Ambulatory Pain Management Richard T. Jermyn D.O., F.A.A.P.M.R. Associate Professor: UMDNJ:SOM Acting Chair: Department of PM&R Director: NMI.

Ambulatory Pain Management Ambulatory Pain Management

Richard T. Jermyn D.O., F.A.A.P.M.R.Richard T. Jermyn D.O., F.A.A.P.M.R.Associate Professor: UMDNJ:SOMAssociate Professor: UMDNJ:SOMActing Chair: Department of PM&RActing Chair: Department of PM&RDirector: NMIDirector: NMI

DisclosureDisclosureRichard Jermyn, DORichard Jermyn, DO

CompanyCompany

Consultant and Consultant and Speaker’s BureauSpeaker’s Bureau

Endo Pharmaceuticals, Endo Pharmaceuticals, Alpharma Inc., and Pfizer Inc.Alpharma Inc., and Pfizer Inc.

Grant ResearchGrant Research Endo PharmaceuticalsEndo Pharmaceuticals

ObjectivesObjectives

Learn how to interview a pain patientLearn how to interview a pain patient Review pharmacology of pain medicationsReview pharmacology of pain medications Common treatments for the pain patientCommon treatments for the pain patient Understand the pathophysiology of painUnderstand the pathophysiology of pain

CASE STUDYCASE STUDY

Patient is a 53 year old female with a 10 year history of Patient is a 53 year old female with a 10 year history of Diabetes Mellitus. Patient has severe pain in feet and Diabetes Mellitus. Patient has severe pain in feet and legs VAS 9 (1-10) for 1 year. Patient admits to not using legs VAS 9 (1-10) for 1 year. Patient admits to not using her insulin and blood sugars are usually above 200. her insulin and blood sugars are usually above 200. You have no medical records.You have no medical records.

Diagnosed with osteoarthitis of both kneesDiagnosed with osteoarthitis of both knees History of Lumbar spinal stenosis History of Lumbar spinal stenosis

Case StudyCase Study

Works as a waitress but strugglesWorks as a waitress but struggles Limited incomeLimited income

Case StudyCase Study

Patient taking Neurontin 600mg Patient taking Neurontin 600mg (Gabapentin) TID (Gabapentin) TID

Percocet 7.5/325 (Oxycodone HCI-Percocet 7.5/325 (Oxycodone HCI-Acetaminophen) 5-6/dayAcetaminophen) 5-6/day

Never has had physical therapy but feels Never has had physical therapy but feels gets exercise at workgets exercise at work

Corticosteriod injections provided no reliefCorticosteriod injections provided no relief

Does this patient have pain?Does this patient have pain?

Is Neurontin (Gabapentin) appropriate?Is Neurontin (Gabapentin) appropriate?

Is Percocet (Oxycodone HCI-Acetaminophen) Is Percocet (Oxycodone HCI-Acetaminophen) appropriate?appropriate?

How to get started?How to get started?

Acute vs Chronic Pain States

Acute Chronic

• Associated with tissue damage

• Increased autonomic nervous activity

• Resolves with healing of injury

• Serves protective function

• Extends beyond expected period of healing

• No protective function• Degrades health and

functioning• Contributes to depressed

mood

vs

Turk, Turk, OkifujiOkifuji. In: . In: BonicaBonica’’ss Management of Pain.Management of Pain. 2001; Chapman, Stillman. In: 2001; Chapman, Stillman. In: Pain and Touch.Pain and Touch. Handbook Handbook of Perception and Cognitionof Perception and Cognition. 2nd ed.. 2nd ed. 1996; Fields. 1996; Fields. NeuropsychiatrNeuropsychiatr Neuropsychol Neuropsychol BehavBehav Neurol.Neurol. 1991;4:831991;4:83--92.92.

Nociceptive Neuropathic

Nociceptive vs Neuropathic Pain States

• Arises from stimulus outside of nervous system

• Proportionate to receptor stimulation

• When acute, serves protective function

• Arises from primary lesion or dysfunction in nervous system

• No nociceptive stimulation required

• Disproportionate to receptor stimulation

• Other evidence of nerve damage

vs

Serra. Serra. Acta Neurol Scand. Acta Neurol Scand. 19991999;173(suppl):7;173(suppl):7--1111..

