4 th Annual Thoughtful Approach to Chronic Pain “New Horizons, What Clearly Works” Managing Chronic Pain in the Primary Care Setting: Advancing Practice in the Post-Opioid Era 1 David J. Tauben, MD, FACP Chief, UW Division of Pain Medicine Hughes M & Katherine G Blake Endowed Professor Clinical Associate Professor Depts of Medicine and Anesthesia & Pain Medicine University of Washington, Seattle WA
54
Embed
Managing Chronic Pain in the Primary Care Setting: Advancing Practice in the Post-Opioid Era 1 David J. Tauben, MD, FACP Chief, UW Division of Pain.
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
4th Annual Thoughtful Approach to Chronic Pain“New Horizons, What Clearly Works”
Managing Chronic Pain in the Primary Care Setting:
Advancing Practice in the Post-Opioid Era
1
David J. Tauben, MD, FACPChief, UW Division of Pain Medicine
Hughes M & Katherine G Blake Endowed ProfessorClinical Associate Professor
Depts of Medicine and Anesthesia & Pain MedicineUniversity of Washington, Seattle WA
DISCLOSURES
CME grant support from:
ER/LA Opioid Analgesics REMS Program Companies
NIH Pain Consortium Center of Excellence in Pain Education
Off-label use of many drugs is recommended in the management of pain and so will be
discussed
2
objectives
1. Evaluate the risks and benefits of drug and non-drug treatments used for pain.
2. Discuss new standards for use of opioids in chronic non-cancer pain.
3. Discuss the emerging models of primary care based pain assessment and treatment tracking
4. Make more informed pain drug treatment decisions in the outpatient setting
3
Understanding pain
“In order to treat something, we must first learn to recognize it.” -William Osler
1. Chronic pain, a complex condition, when understood, assessed, and then treated following a structured approach, improves outcomes
2. Thorough assessment of the common biopsychosocial domains of pain adds important diagnoses also requiring treatment
Pain is NOT nociception, even if it feels that way…
“Unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” (IASP 1979)
Nociceptors selectively respond to noxious stimulation
What we observe during exam of our patients
Response to the experience of diminishment of one’s capacity
The “Loeser Onion”
Predictors of Abnormal Pain Response
History and examination: Demonstration of “non-
anatomic” territory of pain
Depression or other preexisting mood disorder
Distressed socioeconomic status
Overall poor life coping status and satisfaction
Preexisting pain processing disorders: Like fibromyalgia Prior persistent pain
problems
Active emotional distress Particularly anxiety and
fear (of the consequences or significance of an injury.)
Prior surgical complications or failure to resolve pain after previous surgery
Van Susante J, Acta Orthop Belg. 1998.Von Korff M, Pain. 2005 Carroll LJ, Pain 2004Carragee EJ, Spine J 2005
History shapes beliefs, behaviors, & outcomes: Adverse Childhood Events (ACE)
• Recurrent physical/emotional abuse
• Contact sexual abuse• An alcohol and/or drug
abuser in the household• An incarcerated household
member• Someone who is chronically
depressed, mentally ill, institutionalized, or suicidal
• Mother is treated violently• Emotional or physical neglect
20-52% of chronic pain presents and is managed in the primary care setting
• 30% of adult PCP visits/week involve chronic pain
40% receive care by chiropractors 7% by acupuncturists 20% care delivered in the ED
Only 2% by Pain Physicians10
Breuer 2010; Daubresse 2010; Giordano 2009; Krueger & Stone 2008; Marcus 2009; Von Korff 2008
“The Under treatment of Pain” American Medical Association
"In the past several years, there has been growing recognition on the part of health care providers, government regulators, and the public that the under treatment of pain is a major societal problem.”
“Physicians' fears of using opioid therapy, and the fears of other health professionals, contribute to the barriers to effective pain management.”
11
AMA 2004
The Allure of Opioids
1. They make patients happy, …at least
initially.2. They are very available in even the
most remote sites.3. Insurance covers them better than any
other pain treatment.4. The signed prescription closes the visit.
12
TOTAL OUTPATIENT PRESCRIPTIONS OF ER OPIOIDS1991-2008
Extrapolated averages of reduction in Pain Intensity
Turk, D. et al. Lancet 2011; Davies KA, et al. Rheum. 2008; Kroenke K. et al. Gen Hosp Psych. 2009; Morley S Pain 2011; Moore R, et al. Cochrane 2012; Elkins G, et al. Int J Clin Exp Hypnosis 2007.
Yet In spite of Overwhelming evidence…
Efficacy of Behavioral Management/ CBT:
Astin, et al (2002); Keefe & Caldwell (1997); Bradley (2003); Brox et al. (2003); Burns, et al (2003); Chen et al (2004); Cutler et al. (1994); McCracken & Turk (2002); McGrath & Holahan (2003); Morley et al (1999); Okifuji et al (2007); Pincus et al (2002); Roberts et al (1980);Spinhoven et al. (2004); Turner et al (2006); Vlaeyen & Morley (2005); Weydert, et al. (2003)
Efficacy of Multidisciplinary Chronic Pain Programs
Aronoff 1983; Becker et al (2000); Deschner & Polatin (2000); Feuerstein & Zostowny (1996); Flor et al (1992); Gatchel &Turk (1999); Gatchel et al (2007); Guzman et al (2001); Lande & Kulich (); Lang et al (2003); Linton et al (2005); Loeser 1991; McAllister et al (2005); Okifuji (2003); Okifuji et al (1999); Robbins et al (2003); Sanders et al (2005); Skouen et al (2002); Turk (2002) Wright & Gatchel (2002).
