what everyone in primary care needs to know about pain. · 2014-07-03 · berna c, leknes s, holmes...

What Everyone in Primary Care Needs to Know about

Pain.

Kevin Cuccaro, D.O.

Diplomate American Board of Anesthesiology

Subspecialty Certification Pain Medicine

Kevin Cuccaro, D.O. StraightShotHealth.com 1

Goals of lecture

• Why is it Important?

• What is it?

• How do you manage it?


Who am I?

• Anesthesiologist

• Fellowship trained Pain Physician

• Group practice Navy

• Solo specialist


Why should you care about Pain?


“Life is Pain, Highness. Anyone who says differently is selling

something.”

The Princess Bride (1987)


Why?

• Common presenting symptom

• Most common disability

• $600+ Billion Annually

• 100 Million Americans (*)


Why?

• Increased Procedures 130-700%

• Increased Surgeries 300+%

• Increased Opioids 300+%


4% of world population consume 80% of all opioids


Why is this important?

• We are spending huge amounts of money

• We are performing multiple invasive

procedures

• We are killing people


What Is Pain?

“Pain is an unpleasant sensory &

emotional experience associated with

actual or potential tissue damage or

described in terms of such damage.” IASP 1994


Pain Is…

Unpleasant

Sensory AND Emotional

Experience


Pain Experience

Acute

• Adaptive

• Source Defined

• “Broken Leg”

• Peripheral

• Cut, Poke, Drug

Chronic

• Maladaptive

• Nebulous

• “Fibromyalgia”

• Central

• No single treatment


Chronic Pain Experience

Localized Widespread

Multifocal

Affective

Central

Focal

Sensory

Peripheral


Central Sensitivity Syndrome

• Fibromyalgia

• Chronic

Abdominal/Pelvic Pain

• Chronic Back Pain

• Chronic Headaches

• Irritable Bowel

Focal OR Multifocal

Affective

Central


Emotion

(In 3 slides or less)


Two Views of Emotion

Traditional

Emotions are less mature than

reason. Negative emotions

are pathologic & need rational

control.

Progressive

Emotions facilitate awareness,

guide & motivate behavior


Star Trek recognized this…

Traditional Progressive


Emotion

Emotional State

vs

Emotional Process


Neurobiology of Pain

(In 3 slides or less)


Three Dimensions of Pain (Melzack & Casey, 1968)

• Sensory-Discriminative

• Affective-Motivational

• Cognitive-Evaluation


Neurobiology of Pain

Lateral Pain System


• Location, timing, physical

characteristics

• Prompts withdrawal

Medial Pain System


• “Emotional Coloration”

• Defensive behaviors


Pain Experience & Neurobiology

• Sensory

• Emotional

• Experience



• Cognitive-Evaluation


What are we really treating?

Nociception

• Nerve stimulation that

conveys information about

potential tissue damage to

the brain.

• Anesthesia INDEPENDENT

• OBJECTIVE

Pain

• Perception & Response to

Sensory information

• Genetics, prior learning,

current psychological status

& sociocultural influences

• Anesthesia DEPENDENT

• SUBJECTIVE


Influencers

• Genetic

• Epigenetic

• Developmental

• Psychosocial


Influencers

• Childhood Adversities

• Adult victimization

• PTSD

• Stressors

• Emotional State

• Emotional Process

• Beliefs

• Learning


Pain Experience

Complex interplay

between

BIOLOGIC,

PSYCHOLOGIC & SOCIAL

factors

(Biopsychosocial Model)

“Any model that focuses

on only one of these

dimensions will be

incomplete and

inadequate” (Gatchel & Peng, 2007)


How to Manage


To Start…

• Rule out “Badness”

• What’s on the problem list?

– Anxiety, Depression, Abuse, Injury

• History is 90%

• Exam is 9%


Next…

• Do No Harm

• Over vs Undertreatment

• Words have Power

• Don’t dig a deeper hole

• Scheduled follow up *


Follow Up…

• Small Successes

• Encourage & Engage

• Focus on Function

• Behavioral Health


Overall

• Pain is NOT Nociception.

• Chronic Pain is NOT Acute Pain

• Numerous “Interested Parties”

• Significant Noise


Overall

The Lack of A “Good” Solution

Does Not Support A Harmful One


Questions or Comments?


Resources

• “Unlearn Your Pain” Howard Schubiner, MD

• “Back in Control” David Hanscom, MD

• “They Can’t Find Anything Wrong With Me!”

David Clarke, MD

• “Relaxation Revolution” Herbert Benson, MD


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what everyone in primary care needs to know about pain. · 2014-07-03 · berna c, leknes s, holmes...

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