Chronic Pain Management

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Chronic Pain Management

• Elaine Wendt, MD

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Pain is now Fifth Vital Sign
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• The best way to perceive the professional burden
  involved in the care of patients with chronic
  pain is to pick your most comfortable chronic
  medical diagnosis to manage and take out that
  diagnosis and substitute the syndrome, chronic
  pain.

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For Example

• My patient with diabetes will have diabetes
  throughout her lifetime and need medical help to
  manage the diabetes throughout her lifetime while
  I am her physician.
• My patient with chronic pain will have chronic
  pain throughout her lifetime and need medical
  help to manage the chronic pain throughout her
  lifetime while I am her physician.

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Pain management physiologic permanence

• http//www.ama-assn.org/ama/no-index/about-ama/164
  08.shtml
• Somatic pain model
• Local inflammationgtlowered threshold of c-fiber
  excitationgt eventual Rexed lamina 5 wide dynamic
  neuronal intracellular protein changes.
• Neuropathic pain model
• Nerve injurygt changes in location, density,
  number, and type of ion channelsgt altered nerve
  firinggt eventual Rexed lamina 5 wide dynamic
  neuronal intracellular protein changes gt altered
  neurotransmitter dynamicsgt neuronal death/drop
  outgt altered behavior of glial and other
  architectural cells (scar)

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Currently no single pain medication exists that
will take away more than 30 of a patients
chronic pain.
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Set Appropriate Expectations Early
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Assess Pain Score and Functionality

• Wong Baker in EMR
• ICSI Functional Ability Questionnaire

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Make an Appropriate Differential Diagnosis

• Determine biological mechanisms of pain
• Neuropathic pain
• Muscle pain
• Inflammatory pain
• Mechanical / Compressive pain

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Identify and Address Comorbitities Early On
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Perform a Psychological Assessment, including
risk of Addictive Disorders

• Depression
• Anxiety
• Substance Abuse and Dependence
• Sleep disorders
• Personality disorders
• History of abuse
• Coping patterns and resources
• Spirituality
• Working and disability Issues

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Make Therapy GOAL Oriented, Not PAIN Oriented

• By Next visit, I will be able to do

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Use a Treatment Agreement

• Plan of care
• Set personal goals
• Improve sleep
• Increase physical activity
• Manage stress
• Decrease pain

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Use of Controlled Substances is Sometimes
Appropriate. However, there are Associated Risks.
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DEA Practitioners manual

• The Drug Enforcement Administration is pleased
  to provide this updated edition of the 1990
  Practitioners Manual to assist you in
  understanding your responsibilities under the
  Controlled Substances Act (CSA) and its
  implementing regulations. This manual will help
  answer questions that you may encounter in your
  practice and provide guidance in complying with
  federal requirements.
• DEA remains committed to the 2001 Balanced Policy
  of promoting pain relief and preventing abuse of
  pain medications. In enforcing the CSA, it is
  DEAs responsibility to ensure drugs are not
  diverted for illicit purposes. Unfortunately,
  this country is now experiencing an alarming
  prescription drug abuse problem
• Today, more than 6 million Americans are abusing
  prescription drugsthat is more than the number
  of Americans abusing cocaine, heroin,
  hallucinogens, and inhalants, combined.
• Researchers from the Centers for Disease Control
  and Prevention report that opioid prescription
  painkillers now cause more drug overdose deaths
  than cocaine and heroin combined.
• Today more new drug users have begun abusing pain
  relievers (2.4 million) than marijuana (2.1
  million) or cocaine (1.0 million).
• It is more important now than ever to be vigilant
  in preventing the diversion and abuse of
  controlled substances. This manual will help you
  do that by listing some safeguards you can take
  to prevent such diversion. It also explains
  registration, recordkeeping, and valid
  prescription requirements.
• As a practitioner, your role in the proper
  prescribing, administering, and dispensing of
  controlled substances is critical to patients
  health and to safeguarding society against the
  diversion of controlled substances. DEA is
  committed to working jointly with the medical
  community to ensure that those in need are cared
  for and that legitimate controlled substances are
  not being diverted for illegal use.

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Document Informed Consent

• Informed consent for chronic opioid therapy (HCHD
  has bilingual forms)
• Side effects of medication
• Monitoring of medication use
• Refill policy

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Assess Pain Level and Function before and during
Therapy

• Wong Baker Scores
• Attainment of Goals

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Regularly Assess the 4 As

• Analgesia
• Activity
• Adverse effects
• Aberrant behavior

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Document all Assessments and Care Plans

• Texas Medical Board Rules, Ch.170
• http//www.tmb.state.tx.us/rules/docs/CurrentRules
  Revised09-20-07.pdf

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Texas Medical Board Rules, Ch.170

• The Shalls
• the medical record shall document the medical
  history and a physical examination that includes
  a problem-focused exam specific to the chief
  presenting complaint of the patient.
• The medical record shall document the
  physicians rationale for the treatment plan and
  the prescription of drugs for the chief complaint
  of chronic pain and show that the physician has
  followed these guidelines
• Each periodic review shall be documented in the
  medical record

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Summary

• Chronic pain is a chronic illness
• Assess comorbidities early on
• Create goals for therapy
• Use formal contracts for controlled substances
• Reassess and document