Transcript View - Department of Medicine

Staying SANE
While Treating PAIN
Nathan J. Rudin, M.D.
Assistant Professor, Rehabilitation Medicine
University of Wisconsin Medical School
Medical Director, Pain Treatment and Research Center
Patient Visit
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Whole-body pain for six years
Depression; anxiety; physical abuse
Psych hospitalizations
Anxiolytic medication somewhat helpful
Wants opioid medication
Goal – “Get rid of all pain now”
History of Present Illness
How Do You Feel???
How Do You Feel?
Acute Pain
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Temporally related to injury
Resolves during the healing process
Usually responds to analgesics and/or
treatment of underlying cause
Chronic Pain
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Persistent pain serving no useful biological
purpose
Outlasts the healing process
Cutoff?
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Usually 6 months
Often refractory to analgesics
Underlying cause may be hard to identify
Chronic Pain - Psychosocial
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Pain becomes primary
focus of life
Altered social, family,
work roles
Depression, anxiety,
panic
Preexisting psych issues
in certain patients
Chronic Pain - Behavioral
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Learned, reinforced pain behavior
Limited coping skills
Unconscious enabling by family,
friends
Compensation concerns – WC,
litigation
Chronic Pain Syndrome
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Pain lasting six months or more
Pain assumes a primary importance in the
patient’s life
Psychological comorbidities
Dysfunction in multiple life domains
Medical-Palliative Model
PAIN
Diagnosis
Treatment
Pain
Relief
Recovery
Of
Function
Medical-Palliative Pain Care
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Often successful
High patient satisfaction; minimal expense
But:
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Treatment cannot end until pain stops.
Pain is subjective, placing patient in control of treatment,
but without responsibility.
Pain and dysfunction are rewarded by additional attention
& medication.
Medical-Palliative Model
PAIN
Diagnosis
Treatment
NO RELIEF or
INCOMPLETE
RELIEF
Rehabilitation Model
PAIN
Diagnosis
Treatment
NO RELIEF or
INCOMPLETE
RELIEF
Recovery
Of
Function
Rehabilitative Pain Care
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Recovery of function is the primary treatment
goal.
Pain relief is not promised, and may or may
not occur.
Patients must take an active role in improving
their own function and capacity.
Where To Begin?
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Understand the
patient
Diagnosis
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Understand the nature of the patient’s problem
Careful physical examination
Imaging
Ancillary testing (EMG/NCS, etc.)
Specialist evaluation where needed
Psychological Diagnosis
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Screen for depression, anxiety
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Screen for history of abuse
Ask about prior diagnoses
Ask about prior treatment
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Psychiatric hospitalizations
Psychiatry
Counseling
Rx
Specialist evaluation where needed
Motivational Issues
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Income / insurance
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Workers’ Compensation
Litigation
Family attitudes
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Enabling, over-supportive families need education
to stop encouraging pain behaviors
Evaluate The Situation
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Can you treat the problem adequately?
Will psychological status and motivation allow
the patient to participate?
Is specialist input needed?
Define Goals
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“Before you begin,
have an end in
mind.”
-- Astute fortune cookie
author
Define Goals
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Patient’s goals
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Your goals
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Pain relief; pain medication; ? improved function
Reduced pain; improved function; appropriate
medication use
Time frame for treatment?
If treatment fails, next steps?
