Pain Management in Primary Care

Kimberly Zoberi, MDSaint Louis University School

of Medicine

Who treats chronic pain?

Chronic pain specialists

Acupuncturists

Chiropractors

PCP’s

2%

7%

40%

52%

Bruer B, et al, Southern Medical Journal, 2010; 103:738-747

MacFarlane GJ, Rheumatology 2012; 51:1707-1713

Gross AR, Spine 2004; 29:1541-1549 (Cochrane Review – neck pain) Rubinstein SM, Spine 2013; 38:E158-E177 (Systematic rev : Spinal Manipulative Therapy)

Ways to classify pain

►Acute vs. chronic►Nociceptive vs. neuropathic►Psychogenic vs. somatic

Acute vs. Chronic

Acute

Cause is known

Function is protective

Increased autonomic activity

Short duration, resolves with healing

Inflammation, tissue injury

Short term upregulation of pain sensitivity

Chronic

Cause = ?

No protective function

None

Does not resolve with healing

None

Long term changes including allodynia, hyperalgesia, etc.

Nociceptive vs. Neuropathic

►Nociceptive: Appropriate stimulation of nerve endings leads to signaling

►Neuropathic: Dysfunction of nerve

Acute, nociceptive pain

►Examples?►Goals of treatment

Heal the injury Decrease acute pain Prevent progression to chronic pain

►Strategies

Acute, neuropathic pain

►Migraine, herniated disk

Chronic, nociceptive pain

►Arthritis, cancer►BOTH ongoing damage and

upregulation of nerve impulses►Remodeling centrally and dorsal horn

of spinal cord►Multimodal treatment

Chronic, neuropathic pain

►Fibromyalgia, IBS►Not much utility to anti-inflammatories►Neuromodulating agents are key

Psychogenic component

Chronic pain

Insomnia

Anxiety Depression

►Musculoskeletal symptoms and non-REM sleep disturbance in patients with "fibrositis syndrome" and healthy subjects.

►Moldofsky, et al, Psychosomatic Medicine, 1975, 37 (4): 341-351.

► Sleep deprivation patients looked identical to fibromyalgia patients in • mood• somatic complaints• sleep architecture

►Smith et al. The effects of sleep deprivation on pain inhibition and spontaneous pain in women. Sleep. 2007.

►Kundermann et al. The effect of sleep deprivation on pain. Pain Res Manag. 2004

Source: Sleep and Pain, Lavigne (ed) 2007.

How patients feel

What patients want

Physical therapy

Psychotherapy

Neuromodulators

Sleep regulation

Mood regulation

NSAIDS/Co-analgesics

Narcotics

Interventions

Behavioral activation

Family therapy

Anxiety management

TENS

General Treatment Strategy

►Acknowledgement of patient’s pain►Nonpharmacologic treatments

Physical therapy Exercise Heat/ice Coping mechanisms CBT

Pharmacologic treatment

Acetaminophen

Adjuvant pain meds NSAIDS +/- mild opioids

Short acting Opioids PRN

Long Acting Opioids ATC+/- Adjuvant pain meds

Continued pain

Neuropathic Non-neuropathic

+ +

FacilitationSubstance PGlutamateNGFCCK

InhibitionNE/SerotoninDopamineOpioidsGABACannabinoidsAdenosine

Adjuvant Pain Meds

►Neuromodulators►Calcium channel agents

Ca needed for afferent pain fibers to synapse

Gabapentin inhibits this►Sodium channel agents

Na needed for spinal cord neurons to transmit impulses

Topamax inhibits this►Serotonin/NE reuptake inhibitors

Adjuvant pain meds

►Side effects? ►Which one has NO weight gain?

3 Circumstances to Use Opioids

►Moderate to severe pain►Patient has already failed other

therapies►Other therapies (NSAIDs) are

contraindicated

Opioids

►Which patients should NOT use opioids?

Informed Consent for Opioids

Documentation

►How NOT to get in trouble with the DEA

Initial Assessment► Onset, duration► Location, distribution► Quality, character► Intensity► Aggravating and relieving factors► Associated factors

Mood and emotional distress Functional impairment

► Associated features Neurological deficit, hyperalgesia, allodynia

► Previous treatments

Ongoing Assessment(Progress Note)

►4 A’s►Analgesia (use a pain scale)►ADL’s►Adverse effects►Aberrant drug related behavior►Assessment and Plan