Chronic pain
Dec 24, 2015
Chronic pain
www.Thepracticalnursepractitioner.comT
and other statements to address in primary care pain management.
“My whole body aches.”
“What do you mean my MRI is negative?
My back still hurts!
Annemarie M. Kallenbach
RN CNPNo Disclosures
docakilah.wordpress.com
Overview
Fibromyalgia and chronic back pain are two time consuming and frustrating diagnoses seen frequently in clinical practice
Choosing to treat or transferring care to a consultant or specialist has benefits and drawbacks.
Understanding the use of pain contracts /partner agreements and frequent intervals of visits will improve outcomes.
Overview
Chronic low back pain and fibromyalgia share two clinical features. The visits are not quick The visits are not easy.
Overview
Implementing a consistent algorithm that incorporates current recommendations in today’s busy clinic will yield improved results in patient care.
Overview
Chronic pain must to be addressed in a multi directive model.
A clear, practical chart checklist will keep treatment plan on course.
Pain response
Personal experience Labor Stubbing toe on chair leg Burning shoulder pain from too much
time on computer
Provider Response
Jot down 5 honest reactions to seeing back pain-recurrent, fibromyalgia follow up on your schedule.
Provider reactions
Time consumingFrustrated
AngryNervousAgitatedScared
Skeptical
Provider reactions
Excited for the challenge.
Ready to try a multiple facet approach to treatment.
Armed with excellent resources.
Provider reactions
Frustrated Angry Nervous Agitated Scared Skeptical
Excited for the challenge
Ready to try a multiple approach to treatment
Armed with excellent resources
Bring it on!!
Patient questions to ponder
Does you patient have chronic pain? Has a complete workup been done in
the past? Labs, diagnostics
Patient questions to ponder
Has your patient been screened for mental health problems?
Does your patient have a diagnosis of mental health problems?
Is it the correct diagnosis? Is the patient adequately treated for
mental health (pharmacologic agents, talk therapy, support groups, behavior modification)
Patient questions to ponder
Do you believe you can have an honest patient provider relationship?
Kid, you’re asking the wrong guy.
Patient questions to ponder
Does your patient have the ability to go to a chiropractor, PT, massage therapist, acupuncturist, etc?
Patient questions to ponder
Is your patient already on routine opiods?
Is your patient willing to partner to reduce/eliminate ineffective opiods?
Do you have time and interest in treating?
Do you have knowledge to treat?
Provider questions/beliefs
Wasssup?
Can you prescribe narcotics? What classes of narcotics? Long acting narcotics, including Methodone?
Do you have knowledge regarding medical marijuana?
Do you understand parameters for prescribing opioids?
Provider questions/beliefs
Do you have relationships with local pharmacists?
Provider questions/beliefs
Do you have the ability to drug screen your patient?
Provider questions/beliefs
What? I was thiiiirrrsty
State level questions
Does your state have medical marijuana?
Does your state have a narcotic prescription reporting mechanism?
https://sso.state.mi.us
Elements of a Pain History
Taking a Pain History• Location• Radiation• Onset: sudden or insidious• Duration• Frequency: continuousor intermittent• Description• Intensity• Alleviating factors• Exacerbating factors
Chronic pain site
Lumbar
Knee
Neck
Shoulder
Total body
Current (Previous) Medication Regimen
Anti inflamatory Elavil/Pamelor Neurontin Lyrica Antidepressent SSRI SNRI Mood stabilizer Anxiolytic Opiod Tramadol Sleep agent SUBOXONE, METHADONE
Diagnostic work up
Was it complete?Exam findings
X-rayMRIConsult notes
Referrals
Orthopedic Pain management Neurosurgeon Injection therapy Psychologist
Physical therapy,Chiropractic care, massage therapy, Accupuncture
Dates Goals Patient’s adherence to sessions and
to home exercises Trial of TENS
Additive disorder
Tobacco smoker Drug dependence Alcoholic
Collaboration
Partner agreement Pain contract signed
American Pain Foundation
Treatment Options:A Guide for People Living with Pain
American Pain Foundation
Dedicated to eliminating the under treatment of pain in America.
American Pain Foundation
www.painknowledge.org/opioidtoolkit/docs/Treatment%20Options.pdf
American Pain FoundationThe following organizations are represented by those who helpedcreate this publication:
American Academy of Pain ManagementAmerican Academy of Pain MedicineAmerican Alliance of Cancer Pain InitiativesAmerican Board of Hospice and Palliative MedicineAmerican Holistic Nursing AssociationAmerican Pain SocietyAmerican Society for Pain Management NursingAmerican Society of Regional AnesthesiologistsAssociation of Oncology Social WorkHealing Touch InternationalIntercultural Cancer CouncilInternational Association for the Study of PainMidwest Nursing Research SocietyNational Association of Social WorkersOncology Nursing Society
Keep the following tips in mind as you seek treatment for your pain:• Chronic pain can result in physical and psychological challenges. It is important to accept support from loved ones—you need and deserve all the help you can get.• Be sure to seek treatment as early as possible to avoid further problems.• Do not allow your physical illness or pain to take over your life. Pain is a part ofyou, but it should not define who you are.• Try not to let past frustrations of failed treatments stand in your way; there are a wide range of treatments available as detailed in this guide. While your pain might not go away completely, there are ways to reduce it so that it is bearable and you can reclaim parts of your life.
