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dbPAIN AND DISABILITY
CHRONIC PAIN?Miles Belgrade, MD, Adjunct Associate
Professor, Department of Neurology, University of Minnesota
Medical School, and Medical Director, Fairview Pain
Management Center, Minneapolis
Assessment of chronic pain: includes determining
physiologic category, identifying contributing factors that
worsen pain or make it last longer, and recognizing
barriers to assessment and treatment that make pain more
difficult to manage
Physiologic categories: nociceptive?inflammation (eg,
rheumatoid arthritis) or mechanical factors (eg,
spondylolisthesis) causing active irritation of nerve
fibers that carry pain; treat with nonsteroidal
anti-inflammatory drugs (NSAIDs) or narcotics;
muscular?mechanisms not fully understood; no drug therapy
(muscle relaxants do not work well); physical
rehabilitative approach required; neuropathic?due to
disordered or dysfunctioning nervous system; gabapentin
(Neurontin) first-line agent for management;
psychogenic?eg, due to anxiety; treat according to cause,
eg, anxiolytic
Contributing factors: insomnia; occupational factors, eg,
repetitive motion; habit, eg, gum chewing in headache
patient; poor posture, eg, in patient with neck pain;
deconditioning increases pain because activity requires
more work; medical conditions; anxiety about return of pain
causes autonomic arousal, hypervigilance, and pain
behaviors, eg, guarding, that increase pain (managing
anxiety sometimes as important as managing underlying
causes of pain); other symptoms, eg, itching, vomiting
Barriers: social?include insurance noncoverage of pain
treatment, eg, acupuncture; biologic?eg, steroid-dependent
patient with multiple steroid-induced fractures;
behavioral?passivity (patient who will not take initiative
in own care); unrealistic expectations of cure (chronic
pain not curable; unrealistic expectations of cure
especially problematic in obsessive or compulsive patient
because to them, anything less than 100% relief is same as
no relief); low motivation; nonconforming personality;
note?early identification of barriers helps physician know
why management failing and stops him or her from pursuing
therapies that cannot succeed because of barriers
Goals of management: to improve patient?s sense of control,
function, and sense of well-being and overall satisfaction;
not trying to reach lower number on pain scale as in acute
pain
Chronic pain patient in acute care setting: physician must
be alert to changes in pain characteristics that indicate
onset of new condition; example?woman 49 yr of age presents
to emergency department for fifth time in 1 mo with
episodic migraine; she has had episodic migraine since
adolescence; in past 2 yr, headaches have become almost
daily; pain relieved by meperidine (Demerol) and
hydroxyzine (Vistaril); speaker would withhold acute- phase
medications and treat as chronic pain patient; example?man
35 yr of age with 10-yr history of low back pain sustains
injury at work (L5-S1 disc herniations); laminectomy
performed, and shooting leg pain improved; also has
incisional pain plus his chronic diffuse lumbar pain (7 on
scale of 1-10); increasing morphine dose not helping, and
patient demands ?something stronger?; physician must
determine whether pain patient feeling is acute incisional
pain that can be treated with opioids or underlying chronic
pain that cannot; get patient back to baseline chronic
pain, then stop; explain to patient that chronic pain must
be treated on outpatient basis after postoperative care
completed
Temporal categories of pain: acute; chronic recurrent, eg,
migraine; chronic; terminal; neurotransmitters?2 families
of vesicles within nerve endings; vesicles involved in
acute (?good?) pain carry glutamate; dense core vesicles
involved in chronic pain carry other neurotransmitters,
including substance P, brain-derived neurotrophic factor
(BDNF), cholecystokinin (CCK), and calcitonin gene?related
peptide (CGRP); these mediate neuropathic pain and chronic
inflammatory pain, ie, pathologic (?bad?) pain; receptors?3
types of receptors for pain in central nervous system
(CNS); alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionic
acid (AMPA) receptor for acute pain responds to glutamate
and inhibited by opioids; N-methyl-D -aspartate (NMDA) and
neurokinin receptors for neuropathic and pathologic pain
not inhibited by opioids
Goals in management of chronic pain: pain scales of 1 to 10
have ?absolutely no meaning? in chronic pain; in most
chronic pain patients, pain remains within narrow range,
and movement to lower rating on scale virtually impossible;
pain rating not useful guide for therapy; goals should be
to have patient tolerate treatment, increase activity,
engage in life roles, have sense of control over pain, know
what to do when flare occurs, function at higher level,
return to work, and not overuse health care system
Goals in management of acute pain: maximize comfort
(highest priority); achieve symptom control at all costs;
aggressive pharmacologic management
Pain flare in chronic pain: temporary increase in pain
intensity not caused by disease progression and having
characteristics otherwise similar to patient?s baseline
chronic pain
Breakthrough pain: term not used in context of chronic
pain; calls for management with short-acting narcotics;
defined for patients hospitalized with terminal cancer as
baseline stable pain with >20% fluctuation in opioid dose
on 2 days
Pain flare medication cycle: 100% of chronic pain
patients experience flares, regardless of drug used or
dosage; patient often interprets flare as worsening of
condition or development of tolerance to medication, and
requests increase in dosage; if physician complies, patient
may interpret end of flare as result of medication
increase; however, flare temporary by definition; patient
continues on higher dose even after flare subsides; at next
flare, sequence repeated; net effect is higher and higher
dosages of medication and increased side effects, eg,
sedation; physician must have plan for managing flares
without increase in medication dosage, or, if dosage
increased, plan must include return to original dosage at
end of flare or at preset time
Pseudotolerance: apparent failure of medicine to maintain
control of chronic pain, resulting in repeated dose
escalations during flares, without return to baseline doses
once resolution of flare occurs
Algorithm for flares: 1) determine that worsening really
caused by flare, ie, intensity of pain worse but not
characteristics or distribution; 2) identify and manage
contributing factors; 3) identify and manage barriers to
flare resolution; 4) inform patient that this is flare and
that it will improve, but might take several weeks; 5) use
flare management tools, eg, pacing, relaxation, distraction
(reading speaker?s book on flare management takes 2 wk),
stimulation (massage, heat, vibration), temporary increase
in medication with definite cutoff date
Vignettes in opioid management: ?I had to take more pain
medicine?the pain was 10 times worse;? speaker explains
that opioid system poorly related to intensity of pain; ups
and downs in intensity must be managed by other methods,
and patient must inform physician when they occur before
increasing medication dose; ?I can?t help it; my roommate
is chemically dependent; he took my pills;? speaker tells
patient that if his or her environment is not safe for
controlled substances, physician cannot prescribe
controlled substances; he tries to figure out ways to
control environment, eg, lockbox; if these do not work, and
overuse of medication continues, speaker stops prescribing
opioids for that patient; marijuana found on drug screen
and patient says, ?Aw, come on, Doc, ten percent of the
population smokes marijuana;? speaker tells patient that he
cannot continue to prescribe controlled drug while patient
involved in illegal drug activity; marijuana remains in
body for weeks; speaker informs patient that if he or she
stops smoking marijuana, and subsequent drug screen clean,
opioid therapy will continue; if screen shows marijuana
again, opioids discontinued and patient referred for
evaluation of chemical dependency; ?OxyContin [oxycodone]
only lasts 4 hr, so I need to take it more often;?
