the five pillars of chronic pain: a rational approach to ... · 76% of past-year suicide attempts...
TRANSCRIPT
The Five Pillars of Chronic Pain:A Rational Approach to Pain Recovery
Andrew J Smith, MDCM
Staff Physician, Pain and Addiction Medicine
Medical Lead, Interprofessional Pain and Addiction Recovery Clinic
Addiction Medicine Service
Centre for Addiction and Mental Health
Toronto Academic Pain Medicine Institute
Faculty/Presenter Disclosure
Faculty: Andrew J Smith, MDCM
Relationships with commercial interests:
None to report
The Five Pillars of Chronic Pain:Learning Objectives
By the end of this session, participants will be able to:
1. To learn a comprehensive approach to managing chronic pain and risk
2. To understand the burden of chronic pain in our society
3. To differentiate between neuropathic and nociceptive pain
35 yo woman with chronic migraine and facial pain taking opioids and running out early.
• Kicked in head by horse 5 years ago --> brief loss of consciousness; L lancinating facial pain and headaches
• Assaulted by ex-partner 2 years ago bilateral jaw pain; bilateral lancinating facial pain; vertigo, nausea, “drop attacks”; ”space-out spells”; other “migraine” headaches photophobia; eye pain
• Dx with Trigeminal neuralgia; Rx gabapentin (effective); Morphine 10mg IR prn started 2 years ago to facilitate participation in therapy
• Currently taking 25mg tabs: 4 tabs po q4 hr (16-20 tabs per day). Runs out early. Then uses T1s.
• Naproxen 500mg BID daily
• Cannabis 8 g /day ... Alcohol – 10-12 SD on bad headache days (1 year ago: 1 day q2 weeks; now 3 days per week)
What Is Pain? IASP (1986): an unpleasant sensory and emotional experience associated with
actual or potential tissue damage
Acute pain is a vital, protective mechanism that permits us to live in an environment fraught with potential dangers
In contrast, chronic pain serves no such physiologic role and is itself not a symptom, but a disease state
Chronic = pain which lasts beyond the ordinary duration of time that an insult or injury to the body needs to heal Beyond 3-6 months in duration
IASP- International Association for the Study of Pain
Chronic Pain is Common
Prevalence of chronic pain in the adult population may be 20-25% Of which ~50% experience moderate
and 14% experience severe chronic pain daily or most days of the week
Most common reason for visit to family physician (~ 20-25%)
• Opioids have long been used to
manage pain, especially in acute
and palliative contextsSchopflocher, D., Taenzer, P., & Jovey, R. (2011). The prevalence of chronic pain in Canada. Pain Research & Management, 16(6), 445-450.
Steingrimsdottir, O. A., Landmark, T., Macfarlane, G. J., & Nielsen, C. S. (2017). Defining chronic pain in epidemiological studies: A systematic review and meta-
analysis. Pain, 158(11), 2092-2107.
Chronic Pain– Special Populations - 1 Older Adults
Prevalence of Chronic Pain increases with age
1/3 of Canadians > 65 live with chronic pain
Children and Adolescents
Prevalence = 11-18% (King et al, 2011)
Common presentations: recurrent headaches, abdominal pain, back pain, MSK pain
Pain in this group can impact development, lead to chronic pain, substance use and psychological disorders later in life
Females – chronic pain more common across all age groups (FM, IBS, RA, Chronic Pelvic Pain, Migraine)
Groenewald, C. B., Law, E. F., Fisher, E., Beals-Erickson, S. E., & Palermo, T. M. (2019). Associations between adolescent
chronic pain and prescription opioid misuse in adulthood. The Journal of Pain, 20(1), 28-37.
Chronic Pain– Special Populations - 2 Indigenous Peoples – highest prevalence of CP in Canada (Meana et
al, 2004) Indigenous peoples often articulate the experience of physical pain as
being secondary to emotional pain (as a result of racism, colonization, premature death of kin, dispossession, dislocation, community violence)
Veterans – experience chronic diseases 2-3X higher prevalence vs general population (N=670,000) 41% experience chronic pain
63% with CP have concurrent mental health condition
65% of vets with past year suicidal ideation report chronic pain
76% of past-year suicide attempts report chronic pain
Substance users – significantly higher prevalence of chronic pain 31-55%
Unmanaged pain may lead to problematic use of substances more pain and health complications
Chronic Pain in Canada: Laying a Foundation for Action. Canadian Pain Task Force. June 2019. https://www.canada.ca/en/health-canada/corporate/about-health-
canada/public-engagement/external-advisory-bodies/canadian-pain-task-force/report-2019.html
…& Complicated
• Associated with the worst quality of life when compared with other chronic diseases such as chronic cardiovascular or respiratory diseases (Jovey et al. 2010)
• Mood and anxiety disorders are 2 – 7 x more prevalent in populations of chronic pain and migraine patients in primary, specialty and tertiary care samples (Tunks et al 2008)
• Co-morbidities multiply functional compromise and QOL restrictions with pain (NB: OUTCOMES)
• Suicide risk 2x higher in CP population vs the non-pain population (Tang, 2006)
• Increased prevalence of SUDs
Some Pearls….