HELPFUL HINTS ON YOUR ROAD TO PAIN RELIEF
Keep the following tips in mind as you seek treatment for your pain:• Chronic pain can result in physical and psychological challenges. It is important to accept support from loved ones—you need and deserve all the help you can get.• Be sure to seek treatment as early as possible to avoid further problems.• Do not allow your physical illness or pain to take over your life. Pain is a part ofyou, but it should not define who you are.• Try not to let past frustrations of failed treatments stand in your way; there are a wide range of treatments available as detailed in this guide. While your pain might not go away completely, there are ways to reduce it so that it is bearable and you can reclaim parts of your life.
HELPFUL HINTS ON YOUR ROAD TO PAIN RELIEF
COMMON FEATURES OF AN OPIOID AGREEMENT
•Sign an opioid agreement to be kept in your medical file (ask for your own copy)•Obtain prescriptions from only one doctor•Have your prescriptions filled at one pharmacy•Come in for regular office visits (every 2-4 weeks or so)•Agree to have periodic urine drug screening•Bring your pills in to be counted during visits• Follow any additional rules not listed abovehttp://www.painknowledge.org/opioidtoolkit/docs/Treatment%20Options.pdf
Additive disorder
Tobacco smoker Drug dependence Alcoholic
Disability issues
In process
Resolved
Mental health
Concern for metal illness Past history of mental illness Family history of mental illness Bipolar depression Yes/No
Treated satisfactorily Yes/No Depression Yes/No Treated satisfactorily Yes/No
Disability issues
In process
Resolved
Stable on current program
Mental health Addictive disorder Chronic pain
NOT!
Dad left when he found out about Mom and Panda.
Screening for depression and bipolar disease
Depression screen Becks inventory PHQ-9
Bipolar screen – Mood disorder questionnaire (MDQ)
Beck’s Inventory
http://www.fehb.org/CSE/CCSEConference2012/BeckDepressionInventory.pdf
http://www.nhlbi.nih.gov/meetings/workshops/depression/instruments.htm
PHQ-9
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495268/
Mood disorder questionnaire
www.ncbi.nlm.nih.gov/pubmed/12505821
Referral to psychiatrist
EVIDENCE – Know it!
Early MRI
The rate of lumbar spine magnetic resonance imaging in the USis growing at an alarming rate.
Evidence that it is not accompanied by improved patient outcomes.
Overutilization correlates with, and likely contributes to, a 2- to 3-fold increase in surgical rates over the last 10 years.
Knowledge of imaging abnormalities can actually decrease self-perception of health and may lead to fear-avoidance and catastrophizing behaviors that may predispose people to chronicity.
LEVEL OF EVIDENCE: Diagnosis/prognosis/therapy, level 5.Flynn TW, Smith B, Chou R. Appropriate use of diagnostic imaging in
low back pain: a reminder that unnecessary imaging may do as much harm as good. J Orthop Sports Phys Ther. 2011 Nov;41(11):838-46. Epub 2011 Jun 3.
Reason’s to do MRI
Suspect cauda equinaLonger pain than 6-12 weeks
Patient is amenable to injection therapy
Directed care to PT
Ya gonna get a snot bath!!
Referall to pain psychotherapist
Pain management 4 legs of treatment w/ psychologist
Borrie, RA. (2001). Thinking About Pain Psychologically based pain management can provide relief for pain patients. http://www.practicalpainmanagement.com/treatments/psychological/thinking-about-pain
Got MILK? Nope.
Clinical guidelines NSAIDs, acetaminophen, skeletal muscle relaxants (for acute low
back pain), and tricyclic antidepressants (for chronic low back pain) are effective for pain relief.
Opioids, tramadol, benzodiazepines, and gabapentin (for radiculopathy) are effective for pain relief.
Systemic corticosteroids are ineffective . Adverse events, such as sedation, varied by medication, although
reliable data on serious and long-term harms are sparse. Most trials were short term (< or =4 weeks). Few data address efficacy of dual-medication therapy compared with
monotherapy, or beneficial effects on functional outcomes.
Chou R, Huffman LH; American Pain Society; American College of Physicians. (2007). Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007 Oct 2;147(7):505-14.