OxyContin lasts 8 to 12 hr; speaker tells patient that if
he or she cannot stick to q8h dosing, this might be wrong
drug for him or her; ?If I can?t get something for my pain,
I?ll kill myself;? prescribing pain medication that could
be lethal in overdose contraindicated; if speaker thinks
patient has intent and has means to commit suicide, he has
patient escorted to emergency department
Case: 3 yr after car accident, woman still unable to return
to work because of pain; she has been through chiropractic,
medication, exercise, is becoming depressed, and feels that
her life has been taken from her; management choices
include gabapentin (Neurontin), chronic pain management
program, long-acting opioid, acupuncture
Analysis: preliminary data show that while opioids might
help pain, they do not improve function; acupuncture
insufficient for this patient because of multiple barriers,
including mood, disability issues, and insurance issues;
multidisciplinary pain program only modality that has shown
improvement in outcomes such as reduced medication use,
return to work, reduced health care utilization, increased
physical functioning, and decreased pain behavior
Questions and Answers
Tolerance to opioids: occurs relatively early (first
several months), then plateaus; once dose becomes stable,
it usually remains stable
Treatment of neuropathic pain: gabapentin best for general
neuropathic pain; for trigeminal neuralgia, carbamazepine
best; speaker also uses lamotrigine and tricyclic
antidepressants
Prevention of progression to chronic pain after injury:
identify patients at risk as early as possible after injury
and treat aggressively and appropriately; factors that
predict chronic pain problem include psychosocial support
and history of abuse and other childhood challenges
ISSUES IN DISABILITY EVALUATION?Kenneth R. Britton, DO,
Adjunct Clinical Professor, Department of Pain Management
and Rehabilitation, University of Minnesota Medical School,
and Medical Director for Rehabilitation Services, Bethesda
Rehabilitation Hospital, St. Paul
World Health Organization (WHO) definitions:
impair-ment?loss or abnormality of psychologic, physiologic
or anatomic structure or function; produced by disease or
trauma; examples include, weakness, dyspnea, amputation
below knee, anxiety; disability?how im-pairment affects
individual?s ability to perform normal activities, eg,
person with below-the-knee amputation has disability in
activity of walking; handicap?disadvantage resulting from
impairment or disability, eg, inability to access building
because of steps
Physician?s role in disability evaluation: provide medical
care; provide documentation of care and information to
patient and to disability system; patients often need help
negotiating system, and social workers and lawyers can
provide this; not physician?s responsibility to ensure
patients gets disability benefits
Key issues in disability process: maximum medical
im-provement?means ?they?re as good as they?re going to
get?; disability systems and insurance carriers need to
know whether patient has reached this stage; much leeway in
how physician defines ?maximum?; issue is significant gains
as opposed to minor gains; American Medical Association
(AMA) definition of disability?how impairment affects
ability to perform personal, social, or occupational
activities; AMA Guides to Disability Evaluation published
periodically (fifth edition most recent; 2003); Social
Security Administration definition of disability?inability
to engage in substantial gainful activity because of
physical or mental impairment that can be expected to
result in death or which has lasted or can be expected to
last for continuous period of greater than or equal to 12
mo; timeline varies, depending on clinical impression and
understanding; guideline for ?substantial gainful activity?
approximately $900/mo; impairment rating?based on
application of agreed-upon criteria, eg, AMA Guides, state
guidelines; usually expressed as percentage of whole
person; combined rather than additive, eg, if loss of use
of one arm rated 50%, loss of use of both arms rated 75%
(loss of second arm calculated as 50% of 50% remaining
after loss of first arm, ie, 25%, which is then added to
50% due to loss of first arm); independent medical
examination (IME)?medical evaluation performed by physician
not involved in case, ie, physician cannot evaluate own
patient; physicians discouraged from accepting patient for
treatment after performing IME on that patient
Educational Objectives
The goal of this program is to educate the listener about
management of patients with chronic pain and the basics of
disability evaluation. After hearing and assimilating this
program, the clinician will be better able to:
List the physiologic categories of chronic pain.
Describe some factors that contribute to chronic pain and
some barriers to its management.
Explain how chronic pain differs from acute pain at the
neurophysiologic level.
Discuss the goals of management of chronic pain and give
an algorithm for managing pain flares in patients with
chronic pain.
