CHRONIC PAIN MANAGEMENT hamot

CHRONIC PAIN MANAGEMENT Josh Amsler, SRNA Overview  Pain     Pain Pathways  Definition Classifications Overview Nociception  Common Pain Syndromes     Chronic Pain   Chronic Pain Management   Cancer pain Neuropathic pain Pathophysiology Systemic responses Neural blockade Pharmacologic interventions PAIN  Unpleasant sensory and emotional experience associated with actual or potential tissue damage frequent cause of suffering and disability  Most common reason that people seek medical attention  Most SUFFERING  State of severe distress associated with events that threaten the intactness of a person synonymous with Pain  May or may not be accompanied by Pain  Not So what’s the big deal?! WHO is Involved?  WHO  AHRQ  JCAHO  and more… JCAHO says… the right of patients to appropriate assessment and management of pain.  Assess the existence of pain and, if present, its nature and intensity in all patients.  Record the results of the assessment in a way that facilitates regular reassessment and follow-up.  Recognize  Determine and assure staff competency in pain assessment and management, and address pain assessment and management in the orientation of all new staff.  Establish policies and procedures that support the appropriate prescription or ordering of effective pain medications.  Educate patients and their families about effective pain management.  Address patient needs for symptom management in the discharge-planning process. Who is Involved?  WHO  AHRQ  JCAHO  APS APS says…  1. Recognize and treat pain promptly  Chart and display pain and relief (process)  Define pain and relief levels to trigger review (process)  Survey patient satisfaction (outcome)  2. Make information about analgesia readily available (process)  3. Promise patients attentive analgesic care (process)  4. Define explicit policies for use of advanced analgesic technologies (process)  5. Monitor adherence to standards (process) Who is Involved?  WHO  AHRQ  JCAHO  APS  CONGRESS Who is Involved?  WHO  AHRQ  JCAHO  APS  CONGRESS  AAPM, ACPA, APF, and many more… Who’s Responsible?  Physicians/Specialists  Psychologists  Pharmacists  Nurses Therapists  Social Workers  Clerics  Physical Statistics million Americans are partially or totally disabled by chronic pain  Nine out of ten Americans (aged 18 and older) suffer from pain at least once a month  26 million Americans (15%) have severe pain  50% of Americans (aged 65 and older) suffer from pain on a daily basis  50  43% of adults (83 million) report pain frequently affects their participation in life’s activities 55% of senior citizens report suffering from pain on a daily basis Senior citizens report that severe or moderate pain often lasts over two years   In 1995 pain caused 50 million lost work days at a cost of more than $3 billion in lost wages  8% of the workforce claimed short term disability due to pain (average of 17 days)      Pain accounts for 80% of all physician visits 64% of pain sufferers will see a doctor only when they cannot stand the pain any longer 42% of people who visit their doctor for pain feel misunderstood by their physician 22% of chronic pain patients have changed doctors (at least 3 times) in their search for pain relief  Cancer and cancer-related pathology are responsible for 20% of the deaths annually in the United States and 10% of the deaths worldwide.  1/3 of cancer patients undergoing active therapy and 2/3 of those with advanced disease experience pain.  Surveys suggest that 40%-50% of patients experiencing cancer-related pain do not receive effective analgesia. Pain Management Goals • • • • • • Decrease the frequency and / or severity of the pain General sense of feeling better Increased level of activity Return to work Decreased health care utilization Elimination or reduction in medication usage Physiology of Pain  Nociception 4 processes  Categories  of Pain vs. Neuropathic  Nociceptive Somatic vs. Visceral  Acute vs. Chronic Nociception 4 Processes:  Transduction  Transmission  Perception  Modulation Nociception  Nociceptors     Chemical Mediators of Pain  Free nerve endings Sense heat & mechanical and chemical