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21/04/2015
Understanding
persistent pain
Dr. Maureen Allen BN CCFP(EM)
March 4, 2015
"Brainman understands pain in less than 5 minutes“
https://www.youtube.com/watch?v=5KrUL8tOaQs
"Brainman stops his opioids”
https://www.youtube.com/watch?v=MI1myFQPdCE
Objectives
• Understanding pain
• Explore Pain classification
• How helpful are they in 2015?
• Management of pain
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What is pain?
COMPLEX
• Pain is an unpleasant sensory and
emotionalSUBJECTIVE
experience associated with
actual or potential tissue damage or
described in terms of such damage.
Classification of Chronic Pain Task Force on Taxonomy. IASP Press 1994
But did you know pain is also……..
CALL TO ACTION
It is also meant to be Protective…
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Pain protects us through….
A. OUR MUSCLES
SPASM
B. AND BY….HOW WE MOVE
WEAK
But…..
• Not all pain is the same
• Nor is all pain protective
• Despite the severe experience
Best described by….
• Described by intensity (Pain scales)
• Or by time or mechanism
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Pain scales: Good or bad?
It depends........
What are we measuring?
INTENSITY
Von Baeyer C. (2006). Children’s self-reports of pain intensity: Scale selection, limitations and interpretation. Pain Research and
Management. 11(3) 2006: p. 157-162.
Bergman CL. J Emerg Nurs. Emergency Nurses’ Perceived Barriers to Demonstrating Caring When Managing Adult Patient’s Pain.
38(3):218, May 2012.
Mularski RA, White-Chu Foy, Overbay D, et al. Measuring Pain as the Fifth Vital Sign Does Not Improve Quality of Pain Management.
J Gen Intern Med. 21(6):607, June 2006.
The complexity of pain and
suffering
(Physical, psychosocial and spiritual)
PHYSICAL
EMOTIONAL
TOTAL
PAIN
SOCIAL
View pain scales as suffering scales
15/10 pain = 15/10 suffering
SPIRITUAL
Kross E, Berman M, Mischel W, et al. (2011) Social rejection shares somatosensory representations with physical pain. Proceedings of
the National Academy of Sciences, 108, 15: 6270-6275.
Underlying Mechanisms
NOCIECEPTIVE
NEUROPATHIC
(Bone, viscera, tissue)
CENTRAL
NONINFLAMMATORY
•
•
Degenerative arthritis
Degenerative Disc Disease
INFLAMMATORY
•
•
Connective Tissue
Disorders (Lupus, RA)
Inflammatory bowel disease
(Brain and Spinal
Cord)
PERIPHERAL
•
Shingles
•
•
Fibromyalgia
Chronic “persistent” pain
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TIME:
ACUTE PAIN (SHORT-TERM
PAIN)
• Results in new condition or
progression of pre-existing
disease
• Primarily nociceptive (tissue,
bone, organ) but can be
neuropathic
• Protective
• Predictable
• Protective
• Predictable
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Pain
Intensity
0
Time
Injury
Illness
Surgery
Unknown
0/10
6 months
Butler D, Moseley GL. Explain Pain. Noigroup Publications, Adelaide South Australia. ISBN-10 097509 100X. June 2003.
Chronic “persistent” pain
(Long-term Pain)
• Sensitization (Amplification)
• Pain system has become hypervigilant in it’s duty to protect
• Pain experience NOT an accurate
reflection of what is occurring in the
tissue but the pain experienced is
real
• Chronic illness that needs chronic
disease management
• Primarily a central neuropathic pain
syndrome
• “Flare-ups” important to understand
• Not Protective
• Not Predictable
10
Pain
Intensity
0
Injury
Illness
Surgery
Unknown
5/10
Time
6 months
Butler D, Moseley GL. Explain Pain. Noigroup Publications, Adelaide South Australia. ISBN-10 097509 100X. June 2003.