Define key terms and issues in the disability process.
Discussed on This Program
Carbamazepine (several trade names)
Gabapentin [Neurontin]
Hydrocodone bitartrate and acetaminophen [Vicodin, others]
Hydroxyzine [Vistaril, others]
Lamotrigine [Lamictal, Lamictal Chewable Dispersible]
Meperidine HCl [Demerol]
Morphine sulfate (several trade names)
Oxycodone and acetaminophen (several trade names)
Oxycodone HCl (several trade names)
Suggested Reading
Belgrade MJ et al: Diabetic neuropathy. Helping patients
cope with their pain. Postgrad Med 90:263, 1991; Belgrade
MJ: Following the clues to neuropathic pain. Distribution
and other leads reveal the cause and the treatment
approach. Postgrad Med 106:127, 1999; Belgrade MJ: Opioids
for chronic nonmalignant pain. Choosing suitable candidates
for long-term therapy. Postgrad Med 106:115, 1999; Fishman
SM et al: Challenges and choices in drug therapy for
chronic pain. Cleve Clin J Med 70:119, 2003; Glajchen M:
Chronic pain: treatment barriers and strategies for
clinical practice. J Am Board Fam Pract 14:211, 2001; Glenn
B et al: Pain self-management in the process and outcome of
multidisciplinary treatment of chronic pain: evaluation of
a stage of change model. J Behav Med 26:417, 2003; Gross DP
et al: The prognostic value of functional capacity
evaluation in patients with chronic low back pain: part 2:
sustained recovery. Spine 29:920, 2004; Gross DP et al: The
prognostic value of functional capacity evaluation in
patients with chronic low back pain: part 1: timely return
to work. Spine 29:914, 2004; Kalauokalani D et al: Lessons
from a trial of acupuncture and massage for low back pain:
patient expectations and treatment effects. Spine 26:1418,
2001; Lansbury G: Chronic pain management: a qualitative
study of elderly people's preferred coping strategies and
barriers to management. Disabil Rehabil 22:2, 2000; Liu HP
et al: Localization of glutamate receptor subunits of the
alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionate (AMPA)
type in the pancreas of newborn guinea pigs. Pancreas
14:360, 1997; Marcus DA: Obesity and the impact of chronic
pain. Clin J Pain 20:186, 2004; McCarberg BH et al:
Long-acting opioids for chronic pain: pharmacotherapeutic
opportunities to enhance compliance, quality of life, and
analgesia. Am J Ther 8:181, 2001; Nicholson BD: Diagnosis
and management of neuropathic pain: a balanced approach to
treatment. J Am Acad Nurse Pract 15:3, 2003; Patrick LE et
al: Long-term outcomes in multidisciplinary treatment of
chronic low back pain: results of a 13-year follow-up.
Spine 29:850, 2004; Pincus T et al: Cognitive-behavioral
therapy and psychosocial factors in low back pain:
directions for the future. Spine 27:E133, 2002; Potter M et
al: Opioids for chronic nonmalignant pain. Attitudes and
practices of primary care physicians in the UCSF/Stanford
Collaborative Research Network. University of California,
San Francisco. J Fam Pract 50:145, 2001; Ruoff GE:
Challenges of managing chronic pain in the elderly. Semin
Arthritis Rheum 32:43, 2002; Schultz IZ et al: Psychosocial
factors predictive of occupational low back disability:
towards development of a return-to-work model. Pain 107:77,
2004; Szekely JI et al: The role of ionotropic glutamate
receptors in nociception with special regard to the AMPA
binding sites. Curr Pharm Des8:887, 2002; Turk DC et al:
Psychological factors in chronic pain: evolution and
revolution. J Consult Clin Psychol 70:678, 2002;
Turner-Stokes L et al: Outpatient cognitive behavioral pain
management programs: a randomized comparison of a
group-based multidisciplinary versus an individual therapy
model. Arch Phys Med Rehabil 84:781, 2003; Velly AM et al:
Contributing factors to chronic myofascial pain: a
case-control study. Pain 104:491, 2003.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest
Foundation requests all lecturers to disclose any
significant financial relationship with the manufacturer or
provider of any commercial product or service discussed.
The following has been disclosed: Dr. Belgrade is on the
Speakers? Bureau of Pfizer US Pharmaceutical Group, Janssen
Pharmaceutica, and Purdue Fredrick Co.
Drs. Belgrade and Britton were recorded at the 30th Annual
Course, Family Practice Review Update 2004, held May 3-7,
2004, in Minneapolis and sponsored by the Department of
Family Practice and Community Health, University of
Minnesota Medical School. The Audio-Digest Foundation
thanks the speakers and the sponsor for their cooperation
in the production of
Selecting the Approach to Treatment
In overweight and mildly obese patients, diet, exercise,
and lifestyle approaches should be used exclusively. The
behavioral tools available include confirming readiness to
change, using stimulus control to minimize the intake of
high-calorie trigger foods, and offering information on
exercise, relapse prevention, and stress reduction. A
reduced-calorie diet plan that is low in fat, provides
adequate protein for satiety, and is rich in low-calorie,
nutrient-dense fruits and vegetables is advised. The use of
carefully selected meal replacements and portion-controlled
meals to reduce caloric intake and provide security in
calorie counting can be a very effective approach.
Pharmacotherapy is an appropriate adjunct in patients with
a BMI >/= 27 with comorbidities, or >/= 30 without
comorbidities.
Meal Plans and Meal Replacements
Portion control is one of the primary strategies in calorie
control. Typical diet plans specify what foods should be
consumed for meals and snacks, and portion sizes are
usually specified in standard weights and measures.
