Roland F. Chalifoux Jr.,DO

2019 UNECOM Fall CME Program

October 12, 2019

1) Nothing to Disclose regarding Financial affiliations or ties to Industry

(1) IMPROVE QUALITY OF LIFE

(2) REDUCE SUFFERING

OF PATIENTS

WITH ACUTE

& CHRONIC PAIN

&

PAIN SCALE

Martha Jefferson Hospital

PAIN IS NOT AN OPIATE

DEFICIENCY

PAIN

Pain is a symptom of disease and is self limited. Last < 3 months

1. Provoked by a) noxious stimulation

b) tissue injury

c) abnormal functioning of somatic structures

(in emotional, psychological, and autonomic

responses, responses are secondary).

2. Has a biologic function

a) alerting, warning

b) resting, healing

Peripheral Nociceptor

Dorsal root ganglion

Dorsal horn of spinal cord

Spinal thalamic tract

Brain and limbic system

Back down

Ouch!Anatomy

Cortex

DescendingModulation(DLF)

LimbicSystem

AscendingSpinal thalamic

tract

Thalamus

Mid Brain

Medulla

DRGPrimaryafferentNociceptor

© 1998 HVC

Pain, itself, is the disease. It persists beyond the usual course of acute disease.

1. Provoked by

a) chronic pathological process

b) dysfunction of CNS c) psychological and learned environmental factorsd) autonomic and neural endocrine responses may

be absente) a vegetative state may emerge

2. Chronic pain never has a biological function

1) It’s its own Specialty2) Need a specialist with combined expertise of

Anatomy, Physiology, and Pharmacology3) Minimize delay in proper Identification &

Treatment of the Painful Condition(s)4) Minimize potential risk for Addiction by

utilizing:a) NSAIDS

b) Neuropathic Agentsc) Antidepressants

d) Opioids

-Affects 100 million Americans every year

-More than Diabetes, Heart disease, Stroke, and Cancer combined

-Patient centered, individualized, multidisciplinary

- Integrated care is the best approach

- Places an overwhelming emotional, physical, and financial burden on patients and their families

- Can be linked to $600 billion in health care costs, rehabilitation, and lost productivity

Pain is crosspecialty The most common routine

complaint in a primary care setting

90 % of all medical illness has pain as chief complaint

Mismanagement at any level is costly and associated with a high level morbidity

Early diagnosis is cost effective and enhances outcome

Pain is a symptom and not a disease

There is rarely one pain generator

For pain to be a disease, a diagnosis is necessary

Therefore chronic pain when appropriately diagnosed IS A DISEASE

IPM is a powerful tool to define a diagnosis

To comply with federal and state laws, a prescription for a controlled substance must be issued:

for a legitimate medical purpose

by an individual practitioner

acting in the usual course of professional practice

Source: Controlled Substances Act [21 USC 829; 21 C.F.R. 1306.04(a)]

1) No Schedule V. In West Virginia Gabapentin is a Scheduled V

2) Chronic Pain patients can have up to 100 MED/day

3) PDMP required at initial each visit and every 90 days thereof

4) Controls need to be sent electronically

5) 3 hours CME every 2 years

6) Chronic Pain- 30 days

7) Acute Pain- 7 days

Schedule 1 - no legitimate medical use Heroin

Schedule 2 (CII) - high risk of abuse Written Rx only, no refills Oxycodone, Morphine, Hydrocodone, Dilaudid

Schedule 3 (CIII) - intermediate risk of abuse Telephone, up to 6 refills Valium, Xanax, codeine

Schedule 4 (CIV) - lower risk of abuse Fioricet, Soma

Schedule 5 (CV) – low but still risk of abuseGabapentin in West Virginia

Prescribing principles

Drug selection

Dosing to optimize effects

Treating side effects

Managing the poorly responsive patient

Analgesia. Respiratorydepression, miosis,decreased gastricmotility, euphoria. Noceiling effectfor analgesia.

μ

Spinal analgesia,miosis, sedation.Ceiling effectfor analgesia.

k

Respiratorydepression,analgesia.

δ

Hallucination, confusion,stimulation of respiratoryand vasomotor centers.

σ

1. Hardman JG, Limbird LE, Molinoff PE, Ruddon RW, Gilman AG, eds. Goodman and Gilman's The Pharmacological Basis of Therapeutics. 9th ed.New York, NY: McGraw-Hill Book Companies, Inc; 1996:523-527.