Selected Nonpharmacologic Treatment Options from Practice Guidelines
Osteoarthritis(AC R 2000)• Self-management programs• Weight loss• Aerobic exercise• Range-of-motion exercises• Muscle-strengthening
exercises• Assistive devices• Occupational/physical
therapy• Joint protection/energy
conservation
Low Back Pain(Chou 2007) Acupressure/acupuncture• Functional restoration• Interdisciplinary rehabilitation• Interferential therapy• Massage• Transcutaneous/percutaneouselectrical nerve stimulation• Spinal manipulation
Invasive interventions
Sciatica or prolapsed lumbar disc with radiculopathy (level of evidence)
Chemonucleolysis is moderately superior to placebo injection but inferior to surgery. (good)
Epidural steroid injection is moderately effective for short-term (but not long-term) symptom relief. (fair)
Spinal cord stimulation is moderately effective for failed back surgery syndrome with persistent radiculopathy, though device-related complications are common. (fair)
Prolotherapy, facet joint injection, intradiscal steroid injection, and percutaneous intradiscal radiofrequency thermocoagulation are not effective. (good)
Insufficient evidence exists to reliably evaluate other interventional therapies.
Chou R, Atlas SJ, Stanos SP, Rosenquist RW.Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine (Phila Pa 1976). 2009 May 1;34(10):1078-93
Case studies
Arthritis on NSAIDS and HS opioids
Methadone endometriosis
High dose narcotics for chronic low back pain
Overview of some of the more commonly
used nonopioid and ajuvant analgesics.
used to treat chronic pain, including salicylates, acetaminophen, nonsteroidal anti-inflammatory drugs, tricyclic antidepressants, anticonvulsants, N-Methyl-D-Aspartate receptor antagonists, lidocaine, skeletal muscle relaxants, and topical analgesics.
http://www.ncbi.nlm.nih.gov/pubmed/14567202
Gordon, DB, (2003). Nonopioid and adjuvant analgesics in chronic pain management: strategies for effective use. HYPERLINK North Am. 2003 Sep;38(3):447-64,vi.
http://www.ncbi.nlm.nih.gov/pubmed/21176430
Mease, PJ. (2009). Further strategies for treating fibromyalgia: the role of serotonin and norepinephrine reuptake inhibitors. Am J Med. Dec;122(12 Suppl):S44-55
Franco M, Iannuccelli C, Atzeni F, Cazzola M, Salaffi F, Valesini G, Sarzi-Puttini P. Pharmacological treatment of fibromyalgia. Clin Exp Rheumatol. 2010 Nov-Dec;28(6 Suppl 63):S110-6. Epub 2010.
11/18 painful tender points Multimodal pharmacological treatment also combined with non-
pharmacological therapy. Only three drugs (duloxetine, milnacipram, pregabalin) are approved
by the American Food and Drug Administration (FDA) and none by the European Medicines Agency (EMEA
Most of the drugs improve only one or two symptoms; no drug capable of overall symptom control is yet available.
Tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), opioids, non-steroidal anti-inflammatory drugs (NSAIDs), growth hormone, corticosteroids and sedative hypnotics.
As no single drug fully manages FM symptoms, multicomponent therapy should be used from the beginning.
Gradually increasing low doses is suggested in order to maximize efficacy.
The best treatment should be individualized and combined with patient education and non-pharmacological therapy.
CME: Help Your Patients Break Free Assessing and Managing Chronic Pain in Primary Care: Applying Evidence to Practice
http://www.omniaeducation.com/emails/2012images/echo_pain/ECHO_Pain_web.pdf?utm_source=Omnia+Education&utm_campaign=43b013690c-Pain_Echo1_4_2012&utm_medium=email
CME
Bibliography
Borrie, RA. (2001). Thinking About Pain Psychologically based pain management can provide relief for pain patients. http://www.practicalpainmanagement.com/treatments/psychological/thinking-about-pain
Chou R, Qaseem A, Snow V, et al; for the Clinical Efficacy Assessment Subcommittee of the American
College of Physicians and the American College of Physicians/American Pain Society Low Back Pain
Guidelines Panel. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478-491.
Chou R, Fanciullo GJ, Fine PG, et al; for the American Pain Society-American Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2):113-130.
Chou R, Atlas SJ, Stanos SP, Rosenquist RW.Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine (Phila Pa 1976). 2009 May 1;34(10):1078-93
Bibliography
Flynn TW, Smith B, Chou R. Appropriate use of diagnostic imaging in low back pain: a reminder that unnecessary imaging may do as much harm as good. J Orthop Sports Phys Ther. 2011 Nov;41(11):838-46. Epub 2011 Jun 3.
Franco M, Iannuccelli C, Atzeni F, Cazzola M, Salaffi F, Valesini G, Sarzi-Puttini P. Pharmacological treatment of fibromyalgia. Clin Exp Rheumatol. 2010 Nov-Dec;28(6 Suppl 63):S110-6. Epub 2010.
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Hearts - CharlemagneDiamonds - Julius Caesar. Clubs - Alexander the GreatSpades= King David