Transcript 2010 NANS - North American Neuromodulation Society

Patient Selection
What You Must Know
2010 NANS
Joel R Saper, MD, FACP,
FAAN
Director/ Founder Michigan Head
Pain & Neurological Institute
Ann Arbor, Mi
Clinical Professor Neurology, MSU
DISCLOSURE !!!
•Honoraria: GlxSK, Merck,AstraZ,Allergan,
OrthoMcNeil,Elan,Pfizer, Pharmacia
•Advisory Brd/Consultant:Allergan,
OrthoMcNeil,Medtronic, Advanced Bionics, AZ, Ely Lilly,
Pfizer, Esai, Pozen
•Research Grants: GlxSK,Merck,AstraZ,Abbott,Allergan,
OrthoMcNeil, Esai, Pfizer, Pharmacia , Elan, Pozen,
Medtronic, Advanced Bionics
[email protected]
END OF PRESENTATION!
Interventional Procedure Success,
and Adequate Reimbursement,
Depend on Fulfillment of Key
Clinical Outcomes:
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Sustained reduction of pain
Improved Function
Overall cost reduction(utilization)
These are achieved…
Interventional Procedures, and
Adequate Reimbursement,
Depend on Fulfillment of Key
Clinical Outcomes:
• IDing of proper diagnosis and symptom
complex in moderately refractory patients, at a
time and evolution of the illness that assures
reversibility
• Surgical/Procedural competence
• Selecting patients without barriers or conflicts
to sustained benefit!
Barriers and Conflicts
• Wrong Diagnosis
• In case of headache and occipital n. stim: must be
reasonably certain that the occipital nerve stim is
a conduit to trigeminal mediated pain via dorsal
horn modulation, or in 2nd and 3rd order trigeminal
neuronal systems.
• The cervical dorsal horn is a therapeutic locus for
trigeminal and occipital pain modulation via the
O.N.
C2-3 &
TRIGEMINAL/CERVICAL
COMPLEX
• Stimulation of C2-3 roots activates
trigeminal complex (Goadsby, 2001)
• Suggests chronic stimulation could
sensitize 2nd and 3rd order neurons,
activating migraine or other HA
mechanisms
Barriers and Conflicts
• Opioid Dependency
SYNDROME OF MEDICATION
OVERUSE HEADACHE
Characteristics of Rebound Headache
• Occurs in patients with pre-existing HA
• Regular intake, more than 2-3d/wk, for months
• A self-sustaining rhythm of predictable, reliable
& escalating HA frequency & med. use
• Refractory to otherwise appropriate
symptomatic & preventive treatments
• Med withdrawal results in escalation of HA
Saper JR. 1983,1992,1999
MEDICATION OVERUSE
HEADACHE, IHS,2004
Diagnostic criteria:
•Intake (triptans, ergots, opioids) on > 10 d/mo on a
regular basis for > 3 mo
•15 d/mo for simple analgesics
•HA has developed or markedly worsened during overuse
•HA resolves or reverts to previous pattern within 2 mo
after D/C
Applies to:
•Ergotamine, triptan, analgesic, opioid, & combination
medication overuse HA
Opioids and the Brain
Review of literature
• Opioids can cause receptor hypersensivity, opioid
induced hyperalgesia (Mao et al,2002)
• Glutamate induced apototic cell death(Mao.2002)
• Induce CGRP increase in dorsal horn( Meng and
Porecca, 2004)
• Morphine activates glia and increases proinflammatory cytokines(Watkins, 2002)
• Pro-nociceptive cholecystokinin (CCK) is
upregulated in the rostral ventromedial medulla
(RVM) during persistent opioid exposure
• CCK activates descending RVM pain facilitation,
enhancing pain transmission and hyperalgesia
Opioids and the Brain
Review of Literature
• Long-lasting receptor change after initial exposure
to morphine(Lim,et al,Mao, 2005)
• Numerous endocrine disturbances
• Age dependant tolerance: exceptional receptor
sensitivity and tolerance in adolescents(BuntinMushok, 2005)
• Opioid induced MOH more likely to be
unrelieved following D/C than with triptans and
ergots(Lake 2005; others)
• Prevents response to parenteral NSAIDS
(Jakubowski,et al 2005)
Opioids: Endocrine/Immune
System Effects
•In animals, opioids increase GH, inhibits LH, FSH, TSH
•Opioid induced hypogonadism d/t central suppression of
gonadotropin releasing hormone
•75% of men have clinically significant lowered testosterone
levels
•Loss of muscle strength, compression fractures,
osteoporosis, galactorrhea, etc,
Katz,et al, 2009, Clin J Pain; Maggi, 1995; Kavelaars,1991
REBOUND:
A Neurobehavioral Disorder
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Not all pts with daily/frequentHA overuse drugs
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Physical (receptor) alterations (Srikiatkhachorn, 1998,
Mao,2003)
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Behavioral – excessive/obsessive drug-taking,
anticipatory anxiety, fear of pain
(cephalgiaphobia), “orality/security dynamic”
Saper et al, Cephalalgia,2006
In HA patients, and perhaps
others, opioid dependence
induces progression of
pathology, alterations in
personality, a prolonged
craving and reliance on the
tranquilizing effects, well
beyond the analgesic need.