HydrocodoneHydromorphoneCodeineBuprenorphine (Patch)Buprenorphine (Film)Fentanyl PatchMethadoneOxycodoneOxycontinOxymorphoneTramadol (Tramadol)MS ContinTapentadol (Nucynta)

XanaxValiumAtivanKlonopin

RATIO1X4X.15X2X10X7X4X1.5X1.5X3X

.1X1X

.4X

½ Life5 HRS2 HRS3 HRS37 HRS37 HRS25 HRS23 HRS3.0 HRS4.5 HRS8 HRS8HRS20HRS8 HRS

12 HRS60 HRS12 HRS30 HRS

BENZODIAZEPINES

10 mg Hydrocodone (Vicodin) 4X/day = 40 MED Morphine

10 mg Oxycodone (Percocet) 4X/day =60 MED Morphine

2mg Hydromorphone(Dilaudid)4X/day=32 MED Morphine

50 mg Tramadol 4x/day = 20 MED Morphine

Immediate-release preparations Used mainly

For acute pain

For dose finding during initial treatment of chronic pain

For “rescue” dosing

Can be used for long-term management in select patients

Extended-release preparations (ER)

Preferred because of improved treatment adherence and the likelihood of reduced risk in those with addictive disease

Ex: Morphine, Oxycodone, Fentanyl, Buprenorphine, Methadone

Adjust dose q 2–3 d

Meperidine

Poor absorption and toxic metabolite

Propoxyphene

Poor efficacy and toxic metabolite

Mixed agonist-antagonists (pentazocine, butorphanol, nalbuphine, dezocine)

Compete with agonists withdrawal

Analgesic ceiling effect

Produce psychotomimetic effects

Oral and Transdermal—preferred

Oral transmucosal—available for Fentanyl and used for breakthrough pain

Rectal route—limited use

Parenteral—SQ and IV preferred and feasible for long-term therapy

Intraspinal—intrathecal over epidural generally preferred for long-term use

Many of the side effects, as well as the effects, of opioids come from their metabolites

Primarily liver for metabolism Glucuronidation

CYP450 About 30 different isoenzymes

CYP3A4 is the most abundant but wide variability

6-10% Caucasians are CYP2D6 deficient

Renal for excretion

Consider carefully in providing controlled substances:

Continued opioid prescription requires monitoring of “the 4 As”:

Analgesia

Activity

Aberrant behavior

Adverse effect

Urine Drug Screening

Specific drug analysis (blood)

Hair Samples

Saliva Testing

9 Panel One Step iCup -(COC,THC,OPI,AMP,METH,PCP,BZO,BAR,MTD)The iCup Drug Screen Cup is the simplest, self-contained on-step drug test. Results are visible within minutes. A positive result is indicated with one line and a negative result with two. An additional bonus with the iCup is that you may photocopy the results allowing you to maintain a visual record of the test.iCup offers a completely closed system for total urine specimen integrity and easy collection. The clear construction gives optimum observation of urine specimen. The iCup drug screen kit is a single unit with no dipping or pouring. Test results develop quickly in the sealed unit. The system remains closed until disposal of the device. The iCup drug screen is zero exposure, leak-proof and tamper-proof.FDA Approved, 99% Accurate, Set to the SAMSHA Cut-off levels, Results are Ready in Minutes

Source: E.J. Cone, Addiction Research Center

DURATION FOR A POSITIVE SCREEN

•AMPHETAMINE 2-4 DAYS•METHAMPHETAMINE 2-4 DAYS•BARBITURATE 2- 30 DAYS•BENZODIAZEPINE UP TO 30 DAYS•COCAINE 1-3 DAYS•HEROIN/MORPHINE 1-3 DAYS•MARIJUANA CHRONIC - 30- 70 DAYS

OCCASIONAL- 1-3 DAYS•METHADONE A LONG TIME 2-4 DAYS,

MAYBE LONGER (150 HOURS)•PCP 2-7 DAYS OCCASIONAL USE

CHRONIC UP TO 30 DAYS

CHRONIC USE

IMPAIRED CONTROL

COMPULSIVE USE

CONTINUED USE DESPITE HARM

CRAVING

- Not responsive to traditional program of P.T., medications after 3 months

- Imaging is questionable, i.e., Lumbar or Cervical disc bulge but no Radiculopathy

- Spondylosis of the Spine, DJD of the Spine/Knee/Hands/Hips

- If Specialist Referral consult states “Non-Surgical”

- If Specialist states “Nothing I can do”

- Don’t delay referral!

- As in everything in life, the sooner the problem is addressed, the better the outcome for the patient!

- If a patient in “ACUTE” pain is not responding and you want a “quick” consult before modifying your treatment plan

-If you get a patient with “Chronic” pain and you need to stratify and prioritize their painful condition(s)

Diabetic Neuropathy with severe “Pins and Needles” foot pain

Patients with “Spinal Stenosis” and Neurogenic Claudication

Severe or progressive restriction of their neck or back motion

Severe or progressive pain in their shoulders, hips, knees, ankle, foot, wrist.

Severe or progressive phantom limb or post amputation pain

- Titrate Opioids based on patient pathology

- Recommend specific therapeutic “procedures” depending on the age, severity of symptoms, pathology.

