"WHAT IS PAIN, HOW DO WE ASSESS AND

TREAT IT, AND WHAT IS THE ROLE OF

OPIOIDS?"

Katherin Peperzak, MDActing Assistant Professor

UW Dept of Anesthesia & Pain Medicine

NAOEM 2017 Annual Meeting

✓ No financial conflicts of interest

✓ Many non-opioids are “off-label” for pain

✓ Much of pain treatment “best practice” has limited or no RCT

evidence-based support

✓ Much has been borrowed from David Tauben, MD, UW Chief

of Pain Medicine (with permission!)

Disclosures

1. Be able to access and deploy current evidence based treatment guidelines for pain management.

2. Use, interpret, and respond effectively to information derived from pain assessment tools that include measures of function, mood, sleep, risks, and adherence.

3. Know how and when to access pain expertise when chronic pain is not well controlled despite reasonable treatment efforts and/or when significant treatment risks are identified.

4. Take pride, not dread, your patients suffering with chronic pain

Objectives

What is Pain?

Cartesian View of Pain

6

Nociception Without Pain (15th century)

7

“People with something better to do

don’t hurt as much.”

University of Washington: Wilbur Fordyce, c.1970

Henry Beecher, MD

Anzio Beach, Italy 1942

“THERE IS A COMMON BELIEF that wounds are inevitably associated with pain, and, further, that the more extensive the wound the worse the pain. Observation of freshly wounded men in the Combat Zone showed this generalization to be misleading.”

Nociception Without Pain (1942)

Gate Theory

http://science.howstuffworks.com/life/inside-the-mind/human-brain/pain4.htm

What goes up must come down…

https://www.painscience.com/articles/pain-is-weird.php

“Once a danger message arrives at the brain, it has to answer a

very important questions: “How dangerous is this really?” In

order to respond, the brain draws on every credible information

– previous exposure, cultural influence, knowledge, other

sensory cues – the list is endless.”

-Lorimer Moseley

Pain really is in the mind, but not the way you think

TheConversation.com

When the knob gets turned up…

11

https://www.painscience.com/imgs/knob-pain-m.jpg

Pain modifies the CNS such that less

provocation can cause more pain

Any sensory experience of greater amplitude,

duration, or area than expected from a

particular peripheral input may reflect central changes

But how do we diagnose it?

Centralization Continuum

PROPORTION OF INDIVIDUALS IN CHRONIC PAIN

STATES THAT HAVE CENTRALIZED THEIR PAIN

Peripheral Centralized

Acute pain Osteoarthritis SC disease Fibromyalgia

RA Ehler’s Danlos

Tension HA

Low back pain

TMJD IBS

Slide courtesy of Dan Clauw

13

From: Stanos et al. Rethinking chronic pain in a primary care setting.

Postgraduate Medicine 2016

Mixed pain

conditions with

multiple pain

pathophysiologies

such as chronic low

back pain

The “Loeser Onion”

“Unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” (IASP 1979)

Nociceptors selectively respond to noxious stimulation

What we observe during exam of our patients

Response to diminishment of one’s capacity

How Do We Assess Pain?

16

1. Pain intensity*

2. Interference with Enjoyment/Quality of Life*

3. Interference with (General) Function*

4. Pain Impact on Mood

• Anxiety, Depression, PTSD

5. Pain Interference with Sleep

6. Treatment Risks

• Medical: ie. Sleep Apnea (i.e STOP-BANG)

• Addictions (i.e. ORT, SOAPP-R, COMM, DIRE)

How pain should be measuredLinks to pdfs available: search “UW Pain Provider Toolkit”

And, what exactly does “10/10” Pain mean?

18

So for “≥12/10”: “worse than… nothing else matters” ?

3-item “PEG” TOOL

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Krebs et al. 2009

✓AnxietyGAD-7 (or PHQ-4)

✓DepressionPHQ-9 (or PHQ-4)

✓PTSD

Identifying co-occurring MOOD diagnoses

PC-PTSD Screen

In your life, have you ever had any experience that was so frightening, horrible, or upsetting, that in the past month you:

1. Have had nightmares or thought about it when you did not want to?

2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?

3. Were constantly on guard, watchful, or easily startled?

4. Felt numb or detached from others, activities, or your surroundings?

PHQ-4

“When your brain is on fire I can’t help your pain…”

Clinical Report

PainTracker™

• Clinically

actionable data/

just-in-time

decision-making

• “Big-data” for

registry

research, QI,

and ACO

reporting

How Do We Treat Pain?

