Transcript Pain Management- It’s everyone’s business!

Pain Management- It’s
Everyone’s Business!
Dr. Joel Loiselle BSc. MD FRCPC
Staff 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/multidisciplinary 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
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“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).
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 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, 3 rd ed. Baltimore, MD, Lippincott Williams & Wilkins; 2001;241-254.
Injury-induced Pain:
Patient Factors
Injury
Individual
variation in
response to injury:
physiological,
behavioural,
and cultural
Context:
battlefield or
lonely bed
Individual
variation in
response to
treatment
Pain improves
with time
Complaint of pain
McQuay H. BMJ 1997;314:1531.
Three Hierarchical
Levels of Pain
Sensory-Discriminatory Components
Location, intensity, quality
Motivational-Affective Component
Depression, anxiety
Cognitive-Evaluation Component
Thoughts concerning the cause
and significance of the pain
Pain Management: Pathophysiology of Pain and Pain Assessment. AMA, December, 2003
Pain Pathways
PHYSICAL
SUFFERING
PSYCHOSOCIAL
EMOTIONAL
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?
Canadian National Pain Study, 2002
Prevalence of Chronic Pain – (>6 Months) (n=2012)
6 Months or more
Total (n=2012)
18-34 yrs (n=620)
35-54 yrs (n=890)
55+ yrs (n=473)
Male (n=1005)
Female (n=1007)
Less than 6 Months
29%
22%
67%
3%
3%
29%
75%
4%
39%
27%
31%
No Chronic Pain
67%
3%
4%
3%
59%
69%
66%
Moulin D., PR&M, 2002
Canadian National Pain Study, 2002
Condition Causing The Most Pain (n=340)
ALL ARTHRITIS
34%
Osteoarthritis
20%
Rheumatoid arthritis
10%
Arthritis (other mentions)
3%
Migraines/headaches
12%
5%
Fibromyalgia
 Those over 55 years of age are
significantly more likely to cite
arthritis and osteoarthritis
particularly
3%
Degenerative discs
Angina
2%
Osteoporosis
2%
Sciatica
2%
MS
2%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Moulin D., PR&M, 2002
Canadian Survey of
Post-surgical Pain
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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 Society
Position 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 Pain
Addiction/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 #2
Why pain is important to the nurse/ward
staff…
 38 y/o female
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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 drugscommon examples include BZD’s and
dimenhydrinate.
Analgesia is important but safety is paramount!
Case vignette # 3
Why 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:
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Genetic susceptibility?
Preceding pain?
Psychosocial factors?
Age and sex?
Strategies to decrease
Type of procedure? 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 # 4
Why 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 # 5
Why 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
 Function
 ADL
 Sleep
 Socialization
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 # 6
Why 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 anxietyreasonably stable symptoms but more titration has
and will be required.
Palliative Care
EVOLVING MODEL OF PALLIATIVE CARE
D
E
A
T
H
Pain control
t
en
em
Cure/Life-prolonging
Intent
Palliative/
Comfort Intent
“Active
Treatment”
v
rea
Be
Palliative
Care
D
E
A
T
H
-Courtesy of Dr. Mike Harlos
-Medical Director
-Palliative Care Program, Wpg., Mb.
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 Prescribing
Credit for idea:
Dr.Allan Gordon MD
Neurologist and Director
Wasser Pain Management Centre
Mount 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.
2.
3.
4.
Analgesia (pain relief)
Activities (physical and psychosocial functioning)
Adverse Effects (and your advice)
Ambiguous Drug Taking Behaviour
(and your response)
5. Accurate medication record
6. Affect
Jovey R. et al. Managing Pain. 2002 p. 121
Gourlay 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?