- Help identify “malingerers”

-Facet Injections -Facet Rf Ablations (Destroying Sensory Nerves) -Epidurals Cervical-Lumbar -Shoulder Injections (Cortisone & PRP) -Suprascapular Injections and RfA -Stellate Ganglion blocks (RSD and CRPS) -Elbow and Carpal Tunnel Injections -Wrist injection -Hip Injections (Cortisone & PRP) -Knee Injections (Cortisone, Visco-

supplementation, PRP, and Geniculate injection/ Geniculate nerve RfA)

- Treat Meralgia Paresthetica

- Peripheral Nerve entrapment

- Post Surgical Pain

- Arachnoiditis

- Fibromyalgia

- MVA/ Worker’s Compensation

- Ischemic Neuropathic Pain

- Pain Pumps for Intractable Pain

- Spinal Cord Stimulation for Failed Back Pain, Severe Diabetic Neuropathy

Confidential. For Internal Use Only. Do Not Distribute.

▪ INVISIBLE SYSTEMS

▪ LESS PAIN

▪ LESS SUFFERING

▪ LESS MAINTENANCE

▪ HARD-TO-TREAT FOCAL PAIN

2016 – The most significant therapy advancements in 50 years of

Neuromodulation

*BurstDR™ stimulation, patented technology exclusively from St. Jude Medical, is also referred to as Burst stimulation in clinical literature.†Pain and suffering as measured by VAS.

45

Confidential. For Internal Use Only. Do Not Distribute.

▪ DISCREET, INVISIBLE TRIAL

▪ RECHARGE-FREE IMPLANTS

▪ APPLE PROGRAMMERS

▪ BURSTDR PARESTHESIA-FREE THERAPY

Get Rid of the Pain

*BurstDR™ stimulation, patented technology exclusively from St. Jude Medical, is also referred to as Burst stimulation in clinical literature.†Pain and suffering as measured by VAS.

46

NEW WAY OF THINKINGGet Rid of the Pain

Get Rid of the Suffering (directly and indirectly)

Get Rid of the Burden of the System

▪ Imaging studies have shown that chronic

pain is associated with changes in the

brain:

▪ Patients with chronic back pain have

significantly less gray matter volume than

control patients1,2 – mainly in the brainstem

and somatosensory cortex2

▪ CRPS patients exhibit regional gray matter

atrophy, localized white matter anisotropy,

and changes in branching in connectivity of

white matter tracts3

47

Chronic pain results in altered behaviors

Sensory (e.g. spontaneous pain at rest)

Affective (e.g. anxiety, depression, suicide, addiction)

Cognitive (e.g. decreased attention)

Emotional (e.g. reward deficit state)Image adapted from Boorsook D. Cerebrum 2012.1. Apkarian AV, et al. J Neuroscience 2004.

2. Schmidt-Wilcke T, et al. Pain 2006.

3. Geha PY, et al. Neuron 2008.

Altered brain

chemistry

Decrease in gray

matter volume Altered brain

network connectivity

Structural changes

in nerve tracts

Confidential. For Internal Use Only. Do Not Distribute.

• Proven in PET, EEG, fMRI studiesfMRI – functional MRI- measures brain activity by detecting changes in blood flow

*BurstDR™ stimulation, patented technology exclusively from St. Jude Medical, is also referred to as Burst stimulation in clinical literature.†Pain and suffering as measured by VAS.

48

Some neurons fire in a tonic or

continuous manner

49 1. Oswald AM, et al. J Neurosci. 2004.

▪ Both burst & tonic firing neurons may be parallel firing modes within the same sensory system1

▪ Composition of burst & tonic firing neurons varies in the pain pathway thereby creating a need for tailored therapy

Other neurons fire in groups of action potentials (bursts)

followed by periods of dormancy

Other neurons fire in groups of action potentials (bursts) followed by

periods of dormancy (Quiescent)

Some neurons fire in a tonic or continuous manner

▪ There is a non-linear response to burst signals in the cortex

▪ Burst is believed to override the tonic pain stimuli and creates a stronger signal in

cortex than tonic signals

Sherman SM. Nature Neuroscience. 2001.

Visual ResponseBurst Visual

Response

Tonic Visual

Response

51

The DRG’s unique pain processing capabilities and physiological considerations make it an ideal

target to isolate treatment to primary areas of pain3

SPECIFIC

▪ Pain cells in DRG allow for activation without recruiting

non-painful neurons4

PREDICTABLE

▪ The DRG itself is a robust structure with a predictable

intraforaminal location.3

EFFICIENT

▪ Minimal CSF fluid and lower firing threshold of DRG

neurons allow amplitudes set at the Micro-Amp level.5

This Photo by Unknown Author is licensed under CC BY-NC-ND

DiagnosisEstablish Therapy Goals

Oral MedicationsActive Physical Rehabilitation

Psychological Therapy

Corrective Surgery

Therapeutic Nerve Blocks

Oral Opiates

Advanced Pain Therapies

Neurostim Pain Therapy

Intrathecal Pain Therapy

Neuroablation