Acute Pain: a “symptom”

Expected to resolve

Goal is facilitation of recovery from the underlying injury,

surgery, or disease

Chronic Pain: a “disorder”

Illness or injury resolved but pain persists

Goal is improved function

Palliative Care: end-of-life goals

Support and treatment

Goal of care is comfort

“Kind” of pain determines treatment goals

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1. Medical specialties

2. Nursing

3. Pharmacy

4. Physical therapy

5. Occupational therapy

6. Behavioral health

7. Social work

8. Chaplain

9. Addiction (when assessment & management has gone wrong)

Health Professionals Involved In Pain Management

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Cognitive:

• Identify distressing negative cognitions and beliefs

Behavioral approaches:

• Mindfulness, relaxation, biofeedback

Physical:

• Activity coaching, graded exercise land & aquatic with PT, class, trainer, and/or solo

Spiritual:

• Identify and seek meaningfulness and purpose of one’s life

Education (patient and family):

• Promote patient efforts aimed at increased functional capabilities

Non-drug Multimodal Analgesia

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Argoff CE, et al. Pain Medicine 2009;10(S2):53–S66.

Opioids: ≤ 30%

Tricyclics/SNRIs: 30%

Anticonvulsants: 30%

Acupuncture: ≥ 10+%

Cannabis: ? 10-30%

CBT/Mindfulness: ? 30-50%

Graded Exercise Therapy: variable

Sleep restoration: ≥ 40%

Hypnosis, Manipulations,Yoga: “+ effect”

CHRONIC PAIN TREATMENTS“COMPARING” EFFECTIVENESS

Extrapolated averages of reduction in Pain Intensity

Turk, D. et al. Lancet 2011; Davies KA, et al. Rheum. 2008;

Kroenke K. et al. Gen Hosp Psych. 2009; Morley S Pain 2011;

Moore R, et al. Cochrane 2012; Elkins G, et al. Int J Clin Exp

Hypnosis 2007.

Post Herpetic Neuralgia

NNT* 2.1-2.7

Diabetic Peripheral

Neuropathy

NNT 1.2-1.5

Atypical Facial Pain

NNT 2.8-3.4

Fibromyalgia/Central Pain

NNT 1.7

* Number needed to treat: (NNT)

“TRICYCLIC” ANTIDEPRESSANT DRUGSAnalgesic Effectiveness

SOME EVIDENCE:

• Osteoarthritis

• Low Back Pain

• Chronic Pelvic Pain

• Headache

CONFLICTING EVIDENCE:

• Radiculopathy

NO EVIDENCE, but does

help with sleep and mood:

• HIV and Chemotherapy PN

Saarto T, Wiffen PJ. Cochrane 2007

Diabetic Neuropathy

•Duloxetine

Fibromyalgia

•Milnacipran

•Duloxetine

•Venlafaxine

OTHER ANTIDEPRESSANT DRUGS

Clinical Effectiveness Trials

SNRIs SSRIs

• Diabetic Neuropathy– NNT 5-15

• Fibromyalgia

– No evidence of benefit

in reduction of pain

intensity

Norepinephrine is a

principal neurotransmitter

facilitating the

“descending inhibitory

systems”

Multimodal benefits:

✓ PAIN, SLEEP, & MOOD

Antidepressant Analgesia

Millan MJ Prog Neurobio 2002

Ossipov MH, et al. Curr Opin Support Palliat Care 2014

DeFelice M, et a. Pain 2011 (see commentary by Dickenson)

• Antidepressants that elevate synaptic norepinephrine(TCAs > SNRIs) are effective analgesics

• Sedating antidepressants are useful agents to improve both sleep initiation and maintenance

• Anticholinergic side-effects are most common with TCAs• Nausea is common with SNRIs• Dose related QTc prolongation occurs with TCAs >SNRIs• Warn patient and family about risks of suicidality when

any antidepressant is prescribed• Mania may be precipitated by any category of

antidepressant

RX CLINICAL KEY POINTS

ANTIDEPRESSANT ANALGESIA

31

Gabapentin

Pregabalin

Well studied

Fewer side effects than

other anticonvulsants

Limited drug-drug side

effects

100% excreted in the urine

Often used off-label

RX CLINICAL KEY POINTS: “GABAPENTINOIDS”PROTOTYPIC CA++ CURRENT MODULATORS

32

➢Side-effects:

Weight Gain

Edema

Cognitive slowing

Dizziness/Ataxia

Twitching

Suicidality

Pharmacodynamics (“mechanism”):

Selective inhibitory effect on

voltage-gated calcium channels

containing the α2δ-1 subunit.

Larsen MS, et al. Res. Pharm Res. 2014

•Lack of evidence for sustained benefits

•Rebound insomnia

•Risk of over-sedation especially when combined with

opioids

•Complicating development of tolerance, dependency, and

addiction.

Use of benzodiazepines for sleep & anxiety are not

recommended in chronic pain

BENZODIAZEPINES

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Antispasm drugs have limited evidence for effectiveness,

are predominantly sedative, and add polypharmacy to

chronic pain management with little benefit.

Carisoprodol should never be used because of no benefit

and high risk.

When true spasticity is present, as in spinal cord injury and

multiple sclerosis, baclofen and tizanidine may be useful.