The Little Prince – Antoine De Saint-Exupery
• Chronic pain is treatable
• Many causes --> assess thoroughly
• Attend to risk
• Attend to co-morbidities
• 3 Ps of Pain Treatment: Pharm, Psychological, Physical
• Tapering opioids improves outcomes
• Outcomes: Function, QoL, Pain
• The right to effective pain management is not equal to a right to be prescribed opioids
• Treat pain in patients with substance use disorders
ADDOP: The Five Pillars of Pain Management
• Assess: Symptoms and Risk
• Define the problem: where and what is it?
• Diagnose the kind of pain and treat it
• Other issues: mood, anxiety, sleep, addiction, sex
• Personal management, self management
Gordon A. Pain Manag. 2012
Jul;2(4):335-44.
Pillar 1: Assessment
• General history
• Neurological history
• Pain history
• Risk History = “Universal Precautions History”
Homo sum, humani nihil a me alienum puto - Terrance
I am human, and I consider nothing that is human alien to me
Pillar 1: Assessment
• Lancinating pain V2, V3. Triggered by brushing chin
• Cervical headaches exacerbated by movements; cold; stress; radiate up over vertex and behind both eyes R>L). Assoc photophobia, osmophobia.
• Childhood adversity
• Trauma
• Aberrant drug-related behaviours
Pillar 2: Define the Underlying Problem
• General, MSK and neurological exam• Investigation
Neurophysiological testing: EMG/NCT and possibly evoked response
Pain scales including BPI and DN4, S-LANNS
Neuroimaging when indicated
• Where is the lesion and what is the lesion?
• Applies to neurological conditions and non-neurological conditions
• Treating underlying disease sometimes helps reduce pain
Pillar 3: Diagnose Pain and Treat Accordingly
• Nociceptive vs. Neuropathic
• Cancer vs. Non-Cancer
• Acute vs. Chronic
• Mild, Moderate and Severe
Pillar 3: Diagnosis: Nociceptive vs. Neuropathic
Nicholson BD (2003)
Comerci G (2014)
Murat et al (2018)
Pain
Nociceptive Normal stimulation of nociceptors
Thermal, chemical, mechanical
Neuropathic
Abnormal nervous system activation
Somatic Visceral Central Peripheral
Existential Pain that occurs upon questioning and doubting thevalue of one’s ongoing existence as a living, sentient
being
NociplasticDisturbance in central pain processing:
+ excitcability / - inhibition
Pillar 4: Other Symptoms and Conditions
• Sleep
• Mood and Anxiety Disorders
• Substance Use Disorders
• Trauma
• Fatigue
• Sexual Function
Pillar 4: Other Symptoms and Conditions
• Depression
• Suicidal ideation associated with pain
• Dissociative episodes
• Fragmented sleep wakes up sweaty and restless
• Flashbacks and trauma-related nightmares
Pillar 5: Personal Responsibility and Self-Management
• Who’s working harder?
• Lack of buy-in and self management ‘refractory’ patient
• Proactive management of realistic expectations
• Need to educate patient and family about pain management techniques
• Therapeutic alliance is key
• Clinicians need to practice (not just talk about) interprofessional model• Lack of prompt recovery we tend to repeatedly apply medical model – more consults, tests,
drugs
• Other modalities – psychological and otherwise – are left out
Pain as a Motivational Disorder
• A daily reminder of derailment
• Traumatic
• Robs assertiveness
• A neurological signal to STOP
• Multifactorial – multiple concurrent disorders
• Overwhelming
• Isolating
Stages of Change –Where’s the Patient?
Meet them where they are
Continuum of ambivalence
Explore readiness to change, importance and confidence
Treating Chronic Pain: The 3 Ps
•Physical
•Psychological
•Pharmaceutical
Pharmacologic Steps in Neuropathic Pain
TCA Gabapentin / Pregabalin SNRI
Tramadol Opioid Analgesics
Cannabinoids
Fourth Line Agents **
** eg SSRIs, methadone, lamotrigine, topiramate, valproic acid
*** Do not add SNRI to TCA
Add additional
agents
sequentially if
partial but
inadequate pain
relief***
Moulin DE et al. Pain Res Manag. 2014
Non-pharmacologic therapy Self-Management
Cognitive and Behavioural Therapy (CBT)
Meditation
Mindfulness techniques
Exercise
Physical therapy
Interventional approaches: nerve stimulation or block
Acupuncture
Botox
ETC…
Pillar 5: Pain Recovery• Reimagining pain from uncontrollable to manageable
• Fostering optimism and combating despair
• Promotion of patient feelings of success, self-control and efficacy
• Patients attribute success to their own role
• Education in specific skills: pacing, relaxation, problem-solving
• Emphasis on active patient participation and responsibility
ECHO: Introducing a 6th Pillar…• Assess: Symptoms and Risk
• Define the problem: where and what is it?
• Diagnose the kind of pain and treat it
• Other issues: mood, anxiety, sleep, addiction, sex
• Personal management, self management
• OUTCOMES
ECHO Ontario: VISIONThat all primary care providers in
Ontario have the knowledge and support to manage chronic pain safely and effectively.
Our Partners