However, many people do not take the time to weigh and
measure foods, or they may abandon this practice after a
period of time, thinking they can estimate portions fairly
well. A few small mistakes can add up significantly. (See
the Toolkit for a list of common calorie-counting errors
and sample menus.) Patients may be confused about whether
they are supposed to weigh foods before or after cooking,
and they may not account for condiments or other
ingredients.
Meal replacements are foods designed to take the place of a
meal while providing nutrients within a known calorie
limit, and can take the form of shakes, bars, soups, or
frozen portion-controlled meals. Replacing 2 meals per day
with meal replacements has been shown to produce weight
loss results superior to those reported with calorie
counting and can be an effective strategy to teach patients
in a busy healthcare setting.[5,6]
For weight loss, a 1200-calorie meal plan for women and a
1500-calorie meal plan for men is recommended to start.
(See the Toolkit for sample menus.) Meal replacement bars,
shakes, or frozen meals can be substituted for 2 meals per
day, and the third meal includes a salad, 3 to 6 ounces of
lean protein, fresh vegetables, and one half to one cup of
rice, pasta, or potato, with fruit for dessert. Snacks of
whole fruit or vegetables can be used between meals.
Recent research has demonstrated that an increased variety
of intake in all categories of foods, with the exception of
fruits and vegetables, promotes obesity.[7] By reducing
variety, meal replacements help patients maintain a
structured diet and portion control. Many meal replacements
are excellent sources of protein, fiber, vitamins, and
minerals, and may be superior to simply restricting
conventional food intake if careful food choices, which
would ensure nutritional adequacy, are not made.
Trigger Foods
Patients should also understand the need to minimize the
intake of their own "trigger foods," and appropriate
substitutions should be suggested. (See the Toolkit for a
list of lower-calorie alternatives to high-calorie trigger
foods.) Trigger foods are foods that have an unexpected
amount of "hidden" fat or calories, and are often eaten in
response to a stimulus other than hunger. The motivation
for eating trigger foods may be boredom, agitation,
depression, or fatigue. Encourage patients to identify the
trigger foods that are problematic for them and ask that
they target these food-mood connections for behavior
change. Replacing high-fat, high-calorie trigger foods with
healthier substitutes is also an effective strategy.
Protein and Satiety
Protein provides greater satiety than either carbohydrate
or fat, and it is needed for muscle deposition, which can
increase lean body mass, which in turn raises resting
metabolic rate. Voluntary reduction in energy consumption
has been noted in subjects consuming high-protein meals
compared with high-carbohydrate meals when fed ad libitum,
with greater weight loss and fat loss in those consuming
higher protein.[8]
Several studies have demonstrated significantly more
satiety on a high-protein (approximately 30% of energy
intake) vs a high-carbohydrate diet (10% to15% of energy
from protein),[9,10] and 1 study concluded that the
increased proportion of protein to carbohydrate had
positive effects on body composition as well as on blood
lipids, glucose homeostasis, and satiety during weight
loss.[11]
Practical Tips
Patient education can be integrated into a short visit
aimed at initiating a weight-loss effort. Since patients
often see the primary care provider for other reasons, it
may be advisable to set up a separate appointment
specifically for the discussion of the patient's weight.
The first step is for the primary care provider to indicate
his or her own commitment to helping the patient reach the
goals that will lead to improved health and well being.
Discussing previous attempts at weight loss, including past
obstacles, may help determine the patient's readiness to
change diet and lifestyle. Questionnaires assessing this
psychological variable are available and can be
helpful.[12] In this initial discussion, it may also be
helpful to emphasize both the short- and long-term health
benefits of weight reduction. For example, a diabetic
patient may gain better control of blood glucose, or a
hypertensive patient may be able to manage blood pressure
with smaller dosages of antihypertensive drugs.
Once patient readiness has been determined, outline a
simple program and help set goals and appropriate
expectations. Remind the patient that progress can be
measured not only by changes in weight but also by positive
behavior changes. Since the majority of overweight and
obese patients will present with a comorbidity that will
require regular follow-up, have them return to the office
on a regular basis for monitoring. Some providers find that
a quick weight check by an office staff member every few
weeks helps to keep patients on track.
Pharmacotherapy
For individuals with a BMI >/= 27 with comorbid conditions,
or a BMI >/= 30 without any comorbidity, pharmacotherapy
can be used to augment diet, exercise, and lifestyle
modifications. The 2 approved drugs for weight reduction
and weight maintenance can be used for up to 2 years.
Sibutramine is used at a dosage of 10 mg to 15 mg
daily.[13] It inhibits the reuptake of 2 neurotransmitters
in the brain -- serotonin and norepinephrine. This
inhibition results in increased satiety, which enhances
portion control and leads to permanent weight losses of 5%
to 7% in patients. Because sibutramine can cause a mild
increase in blood pressure, patients with comorbid
hypertension should be monitored carefully.
Orlistat is an inhibitor of intestinal lipase that can
achieve a 30% reduction in fat absorption, and is used at a
dosage of 120 mg 3 times per day.[14] It is recommended for
use with a diet containing 30% fat calories. Some patients
use the drug to avoid eating high-fat foods, because
frequent fatty stools are a common treatment effect of
orlistat when dietary fat calories exceed 30%. Patients
should be instructed to take a multivitamin plus
multimineral 2 hours after a dose of orlistat to avoid
depletion of fat-soluble vitamins.