Getting better poses a
conflict!
Many use drugs to have a life;
others to hide from life!
Barriers and Conflicts
• Opioid Dependency
• The “PROBLEM PATIENT”
“It not so much what’s done to
the head but to whose head it’s
done”!
Saper, 1992
Identifying the problem patient is
critical
PSYCHOBIOLOGY OF PAIN
• Psychological variables modulate PAG and nociceptive neurons in
dorsal horn (Fields, 1997)
– Bidirectional control over pain transmission (somatosensory,
cortical, limbic via PAG, engaged by psychological factors)
– Physiological mechanisms convert psychological distress to
painful symptomatology (Fields, 1997)
– Limbic enhanced pain via neuroplastic
mechanisms(Rome,2002)
– Stress evokes proinflammatory cytokines (Watkins, 2005)
The Troubled Patient Must be
Recognized and Confronted Early
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Overt drug misuse/ addictive disease
Severe anxiety / depression/ somatization
“Pain Theater” starring the Drama Queen/King and
cast of supporting enablers and sympathizers
Missed visits
Lost/ “ran short” of scripts
Noncompliance
Anger
Family dysfunction
Usually Axis ll, Cluster B
How can some patients say they
are better?
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Disability lost
Performance expectations: job, family, marital
No more opioids
Relinquishing special status/protections/reduced
expectations
• Some spouses/relatives are only attentive when
partner is ill
• Illness can be the glue that binds a weak
relationship
Chronic impairment and disability, role reversals
and drug dependency may lock even motivated
people into a sick role
Some patients become
“illness locked”!
“ I want to feel better,
but not necessarily GET
better!”
Some patients
cannot/won’t get better!
They are not good procedural
candidates!
Highlights from…
“Conversations With Borderlines,
Narcissists, Sociopaths, Addicts,
Felons and Other Self-Loathing and
Good Friends”
JRSAPER
TOP 20 QUOTES FROM BPD
PTS
“Shove your behavior
contract up your a-- !”
TOP 20 QUOTES FROM BPD
PTS
“I want my Demerol”
TOP 20 QUOTES FROM BPD
PTS
“You’re calling me a drug
addict, aren’t you?”
“My Oxy fell down the toilet”
TOP 20 QUOTES FROM BPD
PTS
“My dog ate my narcotics”
Are there breeds of dogs that love
opioids ONLY…?
• OxyCollie
• OxyRetriever
• PercoSpanial
• VicoCocker
• Morphi-Yorkie
Dogs That Treat Misuse
DetoxerBoxer
“How did that cocaine get in my
urine?”
“Nurse Ratshitt, did you put
cocaine in Herbie’s urine?!!!!”
“My pain is no better, but I need
more Oxycontin because it makes
ME feel better”.”
“Let’s face it, I like the buzz!”
--a headache patient on Actiq
“Let’s face it, it takes 30 seconds
to say yes, but 30 minutes to say
no!”
Dr Howard Heit, 2004
“Sometimes the best medicine is
to stop taking something”
Ashleigh Brilliant
“The head speaks when the
mouth cannot”!
Saper, 2006
(Said in a moment of unrestrained
psychobabble!)
“Treating pain is a thinking
sport”
Dr Jeff Okeson, 2003
“Treating some borderline
patients is a blood sport!
J Saper, 2006
“What do you mean I
have a borderline
personality? I’ve never
even been to Mexico!”
--a perplexed borderline
patient
“Justice will be served only when
the last lawyer on earth has been
strangled with the intestines of
the last politician”!
George Bernard Shaw
“AIM HIGH”
THE BITTER
END… at long
last