tissue damage Modulation of Pain     Neurotransmitters that facilitate transmission of pain substance P, histamine, glutamate, etc…  Preemptive Analgesia  Occurs peripherally, in spinal cord, or in supraspinal structures Either inhibits or facilitates pain Nociceptors become sensitized after repeated stimulation Analgesic state obtained prior to surgical trauma Local anesthetic injection, nerve block, opioids, NSAIDs  Arachidonic Acid Cascade Pain Pathways  Conducted along 3-neuron pathways that transmit noxious stimuli from periphery to cerebral cortex   Dorsal column (posterior/sensory)   1st, 2nd, & 3rd order neurons  Spinothalamic tract(anterolateral/sensory)  A & B-fibers C-fibers Major pain pathway  Inotropic Glutamate Receptors Pain Pathways  A-delta fibers    C-fibers    Myelinated Subcategorized     alpha delta beta gamma        Large diameter Transmit “1st pain” or “fast pain” Localized sensation Sharp, stabbing, stinging, pricking “acute”  Unmyelinated Smaller diameter Transmit “2nd pain” or “slow pain” Diffuse sensation Burning, aching, dull, throbbing “chronic” Pain Pathways  Inotropic Glutamate Receptors: (NMDA)  N-methyl-D-aspartate  Α-amino-acid-3-hydroxyl-5-methyl-4- isoxazole propionic acid (AMPA) Categories of Pain  Nociceptive  Somatic – involving nociceptors – localized, identifiable, sharp  Visceral – diffuse, may be referred, dull  Neuropathic – CNS dysfunction PAIN  Acute     Symptom of disease or injury Primarily due to nociception  Self-limiting  Neural response to a noxious stimuli 2 types (nociceptive pain)   Resolves in a few days/weeks Somatic- skin, subQ tissues, muscles, bones Visceral- internal organ or its covering Post-traumatic, post-operative, obstetrics, MI, etc…  Related to:  PAIN  Chronic     The disease itself Due to nociception, with behavioral and psychological factors playing major role Persists beyond usual course of acute disease  3 types    Varies from 1-6 months  Related to:  Nociceptive- arthritis, osteoarthritis Neuropathic- peripheral or CNS disorders Mixed- cancer, chronic back pain Lesions of peripheral nerves, nerve roots, phantom limb pain, diabetic neuropathy, etc… Intermission… Chronic Pain  Pathophysiology  Caused by combo of peripheral, central, psychological mechanisms  Evaluation  Treatment  Medications  Physical Therapy  Behavioral & Cognitive Therapy  Minimally Invasive Procedures Evaluation expectations  Goal setting  An informed patient is a happy patient  Pain rating scales  ….  Patient Verbal Pain Scale Numeric/Verbal Pain Scale Visual Analog Scale Visual Scale - Pain Faces Evaluation expectations  Goal setting  An informed patient is a happy patient  Pain rating scales  Thorough interview  Physical assessment  Review of medical record  Patient Chronic Pain Syndromes Chronic Pain Syndromes back pain (75%)  Neuropathic pain  Cancer pain  Osteoarthritis (40%)  Headaches & Migraines (26%)  Fibromyalgia (12%)  Complex Regional Pain Syndrome  Low Pharmacologic Aspects  Nonopioid  NSAIDs Analgesics  Acetaminophen  Opioids  Adjuvant  Tricyclic Analgesics Antidepressants  Anticonvulsants  Corticosteroids  Centrally-acting muscle relaxants  Nonpharmacologics Nonopioid Analgesics  Nonsteroidal Anti-inflammatory Drugs Inhibition (NSAIDs)  Cyclooxygenase COX-1  COX-2   Acetaminophen Opioids are they?  How do they work?  Preparations/Delivery  Complications effects  Physical dependence  Tolerance  Addiction  Side  What Opioids are they?  How do they work?  Preparations/Delivery  Complications effects  Dependence  Tolerance  Addiction  Side  What Adjuvants Antidepressants  Anticonvulsants  Corticosteroids  Muscle relaxants  NMDA receptor antagonists  GABA receptor agonists  Tricyclic Minimally Invasive Procedures Minimally Invasive Procedures  Local  anesthetics blocks  Nerve +/- glycerol/alcohol  +/- Pulse radiofrequency ablation blocks  Intrathecal infusion Pump implantation  Continuous epidural analgesia   Joint  Spinal cord stimulation  Diskography Anesthetic Implications opioid therapy  Medication assumptions  Anticonvulsants  Antidepressants  Chronic  Implanted  Pain devices  Stimulators pump  Positioning  Succinylcholine Conclusions Questions?