25
“This review clearly demonstrates that CPPs offer the most efficacious and cost effective, evidence-based treatment for persons with chronic pain.”
“Unfortunately, such programs arenot being taken advantage of because of short-sighted cost-containment policies of third-party payers.”
Gatchel & Okifuji (2006)
Opioid sales, Ods, and addictions
Opioid Overdose Risk
Non-user 1-19 mg. 20-49 mg. 50-99 mg. 100+ mg.0
1
2
3
4
5
6
7
8
9
101.79%
0.68%
0.26%0.16%
0.04%
9-fold increasein risk relative
to low-dosepatients
Dunn et al., Annal Intern Med 2010
**
**
** Significant increment in risk p<0.05
Rela
tive R
isk
by Average Daily Dose of Prescribed Opioids (Morphine Equivalent Dose)
BENZOdiazepines
Lack of evidence for sustained benefits Rebound insomnia Risk of over-sedation especially when
combined with opioids Complicating development of tolerance,
dependency, and addiction.
Use of benzodiazepines for sleep & anxiety are not recommended
in chronic pain 28
29
“Bending the curve”WA State First in NATION with decline in opioid related adverse events
30Source: Jennifer Sabel PhD Epidemiologist, WA State Department of Health, April 18, 2014
METHADONE ods >> other opioids
31
Source: SAMHSA Drug Abuse Warning Network Medical Examiner Component, 2009.
Methadone
For Pain Treatment Effective analgesic Chronic Opioid Therapy Long acting Inexpensive
For Addiction Treatment Requires special DEA
licensing and treatment support
Once daily liquid dosing eases administration
Reduces mortality among heroin users
Significant accumulation with
repeat dosing
• Initial T½ 13-47 hrs up to 48-72 hrs
• 100% hepatic cleared• CYPs: 1A2, 2D6,
3A4
Inhibits its own CYP metabolism
Drug overdosesWashington State 1999-2013
33
Source: C. Banta-Green WA State Department of Health
OpioidsThe Clinical conundrum
OpioidsThe Clinical Challenge
• Not all patients with pain are suitable candidates for chronic opioid therapy (COT).
• Short-term opioid therapy has different goals and purposes and should not progress to COT without reconsideration of goals and purposes.
• Opioid dependence develops in all patients receiving COT, may have a strong psychological component, and is not always easily reversible.
• COT should be goal oriented and discontinued if goals are not met.
• There are significant safety issues that need consideration during COT.
From Ballantyne J, Rehab Clin NA. in press 2015
Opioids are part of plan, not The plan
“Avoid … primary reliance on opioid prescribing, which, when applied alone or in a non-coordinated fashion, may be inadequate to effectively address persistent pain as a disease process and, when employed as the “sole” treatment, is associated with significant societal expense and treatment failure.”
▪ ABPM Pain Medicine Position Paper, Pain Medicine 2009:987-988.
Anti-Spasm drugs
• Antispasm drugs have limited evidence for effectiveness, are predominantly sedative, and add polypharmacy to chronic pain management with little benefit.
• Carisoprodol should never be used because of no benefit and high risk.
• When true spasticity is present, as in spinal cord injury and multiple sclerosis, baclofen and tizanidine may be useful.
• Avoid abrupt withdrawal off baclofen because of the potential for severe rhabdomyolysis and fever.
37van Tulder MW et al. Cochrane Library 2008
antidepressant analgesia
Principal neurotransmitters in “descending inhibitory systems”
Multimodal benefits: PAIN, SLEEP, &
MOOD
DESCENDING INHIBITORY NOXIOUS CONTROL SYSTEMS“Gate Theory”
Ascending pain pathways
Descending pain pathways
Proposed Mechanisms of Antidepressant analgesic effect
39Verdu B. Drugs 2008
CLINICAL KEY Points
Antidepressant Analgesia
• Antidepressants that elevate synaptic norepinephrine (TCAs > SNRIs) are effective analgesics
• Sedating antidepressants are useful agents to improve both sleep initiation and maintenance
• Anticholinergic side-effects are most common with TCAs
• Nausea is common with SNRIs• Dose related QTc prolongation occurs with TCAs
>SNRIs• Warn patient and family about risks of suicidality
when any antidepressant is prescribed• Mania may be precipitated by any category of
antidepressant
40
Tricyclic Antidepressant Effectiveness:
Post Herpetic NeuralgiaNNT* 2.1-2.7
Diabetic Peripheral NeuropathyNNT 1.2-1.5
Atypical Facial PainNNT 2.8-3.4
Fibromyalgia/Central PainNNT 1.7
Saarto T, Wiffen PJ. Cochrane Database of Systematic Reviews 2007
*NNT = Number needed to treat
“Gabapentinoids” for PainPrototypic Ca++ current inhibitors
Gabapentin Pregabalin
• Well studied• Fewer side effects than
other anticonvulsants• Limited drug-drug side
effects• 100% excreted in the urine• Gabapentin absorption via
*Variable levels of quality of evidence to support use
Key Points
Anticonvulsant Drugs for Pain
• Anticonvulsant drugs with both sodium and calcium channel modulating effects are effective in a variety of neuropathic pain disorders, fibromyalgia, and headache.
• Sodium channel ACDs have a wide range of potential serious adverse drug effects, including electrolyte disorders, pancytopenias, and skin rashes, and so require routine laboratory monitoring.
• Gabapentinoids side effects are usually clinically evident: cognitive slowing, weight gain, and edema.
46
Tauben D. Phys Med Rehab Clinic NA, in press 7/2015
From Finnerup et al., 2007 and adapted from Sindrup SH, Jensen TS.1999.