Examples of Nociceptive and Neuropathic Pain

• Arthritis• Mechanical low

back pain• Sports/exercise injuries• Postoperative pain

NeuropathicNociceptive Mixed

• Painful DPN• PHN• Neuropathic low back pain• Trigeminal neuralgia• Central poststroke pain• Complex regional pain syndrome• Distal HIV polyneuropathy

Caused by lesion or dysfunction in the nervous system

Caused by tissue damage

Caused by combination of primary injury and secondary

effects

• Low back pain• Fibromyalgia• Neck pain• Cancer pain

Pain AssessmentPain Assessment

– Quality: sharp shooting, numbness, burningQuality: sharp shooting, numbness, burning– Intensity: VAS (0-10)Intensity: VAS (0-10)– Duration: constant, intermittent, worse at nightDuration: constant, intermittent, worse at night– associated symptoms: bowel/bladder incont.associated symptoms: bowel/bladder incont.– Medical/Surgical History: Medical/Surgical History: – opportunistic infections history: herpes, CMV, opportunistic infections history: herpes, CMV,

Lymes, toxoplasmosis, HIVLymes, toxoplasmosis, HIV– Treatments that have failedTreatments that have failed

Pain AssessmentPain Assessment

Social History:Social History:– Live alone or partneredLive alone or partnered– Single or multiple story homesSingle or multiple story homes– Assistive devicesAssistive devices– FallsFalls– DriveDrive– HobbiesHobbies

Goals for treatment: work, childcare, school, Goals for treatment: work, childcare, school, sportssports

Physical ExamPhysical Exam

Upper motor neuron vs. lower motor neuronUpper motor neuron vs. lower motor neuron

Physical ExamPhysical Exam

Upper motor neuron:Upper motor neuron:– hyper-reflexiahyper-reflexia– spasticityspasticity– hoffmans/babinskihoffmans/babinski– frontal release signsfrontal release signs– ataxia, tremor, dysmetriaataxia, tremor, dysmetria

Physical ExamPhysical Exam

Lower Motor NeuronLower Motor Neuron– decreased reflexesdecreased reflexes– weaknessweakness

Upper Motor NeuronUpper Motor Neuron

Metabolic: common drug effectsMetabolic: common drug effects Lymphoma: CNS tumorsLymphoma: CNS tumors Primary or metastatic cancerPrimary or metastatic cancer CVA: thalamic syndrome, hand-shoulder CVA: thalamic syndrome, hand-shoulder

syndromesyndrome Myelopathy: stenosisMyelopathy: stenosis Infectious disease: meningitis, lymes diseaseInfectious disease: meningitis, lymes disease Neurological: MSNeurological: MS DementiaDementia

Lower Motor NeuronLower Motor Neuron

Peripheral Sensory NeuropathyPeripheral Sensory Neuropathy Mononeuropathy: femoralMononeuropathy: femoral RadiculopathiesRadiculopathies myopathy: CPKmyopathy: CPK

– Drug effectsDrug effects Arthropathies: OAArthropathies: OA Autoimmune: RAAutoimmune: RA Infectious Disease: Herpes zosterInfectious Disease: Herpes zoster

Normal Pain Pathways

Adapted with permission, from Fields. In: Adapted with permission, from Fields. In: The Placebo Effect: AnThe Placebo Effect: An Interdisciplinary ExInterdisciplinary Expplorationloration. 1997.. 1997.

Key:RVM = rostroventral medullaPAG = periaqueductal grey C = cingulate cortexF = frontal cortexSS = somatosensory cortexA = amygdalaH = hypothalamus

Ascending pathwayDescending pathway

TRANSMISSION

Cortex

Thalamus

SS

Midbrain

C FC

AH

PAG

RVM

Medulla

SpinothalamicTract

Injury

Spinal Cord

MODULATIONF

Normal and Abnormal Synaptic Neurotransmission

Supraspinal Influences on Nociceptive Supraspinal Influences on Nociceptive ProcessingProcessing

FacilitationFacilitation

+

Inhibition

Substance P

Glutamate and EAA

Serotonin (5-HT2a

and 5-HT3a receptors)

Descending antinociceptive pathways

Noradrenaline–serotonin (5-HT1a and 5-HT1b receptors)

Opioids

GABA

EAA=excitatory amino acids. 5-HT=serotonin. Fields HL, et al. In: Wall PD, et al., eds. Textbook of Pain. 4th ed; 1999:309-329.Millan MJ. Prog Neurobiol. 2002;66(6):355-474.