Integrating Obesity Treatment
Duloxetine (Cymbalta) ? Duloxetine is a dual uptake
inhibitor of serotonin and norepinephrine approved for the
treatment of major depressive disorder and diabetic
peripheral neuropathic pain. The most common adverse
effects include insomnia, headache, somnolence, dry mouth,
tremor and asthenia. The recommended dose of duloxetine
for treatment of major depressive disorder is 20mg twice
daily to 60mg daily. The recommended dose for diabetic
peripheral neuropathy is 60mg daily.
dbPAIN AND DISABILITY
CHRONIC PAIN?Miles Belgrade, MD, Adjunct Associate
Professor, Department of Neurology, University of Minnesota
Medical School, and Medical Director, Fairview Pain
Management Center, Minneapolis
Assessment of chronic pain: includes determining
physiologic category, identifying contributing factors that
worsen pain or make it last longer, and recognizing
barriers to assessment and treatment that make pain more
difficult to manage
Physiologic categories: nociceptive?inflammation (eg,
rheumatoid arthritis) or mechanical factors (eg,
spondylolisthesis) causing active irritation of nerve
fibers that carry pain; treat with nonsteroidal
anti-inflammatory drugs (NSAIDs) or narcotics;
muscular?mechanisms not fully understood; no drug therapy
(muscle relaxants do not work well); physical
rehabilitative approach required; neuropathic?due to
disordered or dysfunctioning nervous system; gabapentin
(Neurontin) first-line agent for management;
psychogenic?eg, due to anxiety; treat according to cause,
eg, anxiolytic
Contributing factors: insomnia; occupational factors, eg,
repetitive motion; habit, eg, gum chewing in headache
patient; poor posture, eg, in patient with neck pain;
deconditioning increases pain because activity requires
more work; medical conditions; anxiety about return of pain
causes autonomic arousal, hypervigilance, and pain
behaviors, eg, guarding, that increase pain (managing
anxiety sometimes as important as managing underlying
causes of pain); other symptoms, eg, itching, vomiting
Barriers: social?include insurance noncoverage of pain
treatment, eg, acupuncture; biologic?eg, steroid-dependent
patient with multiple steroid-induced fractures;
behavioral?passivity (patient who will not take initiative
in own care); unrealistic expectations of cure (chronic
pain not curable; unrealistic expectations of cure
especially problematic in obsessive or compulsive patient
because to them, anything less than 100% relief is same as
no relief); low motivation; nonconforming personality;
note?early identification of barriers helps physician know
why management failing and stops him or her from pursuing
therapies that cannot succeed because of barriers
Goals of management: to improve patient?s sense of control,
function, and sense of well-being and overall satisfaction;
not trying to reach lower number on pain scale as in acute
pain
Chronic pain patient in acute care setting: physician must
be alert to changes in pain characteristics that indicate
onset of new condition; example?woman 49 yr of age presents
to emergency department for fifth time in 1 mo with
episodic migraine; she has had episodic migraine since
adolescence; in past 2 yr, headaches have become almost
daily; pain relieved by meperidine (Demerol) and
hydroxyzine (Vistaril); speaker would withhold acute- phase
medications and treat as chronic pain patient; example?man
35 yr of age with 10-yr history of low back pain sustains
injury at work (L5-S1 disc herniations); laminectomy
performed, and shooting leg pain improved; also has
incisional pain plus his chronic diffuse lumbar pain (7 on
scale of 1-10); increasing morphine dose not helping, and
patient demands ?something stronger?; physician must
determine whether pain patient feeling is acute incisional
pain that can be treated with opioids or underlying chronic
pain that cannot; get patient back to baseline chronic
pain, then stop; explain to patient that chronic pain must
be treated on outpatient basis after postoperative care
completed
Temporal categories of pain: acute; chronic recurrent, eg,
migraine; chronic; terminal; neurotransmitters?2 families
of vesicles within nerve endings; vesicles involved in
acute (?good?) pain carry glutamate; dense core vesicles
involved in chronic pain carry other neurotransmitters,
including substance P, brain-derived neurotrophic factor
(BDNF), cholecystokinin (CCK), and calcitonin gene?related
peptide (CGRP); these mediate neuropathic pain and chronic
inflammatory pain, ie, pathologic (?bad?) pain; receptors?3
types of receptors for pain in central nervous system
(CNS); alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionic
acid (AMPA) receptor for acute pain responds to glutamate
and inhibited by opioids; N-methyl-D -aspartate (NMDA) and
neurokinin receptors for neuropathic and pathologic pain
not inhibited by opioids
Goals in management of chronic pain: pain scales of 1 to 10
have ?absolutely no meaning? in chronic pain; in most
chronic pain patients, pain remains within narrow range,
and movement to lower rating on scale virtually impossible;
pain rating not useful guide for therapy; goals should be
to have patient tolerate treatment, increase activity,
engage in life roles, have sense of control over pain, know
what to do when flare occurs, function at higher level,
return to work, and not overuse health care system
Goals in management of acute pain: maximize comfort
(highest priority); achieve symptom control at all costs;
aggressive pharmacologic management
Pain flare in chronic pain: temporary increase in pain
intensity not caused by disease progression and having
characteristics otherwise similar to patient?s baseline
chronic pain
Breakthrough pain: term not used in context of chronic
pain; calls for management with short-acting narcotics;
defined for patients hospitalized with terminal cancer as
baseline stable pain with >20% fluctuation in opioid dose
on 2 days
Pain flare medication cycle: 100% of chronic pain
patients experience flares, regardless of drug used or
dosage; patient often interprets flare as worsening of
condition or development of tolerance to medication, and
requests increase in dosage; if physician complies, patient
may interpret end of flare as result of medication
increase; however, flare temporary by definition; patient
continues on higher dose even after flare subsides; at next
flare, sequence repeated; net effect is higher and higher
dosages of medication and increased side effects, eg,
sedation; physician must have plan for managing flares
without increase in medication dosage, or, if dosage
increased, plan must include return to original dosage at
end of flare or at preset time
Pseudotolerance: apparent failure of medicine to maintain
control of chronic pain, resulting in repeated dose
escalations during flares, without return to baseline doses
once resolution of flare occurs
Algorithm for flares: 1) determine that worsening really
caused by flare, ie, intensity of pain worse but not
characteristics or distribution; 2) identify and manage
contributing factors; 3) identify and manage barriers to
flare resolution; 4) inform patient that this is flare and
that it will improve, but might take several weeks; 5) use
flare management tools, eg, pacing, relaxation, distraction
(reading speaker?s book on flare management takes 2 wk),
stimulation (massage, heat, vibration), temporary increase
in medication with definite cutoff date
Vignettes in opioid management: ?I had to take more pain
medicine?the pain was 10 times worse;? speaker explains
that opioid system poorly related to intensity of pain; ups
and downs in intensity must be managed by other methods,
and patient must inform physician when they occur before
increasing medication dose; ?I can?t help it; my roommate
is chemically dependent; he took my pills;? speaker tells
patient that if his or her environment is not safe for
controlled substances, physician cannot prescribe
controlled substances; he tries to figure out ways to
control environment, eg, lockbox; if these do not work, and
overuse of medication continues, speaker stops prescribing
opioids for that patient; marijuana found on drug screen
and patient says, ?Aw, come on, Doc, ten percent of the
population smokes marijuana;? speaker tells patient that he
cannot continue to prescribe controlled drug while patient
involved in illegal drug activity; marijuana remains in
body for weeks; speaker informs patient that if he or she
stops smoking marijuana, and subsequent drug screen clean,
opioid therapy will continue; if screen shows marijuana
again, opioids discontinued and patient referred for
evaluation of chemical dependency; ?OxyContin [oxycodone]
only lasts 4 hr, so I need to take it more often;?
