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 consuming Frustrated

Angry Nervous Agitated Scared

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 Foundationwww.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/14567202Gordon, 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

BibliographyBorrie, 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