Cortical

Spinal

Peripheral Nerve

Cortical

Spinal

Peripheral Nerve

Antidepressant

Anticonvulsants

Psychostimulents

Opiates

Tens

AnticonvulsantsNSAIDS

Epidural

Nerve Blocks

Modalities

Muscle Relax

Exercise

Pain ManagementPain Management

WHO Analgesic ladderWHO Analgesic ladder

MILD

MODERATE

SEVERE

Metabolized by C450 2D6 Metabolized by C450 2D6 isoenzymesisoenzymes

AntiarrythmicsAntiarrythmics Beta-blockersBeta-blockers OpiatesOpiates AntipsychoticsAntipsychotics

SSRI’sSSRI’s TCA’sTCA’s Anti-retroviralsAnti-retrovirals

Mechanism of Action of NSAID Mechanism of Action of NSAID

Arachidonic AcidArachidonic Acid

COX-1 Cox-2

Prostaglandinprostaglandin

Protection ofGastic mucosa

hemostasis

Mediate pain,Inflammation and fever

Specificity of AgentsSpecificity of Agents

CategoryCategory inhibitioninhibition Cox-2Cox-2

Cox-1Cox-1

MedicationsMedications– Celecoxib Celecoxib – AspirinAspirin– Diclofenac (oral, gel, patch)Diclofenac (oral, gel, patch)– EtodolacEtodolac– IbuprofenIbuprofen– Indomethacin Indomethacin

(Indomethacin-Various)(Indomethacin-Various)– MeloxicamMeloxicam– Naprosyn (Naproxen)Naprosyn (Naproxen)

OpioidsOpioids

Agonist and Agonist-antagonistsAgonist and Agonist-antagonists– bind to opioid receptorsbind to opioid receptors

sustained released and short acting agentssustained released and short acting agents Oral route is most preferredOral route is most preferred mainstay for moderate to severe painmainstay for moderate to severe pain never dose as PRNnever dose as PRN

OpioidsOpioids

Start with the lowest possible dose possibleStart with the lowest possible dose possible titrate the drugtitrate the drug place the patient on a schedule and never place the patient on a schedule and never

PRNPRN use combinations of opioids and non-opioidsuse combinations of opioids and non-opioids be aware of tolerencebe aware of tolerence

OpioidsOpioids

Weaker Opioids analgesics:Weaker Opioids analgesics:– oxycodone, hydrocodone, codeineoxycodone, hydrocodone, codeine– available in combinations with ASA/aceto.available in combinations with ASA/aceto.

Stronger Opioid analgesics:Stronger Opioid analgesics:– Roxicodone (Oxycodone HCI) immediate releaseRoxicodone (Oxycodone HCI) immediate release– Oxycontin (Oxycodone HCI) sustained releaseOxycontin (Oxycodone HCI) sustained release– MSContin (Morphine Sulfate), MSIRMSContin (Morphine Sulfate), MSIR– MethadoneMethadone– Duragesic (Fentanyl)Duragesic (Fentanyl)

Dosing of OpioidsDosing of Opioids

Long-acting agents for 24 hr. reliefLong-acting agents for 24 hr. relief

Short-acting agents for breakthru painShort-acting agents for breakthru pain– no more than 2 times daily (debated)no more than 2 times daily (debated)– Combo drugs; Percocet (Oxycodone HCI), Vicodin Combo drugs; Percocet (Oxycodone HCI), Vicodin

(Hydrocodone Bitartrate-Acetaminophen), Lortab (Hydrocodone Bitartrate-Acetaminophen), Lortab (Hydrocodone Bitartrate-Acetaminophen)(Hydrocodone Bitartrate-Acetaminophen)

