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Diagnosing & Treating Musculoskeletal Pain In Working-Aged Adults
The Importance of Identifying The Central Pain Phenotype
9/22/17
Presented By:Paul C. Coelho, MD
Salem Health
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Objectives
• 1. Become familiar with the 'central pain' phenotype and recognize that it is opioid unresponsive.
• 2. Become familiar with the Pain Catastrophizing Scale as a screening tool for the 'central pain' phenotype.
• 3. Become familiar with the 2016 Fibromyalgia Screening Questionnaire for the central pain phenotype.
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Disclosures:The presenters have no financial relationships with a commercial entity producing health care related products and/or services.
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Table of Contents
Early Pain Models
Modern Pain Models
FMS, HA, and LBP
The Central Pain Phenotype
Sample Case
Evidence-Based Treatments
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1980 Model of MSK Pain
Nociceptive NeuropathicPrimarily due to inflammation or tissue damage in the periphery
Damage or entrapment of peripheral nerves.
NSAID/Opioid Responsive Responds to both peripheral and central pharmacotherapy.
Responds to procedures. Does not respond to procedures.
Behavioral factors minor. Behavioral factors minor.
Examples: Osteoarthritis, Rheumatoid arthritis, cancer pain.
Examples: Diabetic peripheral neuropathy, post-herpetic neuralgia.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1829161/
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1990 FMS
https://www.rheumatology.org/Portals/0/Files/1990_Criteria_for_Classification_Fibro.pdf
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US Overdose Deaths1980-2014
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1829161/
0
12500
25000
37500
50000
1980 1983 1986 1989 1992 1995 1998 2001 2004 2007 2010 2013
Wolfe ACR FMS1990
FDA Approves OxyContin1995
APS Pain as a 5th Vital Sign1996
Wolfe Recants FMS2008
IOM 100M In Pain2011
Peak Incidence of Prescription OD 45-54
Portenoy Portenoy/Foley1986
Portenoy Recants2012
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Variation in Opioid Rx’ing forFMS 2007-2009
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4346177/
Peak Incidence of Prescription OD 45-54
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35% of FMS Pt’s Receive SSDI
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4151179/
Disabled Medicare Beneficiaries Rx’d Opioids
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FMS Patients Report High PainLevels In Spite of High Dosages
https://www.ncbi.nlm.nih.gov/pubmed/24310048
N = 582
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Opioids In FMS: Once StartedSeldom Stopped
https://www.ncbi.nlm.nih.gov/pubmed/26443495
N = 100K, 60% Received Opioids.
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30 Day Supply & Risk of COT
https://www.cdc.gov/mmwr/volumes/66/wr/mm6610a1.htm
20% will remain on opioids at 3yrs.
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FMS Is Not Opioid Responsive
https://www.ncbi.nlm.nih.gov/pubmed/26975749
Organization
American Pain Society
American Academy of Pain Medicine
American Academy of Neurology
European League Against Rheumatism
Canadian Pain Society
Canadian Rheumatology Association
British Pain Society
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2017 Model of MSK PainNociceptive Neuropathic Central
Primarily due to inflammation or tissue damage in the periphery
Damage or entrapment of peripheral nerves.
Primarily due to a central disturbance in pain processing.
NSAID/Opioid Responsive Responds to both peripheral and central pharmacotherapy.
Tricyclic neuro-active compounds. Opioid unresponsive.
Responds to procedures. Does not respond to procedures.
Does not respond to procedures.
Behavioral factors minor. Behavioral factors minor. Behavioral Factors Prominent.
Examples: Osteoarthritis, Rheumatoid arthritis, cancer pain.
Examples: Diabetic peripheral neuropathy, post-herpetic neuralgia.
Examples: FMS, cLBP, cHA, IBS.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1829161/
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Comorbid Pain in FMS is the Norm
https://www.ncbi.nlm.nih.gov/pubmed/22364327
Low Back Pain
“Overwhelming evidence reveals that what isoften labeled as a single chronic regional painsyndrome is, upon closer evaluation, a chronicillness beginning much earlier in life, where thepain merely occurs at different points of the bodyat different points in time and is given different labels by subspecialists focusing on “their region” of the body.”
Daniel Clauw, MD
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Prevalence of LBP & HA in FMS
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1829161/
2007 Internet Survey of 2596 FMS Pts
Ave Age = 47If due to chance aloneLBP .3 x .05 =1.5% HA: .2 x .05 =1%
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Prevalence of FMS in cLBP 42%
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1829161/
Chance Alone: .3 x .05 = 1.5%
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Prevalence of FMS in Migraineurs 56%
Chance Alone:.2 x .05 += 1%
https://www.ncbi.nlm.nih.gov/pubmed/25994041
N = 1,730
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Head Ache & LBP Predict FMS
https://www.ncbi.nlm.nih.gov/pubmed/26772544
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Comorbid Pain in FMS is the Norm
https://www.ncbi.nlm.nih.gov/pubmed/22364327
Fibromyalgia
Low Back Pain
Fibromyalgia Fibromyalgia
Head AcheLow Back Pain
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Central Sensitivity Spectrum Disorders
https://www.ncbi.nlm.nih.gov/pubmed/17350675
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Overlapping Chronic Pain Conditions
https://www.ncbi.nlm.nih.gov/pubmed/27586833
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Prescribers are Poor at DiagnosingCentral Pain Syndromes
https://www.ncbi.nlm.nih.gov/pubmed/23071343
23% Sensitivity
N = 312, 240 FMS+
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Prescribers are Poor at DiagnosingCentral Pain Syndromes
https://www.ncbi.nlm.nih.gov/pubmed/23071343
27% Specificity
N = 4M
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Prescribers are Poor at DiagnosingCentral Pain Syndromes
https://www.ncbi.nlm.nih.gov/pubmed/20461781
“You cannot guess at the extent of fatigue, unrefreshed sleep, cognitive problems, multiplicity of symptoms, and extent of pain without a detailed interview. The new criteria obligate you to pay careful attention to the patient if you want to diagnose fibromyalgia.”