OxyContin lasts 8 to 12 hr; speaker tells patient that if
he or she cannot stick to q8h dosing, this might be wrong
drug for him or her; ?If I can?t get something for my pain,
I?ll kill myself;? prescribing pain medication that could
be lethal in overdose contraindicated; if speaker thinks
patient has intent and has means to commit suicide, he has
patient escorted to emergency department
Case: 3 yr after car accident, woman still unable to return
to work because of pain; she has been through chiropractic,
medication, exercise, is becoming depressed, and feels that
her life has been taken from her; management choices
include gabapentin (Neurontin), chronic pain management
program, long-acting opioid, acupuncture
Analysis: preliminary data show that while opioids might
help pain, they do not improve function; acupuncture
insufficient for this patient because of multiple barriers,
including mood, disability issues, and insurance issues;
multidisciplinary pain program only modality that has shown
improvement in outcomes such as reduced medication use,
return to work, reduced health care utilization, increased
physical functioning, and decreased pain behavior
Questions and Answers
Tolerance to opioids: occurs relatively early (first
several months), then plateaus; once dose becomes stable,
it usually remains stable
Treatment of neuropathic pain: gabapentin best for general
neuropathic pain; for trigeminal neuralgia, carbamazepine
best; speaker also uses lamotrigine and tricyclic
antidepressants
Prevention of progression to chronic pain after injury:
identify patients at risk as early as possible after injury
and treat aggressively and appropriately; factors that
predict chronic pain problem include psychosocial support
and history of abuse and other childhood challenges
ISSUES IN DISABILITY EVALUATION?Kenneth R. Britton, DO,
Adjunct Clinical Professor, Department of Pain Management
and Rehabilitation, University of Minnesota Medical School,
and Medical Director for Rehabilitation Services, Bethesda
Rehabilitation Hospital, St. Paul
World Health Organization (WHO) definitions:
impair-ment?loss or abnormality of psychologic, physiologic
or anatomic structure or function; produced by disease or
trauma; examples include, weakness, dyspnea, amputation
below knee, anxiety; disability?how im-pairment affects
individual?s ability to perform normal activities, eg,
person with below-the-knee amputation has disability in
activity of walking; handicap?disadvantage resulting from
impairment or disability, eg, inability to access building
because of steps
Physician?s role in disability evaluation: provide medical
care; provide documentation of care and information to
patient and to disability system; patients often need help
negotiating system, and social workers and lawyers can
provide this; not physician?s responsibility to ensure
patients gets disability benefits
Key issues in disability process: maximum medical
im-provement?means ?they?re as good as they?re going to
get?; disability systems and insurance carriers need to
know whether patient has reached this stage; much leeway in
how physician defines ?maximum?; issue is significant gains
as opposed to minor gains; American Medical Association
(AMA) definition of disability?how impairment affects
ability to perform personal, social, or occupational
activities; AMA Guides to Disability Evaluation published
periodically (fifth edition most recent; 2003); Social
Security Administration definition of disability?inability
to engage in substantial gainful activity because of
physical or mental impairment that can be expected to
result in death or which has lasted or can be expected to
last for continuous period of greater than or equal to 12
mo; timeline varies, depending on clinical impression and
understanding; guideline for ?substantial gainful activity?
approximately $900/mo; impairment rating?based on
application of agreed-upon criteria, eg, AMA Guides, state
guidelines; usually expressed as percentage of whole
person; combined rather than additive, eg, if loss of use
of one arm rated 50%, loss of use of both arms rated 75%
(loss of second arm calculated as 50% of 50% remaining
after loss of first arm, ie, 25%, which is then added to
50% due to loss of first arm); independent medical
examination (IME)?medical evaluation performed by physician
not involved in case, ie, physician cannot evaluate own
patient; physicians discouraged from accepting patient for
treatment after performing IME on that patient
Educational Objectives
The goal of this program is to educate the listener about
management of patients with chronic pain and the basics of
disability evaluation. After hearing and assimilating this
program, the clinician will be better able to:
List the physiologic categories of chronic pain.
Describe some factors that contribute to chronic pain and
some barriers to its management.
Explain how chronic pain differs from acute pain at the
neurophysiologic level.
Discuss the goals of management of chronic pain and give
an algorithm for managing pain flares in patients with
chronic pain.