– Uncombinated drugs; Oxy IR (Oxycodone HCI), Actiq Uncombinated drugs; Oxy IR (Oxycodone HCI), Actiq (Fentanyl Citrate)(Fentanyl Citrate)

Treat side effects such as constipationTreat side effects such as constipation

MethadoneMethadone

Long half life: 24-150hrsLong half life: 24-150hrs Duration of activity: 4-6hrs.Duration of activity: 4-6hrs. Toxicity with overlapping half livesToxicity with overlapping half lives HIV meds can decrease the serum level of HIV meds can decrease the serum level of

methadonemethadone– Immediate withdrawalImmediate withdrawal

MethadoneMethadone

When switching to methadone to another When switching to methadone to another analgesic: decrease 75-90% equi-analgesic analgesic: decrease 75-90% equi-analgesic dosedose

Take maintance Dose decrease 20% and Take maintance Dose decrease 20% and divide to tid-qid.divide to tid-qid.

Short acting for withdrawal symptomsShort acting for withdrawal symptoms

TransdermalTransdermal

98% protein bound98% protein bound– Must have protein to be absorbedMust have protein to be absorbed– Must have protein to be excretedMust have protein to be excreted

Absorption of the drug increased as the Absorption of the drug increased as the temperature increases.temperature increases.– 101-103 degrees101-103 degrees

Tramadol (Ultram)Tramadol (Ultram)

Centrally Acting Oral Opioid AgonistCentrally Acting Oral Opioid Agonist Serotonin and NoradrenerginSerotonin and Noradrenergin Dizziness, Nausea and HeadacheDizziness, Nausea and Headache

AntidepressantsAntidepressants

Works on serotonin and noradrenerginWorks on serotonin and noradrenergin tricyclics, hetero, SNRI, SSRItricyclics, hetero, SNRI, SSRI potentiate the opiatespotentiate the opiates treat depression as a side effecttreat depression as a side effect

AntidepressantsAntidepressants

Effexor: SSRI Effexor: SSRI (Venlafaxine)(Venlafaxine)

Amitriptyline: triAmitriptyline: tri LithiumLithium Desipramine: triDesipramine: tri Nortriptyline:triNortriptyline:tri Paxil:SSRI Paxil:SSRI (Paroxetine)(Paroxetine)

Prozac: SSRI Prozac: SSRI (Fluoxetine)(Fluoxetine)

Serzone Serzone (Nefazodone)(Nefazodone)

Wellbutrin Wellbutrin (buPROPion):(buPROPion): AminoketoneAminoketone

Zoloft:SSRI Zoloft:SSRI (Sertaline)(Sertaline)

Cymbalta: SNRI Cymbalta: SNRI (duloxetine)(duloxetine)

Most neurotransmitters are Most neurotransmitters are inhibitoryinhibitory

Side-effectsSide-effects

Urinary retention, anticholinergic, increased Urinary retention, anticholinergic, increased or decreased blood pressure, drowsiness, or decreased blood pressure, drowsiness, nausea, headache, sweatingnausea, headache, sweating

AntidepressantsAntidepressants

Pain relief is related to serum level.Pain relief is related to serum level. Dose at night to allow improved sleepDose at night to allow improved sleep SSRI’s are believed to be not as beneficial SSRI’s are believed to be not as beneficial

in pain relief until recentlyin pain relief until recently Warn patients about side effectsWarn patients about side effects

AnticonvulsantsAnticonvulsants

Gabapentine (Neurontin):Gabapentine (Neurontin):– works on GABAworks on GABA– start at low doses and titrate upwardstart at low doses and titrate upward– check renal profiles: renal excretioncheck renal profiles: renal excretion– potentiate opioids weaklypotentiate opioids weakly– strong mood stabilizerstrong mood stabilizer

AnticonvulsantsAnticonvulsants

Valproic Acid: extreme caution in liver Valproic Acid: extreme caution in liver disease, monitor blood levels, neural tube disease, monitor blood levels, neural tube defects in fetus, dizziness, headache, defects in fetus, dizziness, headache, thrombocytopeniathrombocytopenia