Avoid abrupt withdrawal off baclofen because of the

potential for severe rhabdomyolysis and fever.

“Anti-spasm” Drugs

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van Tulder MW et al. Cochrane Library 2008

Procedures

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http://minnlawyer.com/files/2014/09/Can-of-Worms.jpg

May have role in selected patients

-Epidural steroid injections

-Sympathetic nerve blocks

-Joint Injections

-Peripheral nerve injections

-Radiofrequency ablation

-Trigger point injections

In general, procedures tend to be most useful in those we see early on in pain treatment

Procedures

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What is the role of opioids?

65 mg of morphine per fluid ounce

From Battlefields

United States Civil War Casualties

Legal (without prescription)

until 1914:

Harrison Narcotics Tax Act

Marketing

still, today,

with discount

coupons!

Accessed Memorial Day, May 29, 2017

…to the general store…to the Internet: Americans Love Their Opioids

OPIOIDS FOR CHRONIC PAIN The Clinical Conundrum

Annals of Internal Medicine • Vol. 162 No. 4 • 17 February 2015

Chronic pain management today: a shocking over-reliance on opioids

40

Every year, 16,000 people die from prescription drug

overdose and 500,000 come to Emergency Departments

due to over-use of opioid pain medications in the US

Source: IMS Prescription Audit 2012

3rd Largest Epidemic In America Influenza Pandemic (1918: 500,000)

HIV (1981-2005: 550,000);

Prescription Opioid ODs (1999-2014: 165,000, and counting)

41

OD DEATHS Ripple Across America

NYT 1/20/2016

OPIOID OVERDOSE RISK by Morphine Equivalent Dose

0

1

2

3

4

5

6

7

8

9

10

<20 mg/day 20-49 mg/day 50-99 mg/day >=100 mg/day

Risk Ratio

Dose in mg MED

Risk of Adverse OD Event

Dunn 2010

Bohnert 2011

Gomes 2011

Zedler 2014

Point of

deflection

9-fold

increased

risk

Calculate the “MED”

Methadone

<20 mg 4x

>20-40 mg 8x

>60-80 mg 10x

>80 mg 12x

AMDG on-line calculator

www.agencymeddirectors.wa.gov

Administration

• On initial visit

• Prior to LA Opioid Therapy

Scoring

• 0-3: low risk (6%)

•> 8: high risk (> 90%)

Assessing Opioid MISUSE Risk

“Opioid Risk Tool” Webster & Webster 2005

Sleep Disordered Breathing on Opioids

Walker JM., et al. J

Clin Sleep Med 2007

46

www.agencymeddirectors.wa.gov/Files/2015AMDGOpioidGuideline.pdf

“Bending The Curve” Of The PRESCRIPTION Opioid Crisis

47

Source: Jennifer Sabel PhD Epidemiologist, WA State Department of Health, April 18, 2014

Jones, 2013; Muhuri et al., 2013

And so it goes, Opioid Overdoses Continue on the Rise

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Source: C. Banta-Green WA State Department of Health

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1. When to initiate

or continue

1. Selection,

dosage,

duration,

follow-up, and

discontinuation

1. Assessing risk

and addressing

harms

12 Recommendations

3 Topic Areas

1. Patient engagement is crucial determinant of timing and ease

• Co-occurring severe psychiatric/behavioral issues may require formal detox program

• Patients with high fear and pain anticipation will benefit from concurrent behavioral health support

2. 5-10% reduction at scheduled intervals (weekly to quarterly)

• Set patient expectations early!

3. Clonidine to partially mitigate withdrawal symptoms

4. Buprenorphine induction and taper over 3-12 weeks

5. ALWAYS avoid benzodiazepines

•When benzos ALSO on board: choose the path that targets least risk (if possible to determine), and that is most easily accomplished (NOTE: neither is “easy”)

Tapering Opioids Isn’t Easy

IMPROVING ACCESS TO PAIN SPECIALISTS

UW TelePain

Contact Information: Cara Towle RN MSN ctowle@u.washington.eduhttp://depts.washington.edu/anesth/care/pain/telepain/index.shtml

or search:

uw telepain

Sessions:

(Pacific time)

Wednesdays

noon-1:30

Thursdays

7:00-8:00 am

University of Washington

“Pain Medicine Provider Toolkit”

http://depts.washington.edu/anesth/care/pain/index.shtml

Access to

Evidence-based

Pain Care

Reflections on the Management of Pain

“Doctors pour drugs of which they know little, for

diseases of which they know less, into patients –

of which they they know nothing at all.”

“The secret of the care for the

patient is in caring for the patient.”

Francis Peabody, 1927

attributed to Voltaire, mid-18th century

John Loeser, MD University of Washington

“Chronic Pain is not a state of opioid deficiency.”

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peperzak@uw.edu

Thank You!