Chronic pain “flare-up’s”
• Increase base-line pain that
can last hours to days
• Sensitization (Amplification)
• NOT the result of new
disease or progression of a
pre-existing condition
• Investigations unchanged
• This is NOT ACUTE pain
• Essential for patient and
clinician to understand
what’s causing “flare-ups”
Flare-up Pain
15/10
Pain
Intensity
Daily baseline pain
5/10
0
Injury
Illness
Surgery
Unknown
Time
Butler D, Moseley GL. Explain Pain. Noigroup Publications, Adelaide South Australia. ISBN-10 097509 100X. June 2003.
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Repeat Flare-ups lead to....
What does central amplification or
sensitization look and feel like?
Other senses
often amplified
What factors contribute to pain amplification
• Spinal cord sets the volume and
Brain adjusts the intensity
• Brain memory (Protective)
• Brain map
• Opioids (Nociceptive sensitization)
• How we think and feel
• Addiction
• Withdrawal
• Activity (Too much, too little)
• Poor sleep
• Frequent or daily “PRN” strategy’s
(Keep patients more pain focused)
Dorsal horn
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Management of complex pain
• How do you get patients from “Find and fix”
to chronic disease management?
• Need to help them shift thinking (Hope)
• De-stigmatize the illness of chronic pain
(Validate that their suffering is real)
• Understand the value of motivational
interviewing (Not everyone ready to
embrace change)
• If patient not ready to shift thinking, then
safety and consistency in care need to be
the priority(Comprehensive care plan and
managing high risk therapies)
• YouTube: Australian Pain society
“Brainman stops his opioids”
“Brainman understand pain in less than 5 minutes”
6 step Approach to Pain and Addiction
STEP 1
Patient presents
with pain
Pain is physical,
psychological and
spiritual
View pain scales as
suffering scales
ACUTE PAIN
What type of pain
STEP 2
STEP 3
are you dealing
with?
CHRONIC PAIN
CHRONIC PAIN
FLARE-UP
Any Interventions
CANCER PAIN OR
PAIN AT EOL
PALLIATIVE CARE
SERVICES
indicated?
STEP 4
Any Alternative
Therapies
indicated?
STEP 5
What
Pharmacology is
available?
STEP 6
Are there concerns
re: Addiction or
Diversion?
Allen MA. A Community based-approach to the treatment of Pain and Addiction. Canadian Journal of Rural Medicine. 2014. 19(1)
Allen MA, Jewers MS, McDonald JS. A Framework for the Treatment of Pain and addiction in the Emergency Department. Journal of Emerg Nursing. Vol 40, Issue 6, pages 552-559.
November 2014.
Pacing
Cannabinoids
Topicals
Noble M, Treadwell JR, Tregear SJ et al. Long term opioid management for Chronic Non-Cancer Pain. Cochrane Database of Systemic
Reviews 2010, Issue 1. Art N.: CD006605. DOI: 10. 1002/14651 858. CD006605. Pub 2.
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Pharmacological choices?
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Acetaminophen (Tylenol)
NSAID’s (Advil, Aleve etc)
TCA (Elavil)
Anticonvulsants (Lyrica, Gabepentin)
Broad spectrum antidepressants
(Duloxetine, Effexor)
CANNABINOID HYPEREMESIS
Topicals
Opioids (SA vrs LA)
Cannabinoids (Smoke, drink or ingest)
Maximum is <2 grams a day
Lidocaine, Ketamine etc...
Low dose naltrexone
Gamma hydroxybutyrate (GHB)
SYNDROME
Lynch, Mary MD. Drugs and Therapeutics for Maritime Practitioners. Pharmacology of Chronic Pain. Vol 20, No 5/6 October/November, 1997.
Golberg et al. JAMA, 2004;292 2381-95.
Ware, Mark. Marijuana as medicine; does it have a future? Clin Pharmacol Ther 83(4): 515-517; 2008.