Discuss Goals
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Bring your goals and the patient’s goals
into congruence
If you are working from different sets of
goals, success is unlikely
Agree upon goals and write them down
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Copies to patient and medical record
Sample Treatment Plan
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Patient name, MR#, birth date
Diagnoses
Goals
Specific treatments for each goal
 Identify who is responsible for each treatment
 Time frame for each goal
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Reassessment interval
Be Firm
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Patient should participate in entire treatment
plan
Reassess pain and function periodically
If no improvement, consider terminating
ineffective treatment
Set Limits
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“I’m out of my pain medication early”
“Picking and choosing” from prescribed
treatments
Missed appointments
Emergency department or urgent care overuse
Inappropriate treatment of staff
Excessive or unnecessary telephone calls
Set Limits
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Enforce adherence to all clinic and medication
policies
Exceptions reinforce unwanted behavior
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Variable interval
Set out policies clearly
Spell out consequences at the start of treatment
Controlled Substances
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Use with defined purpose and goals in mind
Educate patient on appropriate use
For chronic conditions, minimize short-acting
medications
Use and enforce controlled-substance
agreement/contract
Reevaluate efficacy periodically
Dependence And Tolerance
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Tolerance = need for more drug to achieve
same effect
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May lessen if pain is abruptly relieved
Physical dependence = physiologic adaptation
to regular dosage
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Withdrawal syndrome if abruptly discontinued
Addiction / Abuse
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Most patients with acute or chronic pain do not
develop addiction
Hallmarks of addiction:
Compulsive use
 Loss of control of use: self-escalation
 Use despite harm
 Use despite lack of benefit
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Do not use addiction as reason to withhold
acute treatment
Abuse / Addiction / Diversion
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Provide an appropriate and safe taper of medication
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Can usually taper 30% every 1-2 days
Can use clonidine, low-dose benzodiazepines to attenuate
withdrawal
Get specialist’s advice for tapering methadone
Give patient phone numbers for drug rehabilitation
programs
Continue other parts of treatment, if patient is willing
Document your actions in the medical record; if
appropriate, notify ED
Measuring Efficacy
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Analog pain scale (0-10)
Percent change in pain (better or worse)
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Vocational status
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These two scales don’t measure the same thing!
Return to work; improved activity
Psychosocial status
Drug Screens
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Use when initiating treatment, or when diversion
or other drug abuse is suspected
Urine Mass Spectroscopy Panel is the most
effective test
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Indicate specific drugs you are looking for
Routine screening?
Protect Yourself
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Document all opioid prescriptions
Keep photocopies where possible
 Copies can be scanned into
WISCR-IT
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Document rationale for
prescribing
Document efficacy, with periodic
reevaluations
Psychosocial Issues
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Is the patient emotionally stable?
Can the patient think straight?
Are life circumstances stable or chaotic?
Can the patient participate fully and effectively
in treatment?
Psychosocial Issues
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If answer is no:
Refer for psychiatric evaluation and/or counseling
 Make this a condition for other treatment
 If a treatment is unlikely to succeed, defer it until
patient’s psychological status has stabilized
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Psychopharmacology
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Antidepressants
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TCAs best for pain, but bad side effects
SSRIs, SNRIs helpful for anxiety and
depression
Antiepileptics – can help “stabilize
mood”
Specialist referral where needed
Personality Disorders
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Borderline: perhaps the toughest
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Labile mood
Staff “splitting”
May threaten suicide if not granted their requests
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If they do not withdraw that threat, call 911 for emergency
psychiatric workup
Again: set limits and enforce them!
Don’t let yourself be manipulated
Terminating Pain Treatment
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If pain treatment is ineffective or patient does
not/cannot participate, it can be terminated.
For drug therapy, use safe taper as above
Refer for drug rehab if needed
Refer for psych, other services as needed
Encourage patient that you will still provide
other aspects of care
Pain Center Consultation
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Refer for:
Complex cases needing interdisciplinary care
 Diagnostic dilemmas
 Questions about appropriate management
 Specific procedures (epidurals, nerve blocks,
trigger point injection, etc.)
 Diagnostic testing (EMG/NCS, tilt table, QST)
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Recap
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The patient needs to share responsibility for
care.
Use a functionally-oriented care model.
Set goals and assess progress.
Enforce your rules.
Don’t be manipulated.
You can terminate pain treatment if it isn’t
working.
Available online - CRIT: Pain Management Guidelines
Standard Register: UWHC Form # 4002754
Guidelines For Treatment With Controlled Substance Medications
Other References
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CRIT Web page: Guidelines: Pain
Management Guidelines
Health Facts For You: search under Pain
Guidelines for the Assessment and Treatment
of Chronic Pain:
www.wisconsinmedicalsociety.org
Rudin NJ (2001). Chronic pain rehabilitation:
principles and practice. WMJ 100(5): 36-43,
66.