The Five Pillars of Chronic Pain:A Rational Approach to Pain Recovery

Andrew J Smith, MDCM

Staff Physician, Pain and Addiction Medicine

Medical Lead, Interprofessional Pain and Addiction Recovery Clinic

Addiction Medicine Service

Centre for Addiction and Mental Health

Toronto Academic Pain Medicine Institute

Faculty/Presenter Disclosure

Faculty: Andrew J Smith, MDCM

Relationships with commercial interests:

None to report

The Five Pillars of Chronic Pain:Learning Objectives

By the end of this session, participants will be able to:

1. To learn a comprehensive approach to managing chronic pain and risk

2. To understand the burden of chronic pain in our society

3. To differentiate between neuropathic and nociceptive pain

35 yo woman with chronic migraine and facial pain taking opioids and running out early.

• Kicked in head by horse 5 years ago --> brief loss of consciousness; L lancinating facial pain and headaches

• Assaulted by ex-partner 2 years ago bilateral jaw pain; bilateral lancinating facial pain; vertigo, nausea, “drop attacks”; ”space-out spells”; other “migraine” headaches photophobia; eye pain

• Dx with Trigeminal neuralgia; Rx gabapentin (effective); Morphine 10mg IR prn started 2 years ago to facilitate participation in therapy

• Currently taking 25mg tabs: 4 tabs po q4 hr (16-20 tabs per day). Runs out early. Then uses T1s.

• Naproxen 500mg BID daily

• Cannabis 8 g /day ... Alcohol – 10-12 SD on bad headache days (1 year ago: 1 day q2 weeks; now 3 days per week)

What Is Pain? IASP (1986): an unpleasant sensory and emotional experience associated with

actual or potential tissue damage

Acute pain is a vital, protective mechanism that permits us to live in an environment fraught with potential dangers

In contrast, chronic pain serves no such physiologic role and is itself not a symptom, but a disease state

Chronic = pain which lasts beyond the ordinary duration of time that an insult or injury to the body needs to heal Beyond 3-6 months in duration

IASP- International Association for the Study of Pain

Chronic Pain is Common

Prevalence of chronic pain in the adult population may be 20-25% Of which ~50% experience moderate

and 14% experience severe chronic pain daily or most days of the week

Most common reason for visit to family physician (~ 20-25%)

• Opioids have long been used to

manage pain, especially in acute

and palliative contextsSchopflocher, D., Taenzer, P., & Jovey, R. (2011). The prevalence of chronic pain in Canada. Pain Research & Management, 16(6), 445-450.

Steingrimsdottir, O. A., Landmark, T., Macfarlane, G. J., & Nielsen, C. S. (2017). Defining chronic pain in epidemiological studies: A systematic review and meta-

analysis. Pain, 158(11), 2092-2107.

Chronic Pain– Special Populations - 1 Older Adults

Prevalence of Chronic Pain increases with age

1/3 of Canadians > 65 live with chronic pain

Children and Adolescents

Prevalence = 11-18% (King et al, 2011)

Common presentations: recurrent headaches, abdominal pain, back pain, MSK pain

Pain in this group can impact development, lead to chronic pain, substance use and psychological disorders later in life

Females – chronic pain more common across all age groups (FM, IBS, RA, Chronic Pelvic Pain, Migraine)

Groenewald, C. B., Law, E. F., Fisher, E., Beals-Erickson, S. E., & Palermo, T. M. (2019). Associations between adolescent

chronic pain and prescription opioid misuse in adulthood. The Journal of Pain, 20(1), 28-37.

Chronic Pain– Special Populations - 2 Indigenous Peoples – highest prevalence of CP in Canada (Meana et

al, 2004) Indigenous peoples often articulate the experience of physical pain as

being secondary to emotional pain (as a result of racism, colonization, premature death of kin, dispossession, dislocation, community violence)

Veterans – experience chronic diseases 2-3X higher prevalence vs general population (N=670,000) 41% experience chronic pain

63% with CP have concurrent mental health condition

65% of vets with past year suicidal ideation report chronic pain

76% of past-year suicide attempts report chronic pain

Substance users – significantly higher prevalence of chronic pain 31-55%

Unmanaged pain may lead to problematic use of substances more pain and health complications

Chronic Pain in Canada: Laying a Foundation for Action. Canadian Pain Task Force. June 2019. https://www.canada.ca/en/health-canada/corporate/about-health-

canada/public-engagement/external-advisory-bodies/canadian-pain-task-force/report-2019.html

…& Complicated

• Associated with the worst quality of life when compared with other chronic diseases such as chronic cardiovascular or respiratory diseases (Jovey et al. 2010)

• Mood and anxiety disorders are 2 – 7 x more prevalent in populations of chronic pain and migraine patients in primary, specialty and tertiary care samples (Tunks et al 2008)

• Co-morbidities multiply functional compromise and QOL restrictions with pain (NB: OUTCOMES)

• Suicide risk 2x higher in CP population vs the non-pain population (Tang, 2006)

• Increased prevalence of SUDs

Some Pearls….