Phenytoin: nystagimus, lethary, ataxia, Phenytoin: nystagimus, lethary, ataxia, gingival hyperplasia, hepatic diseasegingival hyperplasia, hepatic disease

AnticonvulsantsAnticonvulsants

Gabitril (Tiagabine): GABA reuptake Gabitril (Tiagabine): GABA reuptake inhibitor, caution with liver disease, inhibitor, caution with liver disease, dizziness, fatigue, rare ophthalmologic dizziness, fatigue, rare ophthalmologic effectseffects

Klonopin (Clonazepam): benzodiazepineKlonopin (Clonazepam): benzodiazepine Lamictal (Lamotrigine): rash (serious), Lamictal (Lamotrigine): rash (serious),

dizziness, ataxia, fatigue, blurred visiondizziness, ataxia, fatigue, blurred vision Tegretal: aplastic anemia, rash (SJS), Tegretal: aplastic anemia, rash (SJS),

photosensitivity, dizziness photosensitivity, dizziness

AnticonvulsantsAnticonvulsants

Topomax (Topiramate): sulfa mate: fatigue, Topomax (Topiramate): sulfa mate: fatigue, dizziness, ataxia, parenthesis, kidney stones, dizziness, ataxia, parenthesis, kidney stones, mental cloudiness, weight loss.mental cloudiness, weight loss.

Zonegran: Somnolence, dizziness, anorexia, Zonegran: Somnolence, dizziness, anorexia, headache, nauseaheadache, nausea

Lyrica (Pregabalin): Schedule V, sedation, weight Lyrica (Pregabalin): Schedule V, sedation, weight gaingain– May be less sedating than Neurontin (Gabapentin)May be less sedating than Neurontin (Gabapentin)– Indicated for post-herpetic neuralgia, diabetic Indicated for post-herpetic neuralgia, diabetic

neuropathyneuropathy

AntispasmodicsAntispasmodics

Flexeril (Cyclobenzaprine): central acting, Flexeril (Cyclobenzaprine): central acting, unknown mechanism, anticholinergic side unknown mechanism, anticholinergic side effectseffects

baclofen: central acting, drowsiness, baclofen: central acting, drowsiness, confusion, seizures with abrupt withdrawalconfusion, seizures with abrupt withdrawal

parafon forte: central acting, GI upset, parafon forte: central acting, GI upset, drowsinessdrowsiness

Muscle RelaxantsMuscle Relaxants

Robaxane: central acting, drowsiness, Robaxane: central acting, drowsiness, dizziness, GI upset, blurred vision, dizziness, GI upset, blurred vision, headacheheadache

Skelaxin (Metaxalone): central acting Skelaxin (Metaxalone): central acting leukopenia, hemolytic anemia, dizziness leukopenia, hemolytic anemia, dizziness

SOMA: addictive, dizziness, nauseaSOMA: addictive, dizziness, nausea Tizanidine: alpha adrenergic agonist, Tizanidine: alpha adrenergic agonist,

anticholinergic, fatigue, urinary retention anticholinergic, fatigue, urinary retention

Psycho-stimulantsPsycho-stimulants

Serotonin and noradrenergicSerotonin and noradrenergic potentiate opioidspotentiate opioids powerful mood stabilizerpowerful mood stabilizer improves appetite when wastingimproves appetite when wasting improves sedationimproves sedation dose in am and noon onlydose in am and noon only

TopicalTopical

Lidoderm patch (Lidocaine)Lidoderm patch (Lidocaine) CapsaicinCapsaicin Ketomine topical (compound pharm)Ketomine topical (compound pharm) Flector Patch (diclofenac)Flector Patch (diclofenac) Voltaren Gel (diclofenac)Voltaren Gel (diclofenac)

Drug Abuse and OpioidsDrug Abuse and Opioids

Not as common in the elderlyNot as common in the elderly Place patient in a drug agreementPlace patient in a drug agreement

– monthly visitmonthly visit– one pharmacy onlyone pharmacy only– can not use, sell, trade drugscan not use, sell, trade drugs– take as specified - no renewalstake as specified - no renewals

Detox when appropriate - not when sickDetox when appropriate - not when sick Treat other symptoms: depressionTreat other symptoms: depression