Define key terms and issues in the disability process.
Discussed on This Program
Carbamazepine (several trade names)
Gabapentin [Neurontin]
Hydrocodone bitartrate and acetaminophen [Vicodin, others]
Hydroxyzine [Vistaril, others]
Lamotrigine [Lamictal, Lamictal Chewable Dispersible]
Meperidine HCl [Demerol]
Morphine sulfate (several trade names)
Oxycodone and acetaminophen (several trade names)
Oxycodone HCl (several trade names)
Suggested Reading
Belgrade MJ et al: Diabetic neuropathy. Helping patients
cope with their pain. Postgrad Med 90:263, 1991; Belgrade
MJ: Following the clues to neuropathic pain. Distribution
and other leads reveal the cause and the treatment
approach. Postgrad Med 106:127, 1999; Belgrade MJ: Opioids
for chronic nonmalignant pain. Choosing suitable candidates
for long-term therapy. Postgrad Med 106:115, 1999; Fishman
SM et al: Challenges and choices in drug therapy for
chronic pain. Cleve Clin J Med 70:119, 2003; Glajchen M:
Chronic pain: treatment barriers and strategies for
clinical practice. J Am Board Fam Pract 14:211, 2001; Glenn
B et al: Pain self-management in the process and outcome of
multidisciplinary treatment of chronic pain: evaluation of
a stage of change model. J Behav Med 26:417, 2003; Gross DP
et al: The prognostic value of functional capacity
evaluation in patients with chronic low back pain: part 2:
sustained recovery. Spine 29:920, 2004; Gross DP et al: The
prognostic value of functional capacity evaluation in
patients with chronic low back pain: part 1: timely return
to work. Spine 29:914, 2004; Kalauokalani D et al: Lessons
from a trial of acupuncture and massage for low back pain:
patient expectations and treatment effects. Spine 26:1418,
2001; Lansbury G: Chronic pain management: a qualitative
study of elderly people's preferred coping strategies and
barriers to management. Disabil Rehabil 22:2, 2000; Liu HP
et al: Localization of glutamate receptor subunits of the
alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionate (AMPA)
type in the pancreas of newborn guinea pigs. Pancreas
14:360, 1997; Marcus DA: Obesity and the impact of chronic
pain. Clin J Pain 20:186, 2004; McCarberg BH et al:
Long-acting opioids for chronic pain: pharmacotherapeutic
opportunities to enhance compliance, quality of life, and
analgesia. Am J Ther 8:181, 2001; Nicholson BD: Diagnosis
and management of neuropathic pain: a balanced approach to
treatment. J Am Acad Nurse Pract 15:3, 2003; Patrick LE et
al: Long-term outcomes in multidisciplinary treatment of
chronic low back pain: results of a 13-year follow-up.
Spine 29:850, 2004; Pincus T et al: Cognitive-behavioral
therapy and psychosocial factors in low back pain:
directions for the future. Spine 27:E133, 2002; Potter M et
al: Opioids for chronic nonmalignant pain. Attitudes and
practices of primary care physicians in the UCSF/Stanford
Collaborative Research Network. University of California,
San Francisco. J Fam Pract 50:145, 2001; Ruoff GE:
Challenges of managing chronic pain in the elderly. Semin
Arthritis Rheum 32:43, 2002; Schultz IZ et al: Psychosocial
factors predictive of occupational low back disability:
towards development of a return-to-work model. Pain 107:77,
2004; Szekely JI et al: The role of ionotropic glutamate
receptors in nociception with special regard to the AMPA
binding sites. Curr Pharm Des8:887, 2002; Turk DC et al:
Psychological factors in chronic pain: evolution and
revolution. J Consult Clin Psychol 70:678, 2002;
Turner-Stokes L et al: Outpatient cognitive behavioral pain
management programs: a randomized comparison of a
group-based multidisciplinary versus an individual therapy
model. Arch Phys Med Rehabil 84:781, 2003; Velly AM et al:
Contributing factors to chronic myofascial pain: a
case-control study. Pain 104:491, 2003.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest
Foundation requests all lecturers to disclose any
significant financial relationship with the manufacturer or
provider of any commercial product or service discussed.
The following has been disclosed: Dr. Belgrade is on the
Speakers? Bureau of Pfizer US Pharmaceutical Group, Janssen
Pharmaceutica, and Purdue Fredrick Co.
Drs. Belgrade and Britton were recorded at the 30th Annual
Course, Family Practice Review Update 2004, held May 3-7,
2004, in Minneapolis and sponsored by the Department of
Family Practice and Community Health, University of
Minnesota Medical School. The Audio-Digest Foundation
thanks the speakers and the sponsor for their cooperation
in the production of
Selecting the Approach to Treatment
In overweight and mildly obese patients, diet, exercise,
and lifestyle approaches should be used exclusively. The
behavioral tools available include confirming readiness to
change, using stimulus control to minimize the intake of
high-calorie trigger foods, and offering information on
exercise, relapse prevention, and stress reduction. A
reduced-calorie diet plan that is low in fat, provides
adequate protein for satiety, and is rich in low-calorie,
nutrient-dense fruits and vegetables is advised. The use of
carefully selected meal replacements and portion-controlled
meals to reduce caloric intake and provide security in
calorie counting can be a very effective approach.
Pharmacotherapy is an appropriate adjunct in patients with
a BMI >/= 27 with comorbidities, or >/= 30 without
comorbidities.
Meal Plans and Meal Replacements
Portion control is one of the primary strategies in calorie
control. Typical diet plans specify what foods should be
consumed for meals and snacks, and portion sizes are
usually specified in standard weights and measures.