Fredrick Wolfe
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Diagnosing Central Sensitivity Spectrum Disorders
https://www.ncbi.nlm.nih.gov/pubmed/26266995
1. Pain in many body regions. 2. Higher current and lifetime history of chronic pain in several
body regions.3. Multiple somatic symptoms (e.g., fatigue, memory difficulties,
sleep problems, mood disturbance)4. Negative Affect, dispositional pessimism, pain catastrophizing.5. More sensitive to other sensory stimuli (e.g., bright light, loud noises,
odors, other sensations in internal organs)6. 1.5 to 2x more common in women.7. Strong family history of chronic pain.8. High self-reported pain & distress (VAS/NPS/PSD/PCS)9. Pain triggered or exacerbated by stressors.10. Peak prevalence of FMS age 30-59 (working-age).*11. Essentially normal physical examination +/- diffuse tenderness.
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2016 FMS Survey Questionnaire96% Sensitivity, 92% Specificity
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Pain Catastrophizing ScaleModerate Risk 20-29
High Risk > 30
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Elevated PCS Predicts Abuse
https://www.ncbi.nlm.nih.gov/pubmed/23618767
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Elevated PCS Predicts Abuse
https://www.ncbi.nlm.nih.gov/pubmed/24612286
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Elevated PCS Predicts Abuse
https://www.ncbi.nlm.nih.gov/pubmed/23809983
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Why Is Dx’ing FMS/CSS Important?
https://www.ncbi.nlm.nih.gov/pubmed/26266995
1. It is opioid unresponsive.2. Prognosis: It does not improve with time.3. When present amid other CNP conditions – HA, LBP,
etc. – it is likely to be the primary source of morbidity.
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FMS Is Opioid Unresponsive
https://www.ncbi.nlm.nih.gov/pubmed/26975749
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Natural Hx of FMS
https://www.ncbi.nlm.nih.gov/pubmed/21765102
N = 1,55511yr f/u
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Natural Hx of FMS
https://www.ncbi.nlm.nih.gov/pubmed/28077978
N = 762yr f/u
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FMS is the Primary Source of Morbidity in Mixed Pain States
https://www.ncbi.nlm.nih.gov/pubmed/27049402
N = 383, 76 FMS+
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FMS is the Primary Source of Morbidity in Mixed-Pain States
https://www.ncbi.nlm.nih.gov/pubmed/28182837
N = 156, 25 FMS+
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Sample Case
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Joyce
Joyce is a 45y/o woman who recently moved from CA to Douglas, County to retire. Her past medical history is significant for a work related back injury for which she was medically retired. She now receives SSD and seeks to establish care with you for primary care needs as well as pain management. Her medication regimen consists of Lisinopril for HTN. She is requesting “Percocet” for pain.
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>13 = FMS
7
10
17
Joyce
>13 = FMS
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Joyce
>30 Abnl
443
44
3
43
344
44
48/52
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Evidence-Based Treatments of FMS
https://www.ncbi.nlm.nih.gov/pubmed/28077978
Treatment Evidence Level
Patient Education 1A
Graded Exercise 1A
CBT 1A
Tricyclics 1A
SNRI’s 1A
Gabapentenoids 1A
NSAIDS 5D
Opioids 5D
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Centralized Pain Pt Handout
https://www.painscience.com/articles/central-sensitization.php
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Evidence-Based Treatments for FMS
https://www.youtube.com/watch?v=pgCfkA9RLrM
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Evidence-Based Treatments for FMS
https://fibroguide.med.umich.edu/
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Evidence-Based Treatments for Pain Catastrophizing
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Resources
Fibromyalgia Screening Questionnairehttp://www.slideshare.net/101N/pcp-pain-screening-tool
Evidence-Based Treatments for FMS, Dr. Clauw JAMAhttp://www.slideshare.net/101N/fibromyalgia-clinical-review
Daniel Clauw, MD Youtube Video for patientshttps://www.youtube.com/watch?v=pgCfkA9RLrM&t=6s
Sample Centralized Pain Patient Handouthttp://www.slideshare.net/101N/central-sensitization-70569194
List of non-opioid alternatives for chronic non-cancer painhttp://www.slideshare.net/101N/nonopioid-alternatives-for-chronic-noncancer-pain