic Pain (HMC 6mg tid).

Refuses Epidural. PCA HM instituted: 0.2 mg/h with a bolus of 0.4- 0.6 mg LO of 5 min (usual adjuvants of Acetaminophen and NSAID’s given)

Thirty min. after getting to the ward (1730), the pt received dimenhydrinate 25 mg iv. Three hours later (2030) got an

additional 50 mg of dimenhydrinate po.

Pt transferred to stepdown unit at 0100 b/c of somnolence.

Important concept #2

Caution with other sedating drugs- common examples include

BZD’s and dimenhydrinate.

Analgesia is important but safety is paramount!

Case vignette # 3Why pain is important to the surgeon (again)… Urology slate;

Pt #1: 68 y/o male for a lap. nephrectomy

Pt #2: 42 y/o male for a lap. nephrectomy

Pt #1- requires a total of 10 mg iv Morphine in PARR. (PCA morphine use was as expected).

Pt #2- requires a total of 30 mg iv Morphine in PARR. (Used 100 mg of iv HM in the first 24h!)

What is going on???

Chronic Post surgical Pain (CPSP)

Risk factors: Genetic susceptibility? Preceding pain? Psychosocial factors? Age and sex? Type of procedure?

Strategies to decrease CPSP:

-Multi-modal analgesia?

-NMDA antagonist?

-Analgesia for a longer period of time?

-Surgical technique?

Important concept # 3

Individualize therapy and recognize early chronic

post surgical pain syndromes (NeP).

Case vignette # 4Why pain is important to the family physician/geriatrician… 72 y/o female with post polio syndrome and transverse myelitis (recovered). Also suspected to suffer from fibromyalgia (rheumatology opinion).

Consult reads: “Patient has chronic pain and is also insane. Continuously returning for opioid prescriptions (Codeine). Suggestions please.”

Assesment: Consistent with NeP pain syn. and FM. Pt settled very nicely with TCA and MSC

(no aberrant behavior over 5 yrs of care).

Guidelines from AGS: http://www.americangeriatrics.org/education/pharm_management.shtml

…”the longevity revolution” or “..the silver tsunami…”

- Over 50% of pts in nursing home patients suffer from pain and 80% could benefit from palliative care.

Case vignette # 5Why pain is important to the family physician… 81 y/o male with a RC Tear and Spinal Stenosis. Minimal activity b/c of pain. Fragile- numerous co-morbid conditions.Tx:

Lumbar ED steroid.

Surgical consult- disability minimal with RC.

Tramadol XL 200 mg OD and Tramacet 1-2 tabs per day.

Function re-established- stable for 2 yrs.

Treatment Goals in

Patients with Chronic Pain

Decrease pain

FunctionADLSleepSocialization

Minimize adverse effects

Quotes from this paper:

- CNCP 15-25% at any given time.

- …increases to 50% in pt’s older than 65.

- 18% of American respondents did not seek care as they felt their complaints would be ignored.

- Worldwide 10 million new cases CA/yr.

- 80% of pts with CA experience pain (may be more with advanced disease).

-By 2020- figure will double with 70% occurring in third world countries.

- 60-80% of pts suffering from HIV will have pain.

Why pain is important to health advocates, policy makers and world leaders….

Case vignette # 6Why pain is important to personal care home staff (including pharmacy)… 85 y/o female with IHD and PVD. Neither issue is amenable to surgical correction. Pt also suffers from extreme anxiety. Many medications have been tried without success (somnolence). Pt is frustrated and chooses a “palliative care approach”.

Ischemic pain is both nociceptive and NeP (many times difficult to treat).

Pain stabilized on methadone and increased dose of oxycodone for B/T. Using clonazepam for anxiety- reasonably stable symptoms but more titration has and will be required.

Palliative Care

Cure/Life-prolongingCure/Life-prolongingIntentIntent

Palliative/Palliative/Comfort IntentComfort Intent

BereavementBereavementDEATH

“Active Treatment”

PalliativePalliativeCareCare

DEATH

EVOLVING MODEL OF PALLIATIVE CAREEVOLVING MODEL OF PALLIATIVE CARE

-Courtesy of Dr. Mike Harlos-Medical Director -Palliative Care Program, Wpg., Mb.

Pain control

Case vignette # 7- Why pain is important to the ER staff…

35 y/o female- 6 mo. Hx of vague abd pain. Previous gastric bypass procedure- remains moderately

obese. Admits to excess ETOH. Pt has numerous tattoos covering her body. Presents several times to

ER over months to have abd pain assessed.

Presents Friday nt with abd pain - thought to be drug seeking- therefore sent home.

Presents Saturday with perf’ed viscus. Laparotomy reveals widespread gastric cancer.

Pt declines further tx and PC is consulted. Symptoms controlled- pts dies 3d after

transfer to PC ward.

The Seven Stages of Opioid PrescribingCredit for idea: Dr.Allan Gordon MDNeurologist and DirectorWasser Pain Management CentreMount Sinai Hospital

Stage 1- Opioid Naive

Stage 2- Opiophobic

Stage 3- Opioiphillic

Stage 4- Opioid Expert

Stage 5- Opioid Disaster

Stage 6- Acquired Opioiphobia

Stage 7- Opioid Balance

Dr. Gordon’s messages: Do not fall into the trap of treating all pain the same (ie. opioids).

Appropriate diagnosis and targeted therapy according to the etiology of the pain is key.

A multimodal/comprehensive approach to pain management is essential (and this also involves the patient/family).

Universal Precautions in Pain Medicine Diagnosis with appropriate differential Psychological assessment including risk of

addictive disorders Informed consent (verbal v. written/signed) Treatment agreement (verbal v. written/signed) Pre trial assessment of pain/function Appropriate trial of opioid therapy +/- adjuvants Reassessment of pain score and level of function Regular assess the “Four A’s” of pain medicine Periodically review Pain Diagnosis and co- morbid

conditions including addictive disorders DOCUMENT, DOCUMENT, DOCUMENT

Essential Follow-up Documentation: The “6 A s”

1. Analgesia (pain relief)2. Activities (physical and psychosocial

functioning)3. Adverse Effects (and your advice)4. Ambiguous Drug Taking Behaviour

(and your response)5. Accurate medication record6. Affect

Jovey R. et al. Managing Pain. 2002 p. 121Gourlay DL, Heit HA, Almahrezi A. Universal precautions in

pain medicine: A rational approach to the treatment of chronic pain. Pain Medicine 2005;6:107-112.

Take the time- assess and listen!

Important concepts:1- Pain is not a diagnosis but it may be a disease.2-Caution with other sedating drugs- common examples include

BZD’s and gravol.3- Individualize therapy and recognize early chronic post

surgical pain syndromes (NeP).4- As it relates to chronic pain, fxn may be a more important

outcome than pain relief.5- Don’t get caught in the trap and treat all types of pain

the same (at the same time do not be afraid to use opioids if indicated).

Why pain is important to……the surgeon.…the family physician.…the nurse.…entire paramedical team.…the ER team.…the politician and global advocates.

Education is where it starts.

Link: http://www.medschoolforyou.com/Subjects.aspx

Comments and Questions?