The Little Prince – Antoine De Saint-Exupery

• Chronic pain is treatable

• Many causes --> assess thoroughly

• Attend to risk

• Attend to co-morbidities

• 3 Ps of Pain Treatment: Pharm, Psychological, Physical

• Tapering opioids improves outcomes

• Outcomes: Function, QoL, Pain

• The right to effective pain management is not equal to a right to be prescribed opioids

• Treat pain in patients with substance use disorders

ADDOP: The Five Pillars of Pain Management

• Assess: Symptoms and Risk

• Define the problem: where and what is it?

• Diagnose the kind of pain and treat it

• Other issues: mood, anxiety, sleep, addiction, sex

• Personal management, self management

Gordon A. Pain Manag. 2012

Jul;2(4):335-44.

Pillar 1: Assessment

• General history

• Neurological history

• Pain history

• Risk History = “Universal Precautions History”

Homo sum, humani nihil a me alienum puto - Terrance

I am human, and I consider nothing that is human alien to me

Pillar 1: Assessment

• Lancinating pain V2, V3. Triggered by brushing chin

• Cervical headaches exacerbated by movements; cold; stress; radiate up over vertex and behind both eyes R>L). Assoc photophobia, osmophobia.

• Childhood adversity

• Trauma

• Aberrant drug-related behaviours

Pillar 2: Define the Underlying Problem

• General, MSK and neurological exam• Investigation

Neurophysiological testing: EMG/NCT and possibly evoked response

Pain scales including BPI and DN4, S-LANNS

Neuroimaging when indicated

• Where is the lesion and what is the lesion?

• Applies to neurological conditions and non-neurological conditions

• Treating underlying disease sometimes helps reduce pain

Pillar 3: Diagnose Pain and Treat Accordingly

• Nociceptive vs. Neuropathic

• Cancer vs. Non-Cancer

• Acute vs. Chronic

• Mild, Moderate and Severe

Pillar 3: Diagnosis: Nociceptive vs. Neuropathic

Nicholson BD (2003)

Comerci G (2014)

Murat et al (2018)

Pain

Nociceptive Normal stimulation of nociceptors

Thermal, chemical, mechanical

Neuropathic

Abnormal nervous system activation

Somatic Visceral Central Peripheral

Existential Pain that occurs upon questioning and doubting thevalue of one’s ongoing existence as a living, sentient

being

NociplasticDisturbance in central pain processing:

+ excitcability / - inhibition

Pillar 4: Other Symptoms and Conditions

• Sleep

• Mood and Anxiety Disorders

• Substance Use Disorders

• Trauma

• Fatigue

• Sexual Function

Pillar 4: Other Symptoms and Conditions

• Depression

• Suicidal ideation associated with pain

• Dissociative episodes

• Fragmented sleep wakes up sweaty and restless

• Flashbacks and trauma-related nightmares

Pillar 5: Personal Responsibility and Self-Management

• Who’s working harder?

• Lack of buy-in and self management ‘refractory’ patient

• Proactive management of realistic expectations

• Need to educate patient and family about pain management techniques

• Therapeutic alliance is key

• Clinicians need to practice (not just talk about) interprofessional model• Lack of prompt recovery we tend to repeatedly apply medical model – more consults, tests,

drugs

• Other modalities – psychological and otherwise – are left out

Pain as a Motivational Disorder

• A daily reminder of derailment

• Traumatic

• Robs assertiveness

• A neurological signal to STOP

• Multifactorial – multiple concurrent disorders

• Overwhelming

• Isolating

Stages of Change –Where’s the Patient?

Meet them where they are

Continuum of ambivalence

Explore readiness to change, importance and confidence

Treating Chronic Pain: The 3 Ps

•Physical

•Psychological

•Pharmaceutical

Pharmacologic Steps in Neuropathic Pain

TCA Gabapentin / Pregabalin SNRI

Tramadol Opioid Analgesics

Cannabinoids

Fourth Line Agents **

** eg SSRIs, methadone, lamotrigine, topiramate, valproic acid

*** Do not add SNRI to TCA

Add additional

agents

sequentially if

partial but

inadequate pain

relief***

Moulin DE et al. Pain Res Manag. 2014

Non-pharmacologic therapy Self-Management

Cognitive and Behavioural Therapy (CBT)

Meditation

Mindfulness techniques

Exercise

Physical therapy

Interventional approaches: nerve stimulation or block

Acupuncture

Botox

ETC…

Pillar 5: Pain Recovery• Reimagining pain from uncontrollable to manageable

• Fostering optimism and combating despair

• Promotion of patient feelings of success, self-control and efficacy

• Patients attribute success to their own role

• Education in specific skills: pacing, relaxation, problem-solving

• Emphasis on active patient participation and responsibility

ECHO: Introducing a 6th Pillar…• Assess: Symptoms and Risk

• Define the problem: where and what is it?

• Diagnose the kind of pain and treat it

• Other issues: mood, anxiety, sleep, addiction, sex

• Personal management, self management

• OUTCOMES

ECHO Ontario: VISIONThat all primary care providers in

Ontario have the knowledge and support to manage chronic pain safely and effectively.

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