However, many people do not take the time to weigh and
measure foods, or they may abandon this practice after a
period of time, thinking they can estimate portions fairly
well. A few small mistakes can add up significantly. (See
the Toolkit for a list of common calorie-counting errors
and sample menus.) Patients may be confused about whether
they are supposed to weigh foods before or after cooking,
and they may not account for condiments or other
ingredients.
Meal replacements are foods designed to take the place of a
meal while providing nutrients within a known calorie
limit, and can take the form of shakes, bars, soups, or
frozen portion-controlled meals. Replacing 2 meals per day
with meal replacements has been shown to produce weight
loss results superior to those reported with calorie
counting and can be an effective strategy to teach patients
in a busy healthcare setting.[5,6]
For weight loss, a 1200-calorie meal plan for women and a
1500-calorie meal plan for men is recommended to start.
(See the Toolkit for sample menus.) Meal replacement bars,
shakes, or frozen meals can be substituted for 2 meals per
day, and the third meal includes a salad, 3 to 6 ounces of
lean protein, fresh vegetables, and one half to one cup of
rice, pasta, or potato, with fruit for dessert. Snacks of
whole fruit or vegetables can be used between meals.
Recent research has demonstrated that an increased variety
of intake in all categories of foods, with the exception of
fruits and vegetables, promotes obesity.[7] By reducing
variety, meal replacements help patients maintain a
structured diet and portion control. Many meal replacements
are excellent sources of protein, fiber, vitamins, and
minerals, and may be superior to simply restricting
conventional food intake if careful food choices, which
would ensure nutritional adequacy, are not made.
Trigger Foods
Patients should also understand the need to minimize the
intake of their own "trigger foods," and appropriate
substitutions should be suggested. (See the Toolkit for a
list of lower-calorie alternatives to high-calorie trigger
foods.) Trigger foods are foods that have an unexpected
amount of "hidden" fat or calories, and are often eaten in
response to a stimulus other than hunger. The motivation
for eating trigger foods may be boredom, agitation,
depression, or fatigue. Encourage patients to identify the
trigger foods that are problematic for them and ask that
they target these food-mood connections for behavior
change. Replacing high-fat, high-calorie trigger foods with
healthier substitutes is also an effective strategy.
Protein and Satiety
Protein provides greater satiety than either carbohydrate
or fat, and it is needed for muscle deposition, which can
increase lean body mass, which in turn raises resting
metabolic rate. Voluntary reduction in energy consumption
has been noted in subjects consuming high-protein meals
compared with high-carbohydrate meals when fed ad libitum,
with greater weight loss and fat loss in those consuming
higher protein.[8]
Several studies have demonstrated significantly more
satiety on a high-protein (approximately 30% of energy
intake) vs a high-carbohydrate diet (10% to15% of energy
from protein),[9,10] and 1 study concluded that the
increased proportion of protein to carbohydrate had
positive effects on body composition as well as on blood
lipids, glucose homeostasis, and satiety during weight
loss.[11]
Practical Tips
Patient education can be integrated into a short visit
aimed at initiating a weight-loss effort. Since patients
often see the primary care provider for other reasons, it
may be advisable to set up a separate appointment
specifically for the discussion of the patient's weight.
The first step is for the primary care provider to indicate
his or her own commitment to helping the patient reach the
goals that will lead to improved health and well being.
Discussing previous attempts at weight loss, including past
obstacles, may help determine the patient's readiness to
change diet and lifestyle. Questionnaires assessing this
psychological variable are available and can be
helpful.[12] In this initial discussion, it may also be
helpful to emphasize both the short- and long-term health
benefits of weight reduction. For example, a diabetic
patient may gain better control of blood glucose, or a
hypertensive patient may be able to manage blood pressure
with smaller dosages of antihypertensive drugs.
Once patient readiness has been determined, outline a
simple program and help set goals and appropriate
expectations. Remind the patient that progress can be
measured not only by changes in weight but also by positive
behavior changes. Since the majority of overweight and
obese patients will present with a comorbidity that will
require regular follow-up, have them return to the office
on a regular basis for monitoring. Some providers find that
a quick weight check by an office staff member every few
weeks helps to keep patients on track.
Pharmacotherapy
For individuals with a BMI >/= 27 with comorbid conditions,
or a BMI >/= 30 without any comorbidity, pharmacotherapy
can be used to augment diet, exercise, and lifestyle
modifications. The 2 approved drugs for weight reduction
and weight maintenance can be used for up to 2 years.
Sibutramine is used at a dosage of 10 mg to 15 mg
daily.[13] It inhibits the reuptake of 2 neurotransmitters
in the brain -- serotonin and norepinephrine. This
inhibition results in increased satiety, which enhances
portion control and leads to permanent weight losses of 5%
to 7% in patients. Because sibutramine can cause a mild
increase in blood pressure, patients with comorbid
hypertension should be monitored carefully.
Orlistat is an inhibitor of intestinal lipase that can
achieve a 30% reduction in fat absorption, and is used at a
dosage of 120 mg 3 times per day.[14] It is recommended for
use with a diet containing 30% fat calories. Some patients
use the drug to avoid eating high-fat foods, because
frequent fatty stools are a common treatment effect of
orlistat when dietary fat calories exceed 30%. Patients
should be instructed to take a multivitamin plus
multimineral 2 hours after a dose of orlistat to avoid
depletion of fat-soluble vitamins.
Integrating Obesity Treatment
Duloxetine (Cymbalta) ? Duloxetine is a dual uptake
inhibitor of serotonin and norepinephrine approved for the
treatment of major depressive disorder and diabetic
peripheral neuropathic pain. The most common adverse
effects include insomnia, headache, somnolence, dry mouth,
tremor and asthenia. The recommended dose of duloxetine
for treatment of major depressive disorder is 20mg twice
daily to 60mg daily. The recommended dose for diabetic
peripheral neuropathy is 60mg daily.
posted by PainNP @ 4:06 PM
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