Chronic Pain Management

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					Chronic Pain
 Elaine Wendt, MD
Pain is now “Fifth Vital Sign”
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.”
                    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
        Pain management: physiologic
   Somatic pain model
       Local inflammation>lowered threshold of c-fiber
        excitation> eventual Rexed lamina 5 wide dynamic
        neuronal intracellular protein changes….
   Neuropathic pain model
       Nerve injury> changes in location, density, number, and
        type of ion channels> altered nerve firing> eventual Rexed
        lamina 5 wide dynamic neuronal intracellular protein
        changes > altered neurotransmitter dynamics> neuronal
        death/drop out> altered behavior of glial and other
        architectural cells (scar)
  Currently no single pain
medication exists that will take
 away more than 30 % of a
   patient’s chronic pain.
Set Appropriate Expectations
    Assess Pain Score and Functionality

   Wong Baker in EMR
   ICSI Functional Ability Questionnaire
    Make an Appropriate Differential

   Determine biological mechanisms of pain
   Neuropathic pain
   Muscle pain
   Inflammatory pain
   Mechanical / Compressive pain
 Identify and Address
Comorbitities Early On
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
Make Therapy GOAL
 Oriented, Not PAIN
By Next visit, I will be able to do…
        Use a Treatment Agreement
   Plan of care
       Set personal goals
       Improve sleep
       Increase physical activity
       Manage stress
       Decrease pain
 Use of Controlled Substances is
Sometimes Appropriate. However,
   there are Associated Risks.
      DEA Practitioner’s manual
   “The Drug Enforcement Administration is pleased to provide this updated edition of the 1990
    Practitioner’s 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 DEA’s 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 drugs—that 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
   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.”
     Document Informed Consent
   Informed consent for chronic opioid therapy
       (HCHD has bilingual forms)
       Side effects of medication
       Monitoring of medication use
       Refill policy
     Assess Pain Level and Function
      before and during Therapy

   Wong Baker Scores
   Attainment of Goals
     Regularly Assess the 4 “A’s”
   Analgesia
   Activity
   Adverse effects
   Aberrant behavior
Document all Assessments and Care
   Texas Medical Board Rules, Ch.170
        Texas Medical Board Rules,
   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 physician’s
        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”
   Chronic pain is a chronic illness
   Assess comorbidities early on
   Create goals for therapy
   Use formal contracts for controlled substances
   Reassess and document

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