Pharmacological treatment
goals
PHARMACOLOGY
TREATMENT GOALS
CHRONIC PAIN AND
ACUTE PAIN
CHRONIC PAIN
FLARE-UP
80-100% Pain reduction
30-40% Pain reduction
Minimize Sedation
Avoid Sedation
Improve Function
Improve Function
CANCER PAIN OR
PAIN AT THE END OF
LIFE
80-100% Pain reduction
May Cause Sedation
May Compromise
Function
Allen MA. A Community based-approach to the treatment of Pain and Addiction. Canadian Journal of Rural Medicine. 2014. 19(1)
Allen MA, Jewers MS, McDonald JS. A Framework for the Treatment of Pain and addiction in the Emergency Department. Journal of Emerg Nursing. Vol 40, Issue 6, pages 552-559.
November 2014.
Pain treatments based on
Underlying Mechanisms
NOCIECEPTIVE
Non-inflammatory
Inflammatory
NEUROPATHIC
Peripheral
Central
(Amplification)
*OPIOIDS (<2 weeks due to nociceptive sensitization)
NSAIDS (Caution with RI, HTN,GI)
Acetaminophen
Immunosuppressants
Anti-inflammatories
Biologicals
Tricyclic's
SNRI’s
Alpha-2-delta ligand anticonvulsants
Gabapentin
Pregabalin
Tricyclic's
SNRIs
•
•
•
•
*Injections and surgical procedures less effective or
centralized pain
Kroerke K, et al. Gen Hospital Psychiatry 2009, 31(3) 206-219
ineffective for individuals with
Dray A. Rheum Disc. Clinc. N Am 2008
Finnerup NB et al. Pain. 2010
*Noble M, Treadwell JR, Tregear SJ. Long-term opioid management for chronic non-cancer pain. Cochrane Database. Syst
Rev. 2010. CD 004959.
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Evidence: Fibromyalgia
Strong
evidence
Moderate
evidence
Weak
evidence
No evidence
•
•
•Dual reuptake inhibitors
•TCA’s: Amitriptyline, Cyclobenzaprine
•SNRI’s and NSRI’s: Minacipran, Duloxetine, Venlafaxine
•Anticonvulsants
•Pregabalin, gabapentin
•Tramadol
•Older less selective SSRI’s or NRI’s
•Gamma hydroxybutyrate (GHB)
•Low dose naltrexone
•Cannabinoids
•Growth hormone
•5-hydroxytryptamine (Serotonin)
•Tropisetron (Novoban) Antiemetic-Serotonin 5-HT3 antagonist
•S-adenosyl-L-methionine (SAMe) (Supplement)
•Opioids
•Corticosteroids
•NSAID’s
•Benzodiazepine and nonbenzodiazepine hypnotics
•Guanifenesin (Expectorant)
Lynch, Mary MD. Drugs and Therapeutics for Maritime Practitioners. Pharmacology of Chronic Pain. Vol 20, No 5/6 October/November, 1997.
Modified from Golberg et al. JAMA, 2004;292 2381-95.
If it only gets you through the day is it holding you
back?
15 joints a day?!
WTF?
Permission granted Chronicle Herald Dec 2013
Three most important strategy’s you can give
your patient
• Help them become more
active WITHOUT flaring them
up (pacing)
• Help them find a more
effective sleep strategy without
making them hung over during
the day
• Help them engage in a life of
purpose and gratitude by
helping them re-connect to the
people and things that matter
in their life that can bring joy
and happiness back into their
life
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Remember the journey……
• Is the patient’s
• You’re there to provide your
expertise and to support them
• But….Not everyone is ready to
embrace change
• Do not measure your success by
pain reduction alone
• Look at your functional and ADL
goals
• Understand what’s realistic with
respect to time frame for
recovery
• Nervous system need consistency
and to feel safe with the activities
Summary
• Pain is subjective
• Validate that the pain and suffering
are real
• Approach varies depending on where
they are on the change continuum
• Know what we bring to the table
(Attitudes, judgement, stigma)
• Know what type of pain you’re
treating
• Knowledge is power for you and the
client
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