kirsten y. day, md associate professor department of family and community medicine ucsf/sfgh fhc
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Nuts & Bolts of Outpatient Pain Management Spring NP/PA/CNM PPG Conference 4.18.13 Carr Auditorium. Kirsten Y. Day, MD Associate Professor Department of Family and Community Medicine UCSF/SFGH FHC. Nuts & Bolts of Outpatient Pain Management Objectives. Pain Physiology Evaluation of Pain - PowerPoint PPT PresentationTRANSCRIPT
Nuts & Bolts of OutpatientPain Management
Spring NP/PA/CNM PPG Conference4.18.13
Carr Auditorium
Kirsten Y. Day, MDAssociate Professor
Department of Family and Community Medicine UCSF/SFGH FHC
Nuts & Bolts of OutpatientPain ManagementObjectives
Pain PhysiologyEvaluation of Pain
History and PhysicalFactors that Influence Pain
Management of PainPhysical ModalitiesPsychological ModalitiesPharmacologic Modalities
Meds commonly UsedHow to Evaluate Effectiveness
Insurance IssuesTolerance, Dependence, Addiction and Pseudo-AddictionChronic Narcotic Use in Substance Use Disorders
Nuts & Bolts of OutpatientPain Management Physiology of Pain
Who, except the gods, can live time through forever without any pain?
- Aeschylus
Nuts & Bolts of OutpatientPain Management Physiology of Pain
Acute Pain is an Early Warning System
Nuts & Bolts of OutpatientPain Management Physiology of Paino Nociceptive Pain
o Somatico Tissue Damage - Temperature, Trauma, Chemicalo Once Stimulated, become hyperactiveo Localized, constant, throbbing, aching
o Visceralo Stretching or Pressureo Referred paino Generalized, less constant or colicky, cramping
o Neuropathic Paino Damage directly to neurons cause abnormal neural activityo Constant, frequently burning or electrical with periods of marked
increases in pain
Nuts & Bolts of OutpatientPain Management Physiology of Pain
oStress Analgesia Short-term intense pain controlled with short-term nervous system
changes
oHyperalgesia Lowered pain threshold produces pain with less stimulation
oAllodynia Previously non-painful stimuli are now painful
Nuts & Bolts of OutpatientPain Management Physiology of Pain
Response
Stimulus Intensity
Pain Threshold
Pain Tolerance
Normal Hyperalgesia Allodynia
Nuts & Bolts of OutpatientPain Management Evaluation of Pain
o Pain is real when you get other people to believe in it. If no one believes in it but you, your pain is madness or hysteria.
- Naomi Wolf
Nuts & Bolts of OutpatientPain Management Evaluation of Pain
o Subjective - NOT a vital sign
o History is the foundation for evaluationo PQRST - Provocation, Quality, Radiation, Severity, Timeo Location QuEST - Location, Quality, Exacerbating/relieving,
Severity, Temporal profileo Functionality
Nuts & Bolts of OutpatientPain Management Evaluation of Pain
o Physical Examinationo General
o Movemento Gaito Positioning
o Affecto Vital Signs in acute setting
Nuts & Bolts of OutpatientPain Management Evaluation of Pain
o Physical Examinationo Focused System Examo Musculoskeletal
o Palpationo Range of Motiono Strength and Laxity
o Neurologico Determine distribution of symptomso Sources of Referred Pain
Nuts & Bolts of OutpatientPain Management Evaluation of Pain
oDiagnosiso Chronic Pain is not a diagnosiso LBP is a symptom, not a diagnosis
DJD Radiculopathy Disk Disease Spinal Stenosis Myofascial dysfunction Sacroiliac dysfunction
o Fibromyalgia - Tender points in specific patternso Myofascial Pain - Trigger points with twitch response and
specific referred pain patterns
Nuts & Bolts of OutpatientPain Management Evaluation of Pain
Factors that Influence Pain
o Cognitive, Emotional factorso Environmental Factors
o repeated injuryo lack of healing
o Timing - duration of pain experience
Nuts & Bolts of OutpatientPain Management Management of Pain
o Physical Modalities
o Psychological Modalities
o Pharmacologic Modalities
o Insurance Issues
Nuts & Bolts of OutpatientPain Management Management of Pain
o Physical Modalities o Exerciseo Thermal Therapyo Manual Medicine Disciplines
o Physical Therapyo Chiropractico Osteopathyo Acupunctureo Trigger Point Injection
o The only treatments that can “Cure”o Myofascial Paino Joint dysfunction
Nuts & Bolts of OutpatientPain Management Management of Pain
oPsychological ModalitiesoCognitive Behavioral TherapyoBiofeedbackoStress Reduction Techniques
Nuts & Bolts of OutpatientPain Management Management of Paino Pharmacologic Modalities
o Step Therapy1. Mild pain - Acetaminophen and NSAIDs2. Moderate Pain - Combination Analgesics
o APAP/Codeine (Tylenol #3), APAP/Hydrocodone (Vicodin), APAP-Oxycodone (Percocet)
3. Severe or Refractory Pain - Opiateso Morphineo Methadoneo Oxycodoneo Fentanyl
Nuts & Bolts of OutpatientPain Management Management of Pain
Nuts & Bolts of OutpatientPain Management Management of Pain
o Pharmacologic Modalitieso Targeted Treatment
o NSAIDS - Inflammatory and Prostaglandin mediated processes
o Lidocaine - Myofascial Pain by Trigger Point Injection or Topical Patches
o Antiepileptics - Neuropathic paino Tegretolo Depakoteo Gabapentin
o Tricyclic Antidepressants - Neuropathic pain
Nuts & Bolts of OutpatientPain Management Management of Pain
o Clonidine - augmentative pain relief
o SSRI’s - somatic symptoms with or without depressed mood
o “Muscle Relaxants”o Centrally actingo Only helpful in Acute injury or Exacerbations
Nuts & Bolts of OutpatientPain Management Management of Paino Pharmacokinetics of Opiates
o Duration of Action - o 4-6 hrs for almost all orals (fentanyl 1-2 hrs.)o Controlled Release (CR) or Sustained Release (SR) 8-12 hours
o Onset of Action - o Accelerated with IV dosing versus PO or IM (max effect at 10-20 min
for morphine IV)o CR or SR have delayed onset and maximum effect
o Steady state o 12-24 hrs with short actingo 48-72 hrs with long acting.
o Metabolism and drug interactions.
Nuts & Bolts of OutpatientPain Management Management of Pain
oTitrating doseso Choose medications based on type and severity of
paino Give initial doses in short acting agents, assess and
titrate at 12 hrs.o With mild to mod pain increase by 25-50% of doseo With mod to severe increase by 50-100% of dose
o Convert to long acting agents o Inpatients - within 24 hrs. o Outpatients - Once dosing is stableo Provide short acting agents of 10-15% of long acting dose
for breakthrough pain.
Nuts & Bolts of OutpatientPain Management Management of Pain
Evaluationo Function
o Activitieso Whato How Longo How Often
o Sleepo Mood
o Side Effects of Opiates o Constipation, nausea, histamine release, urinary urgency/retentiono Evaluate promptly and frequently for side effects and treat as indicated
Nuts & Bolts of OutpatientPain Management Management of Pain
o Insurance Issueso Psychological - CBT, Chronic Pain Groupso Physical Modalities
o Medicare - Chiropractic and Physical Therapyo Medicaid and SFHP/Slid Scale - Physical Therapy
o Pharmacologic Treatmentso Formulary Restrictions
o Medicare Do Medicaido SFHP/Slid Scale, HSF
o Formulary Overrideso TAR, PAR, PAo Diagnosis and failure of formulary options or medical reason formulary
options are contraindicated
Nuts & Bolts of OutpatientPain Management Tolerance, Dependence, Addiction and Pseudo-Addiction
o Tolerance o Normal Physiologic Response to be expected with long-term use. o Expect to have to adjust doses over time.
o Physical Dependence o Normal Physiologic Response to be expected with long-term use. o Physical withdrawal with abrupt cessation or reduction
o Addiction o Neurobiological disordero Compulsive use despite harm, impaired control.
o Pseudo-Addiction o Patient behaviors that mimic addiction, caused by provider’s failure to
treat pain either adequately or timely o Some patients are drug-seeking because they're in pain. . .
Nuts & Bolts of OutpatientPain Management Chronic Pain and Substance Use Disorders
o Prevalence of Chronic Pain high amongst Substance Abusing Patientso 37-61% of patients on Methadone Maintenanceo HMO patients entering drug/alcohol treatment OR 2-3 versus controls for
HA, LBP, and arthritis
o Other Considerationso Stimulant and opiate abuse result in increased pain sensitivityo Relapse
o 30% in recovery relapse on Rx opiateso Untreated pain is a frequent trigger for relapse
Nuts & Bolts of OutpatientPain Management Chronic Pain and Substance Use Disorders
o When to use Opioids for patients with Addictive Disorderso Pain is moderate to severeo Pain has a significant impact on function and quality of lifeo Non-opioids have been tried and failedo The patient agrees to have opioid use closely monitored
Nuts & Bolts of OutpatientPain Management Objectives
Pain PhysiologyEvaluation of Pain
History and PhysicalFactors that Influence Pain
Management of PainPhysical ModalitiesPsychological ModalitiesPharmacologic Modalities
Meds commonly UsedHow to Evaluate Effectiveness
Insurance IssuesTolerance, Dependence, Addiction and Pseudo-AddictionChronic Narcotic Use in Substance Use Disorders
Nuts & Bolts of OutpatientPain Management Remember. . .
o Pain is Subjectiveo Evaluate and determine a Diagnosiso Aim treatment at Diagnosiso Provide timely follow-up, evaluation and treatmento Communication with Pharmacist and know your
formulary
Nuts & Bolts of OutpatientPain Management
Spring NP/PA/CNM PPG Conference4.18.13
Carr Auditorium
Kirsten Y. Day, MDAssociate Professor
Department of Family and Community Medicine UCSF/SFGH FHC