Diagnosing & Treating Musculoskeletal Pain In Working-Aged Adults The Importance of Identifying The Central Pain Phenotype 5/6/17 Presented By: Daniel Clauw, MD Paul Coelho, MD

Disclosures: Dr. Clauw Consulting Pfizer, Forest, Eli Lilly, Pierre Fabre, Cypress Biosciences, Wyeth, UCB, Astra Zeneca, Merck, J&J, Nuvo, Jazz, Abbott, Cerephex, Iroko, Tonix, Theravance, Samumed, Zynerba, Aptinyx Research Support Pfizer, Cypress Biosciences, Forest, Merck, Nuvo, Cerephex Dr. Coelho Has no disclosures. He will not be discussing any off-label uses of medications or devices.

Table of Contents Early Pain Models Modern Pain Models FMS, HA, and LBP The Central Pain Phenotype Sample Case Evidence-Based Treatments

1980 Model of MSK Pain Nociceptive Neuropathic Primarily due to inflammation or tissue damage in the periphery Damage or entrapment of peripheral nerves. NSAID/Opioid Responsive Responds to both peripheral and central pharmacotherapy. Responds to procedures. Does not respond to procedures. Behavioral factors minor. Examples: Osteoarthritis, Rheumatoid arthritis, cancer pain. Examples: Diabetic peripheral neuropathy, post-herpetic neuralgia. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1829161/

1990 FMS https://www.rheumatology.org/Portals/0/Files/1990_Criteria_for_Classification_Fibro.pdf

Portenoy Portenoy/Foley US Overdose Deaths 1980-2014 Peak Incidence of Prescription OD 45-54 Portenoy Recants 2012 Portenoy Portenoy/Foley 1986 Porter & Jick 1980 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1829161/

Variation in Opioid Rx’ing for FMS 2007-2009 Peak Incidence of Prescription OD 45-54 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4346177/

35% of FMS Pt’s Receive SSDI Disabled Medicare Beneficiaries Rx’d Opioids https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4151179/

FMS Patients Report High Pain Levels In Spite of High Dosages https://www.ncbi.nlm.nih.gov/pubmed/24310048

Opioids In FMS: Once Started Seldom Stopped N = 100K, 60% Received Opioids. https://www.ncbi.nlm.nih.gov/pubmed/26443495

Opioids In FMS: Once Started Seldom Stopped N = 64K, 44% Received Opioids. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5117947/

30 Day Supply & Risk of COT 20% will remain on opioids at 3yrs. https://www.cdc.gov/mmwr/volumes/66/wr/mm6610a1.htm

FMS Is Not Opioid Responsive Organization American Pain Society American Academy of Pain Medicine American Academy of Neurology European League Against Rheumatism Canadian Pain Society Canadian Rheumatology Association British Pain Society https://www.ncbi.nlm.nih.gov/pubmed/26975749

2017 Model of MSK Pain Nociceptive Neuropathic Central Primarily due to inflammation or tissue damage in the periphery Damage or entrapment of peripheral nerves. Primarily due to a central disturbance in pain processing. NSAID/Opioid Responsive Responds to both peripheral and central pharmacotherapy. Tricyclic neuro-active compounds. Opioid unresponsive. Responds to procedures. Does not respond to procedures. Behavioral factors minor. Behavioral Factors Prominent. Examples: Osteoarthritis, Rheumatoid arthritis, cancer pain. Examples: Diabetic peripheral neuropathy, post-herpetic neuralgia. Examples: FMS, cLBP, cHA, IBS. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1829161/

Comorbid Pain in FMS is the Norm “Overwhelming evidence reveals that what is often labeled as a single chronic regional pain syndrome is, upon closer evaluation, a chronic illness beginning much earlier in life, where the pain merely occurs at different points of the body at different points in time and is given different labels by subspecialists focusing on “their region” of the body.” Daniel Clauw, MD Low Back Pain https://www.ncbi.nlm.nih.gov/pubmed/22364327

Prevalence of LBP & HA in FMS 2007 Internet Survey of 2596 FMS Pts Ave Age = 47 If due to chance alone LBP .3 x .05 =1.5% HA: .2 x .05 =1% https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1829161/

Prevalence of LBP & HA in FMS https://www.ncbi.nlm.nih.gov/pubmed/27281286/

Prevalence of FMS in cLBP 42% Chance Alone: .3 x .05 = 1.5% https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1829161/

Prevalence of FMS in Migraineurs 56% Chance Alone: .2 x .05 += 1% https://www.ncbi.nlm.nih.gov/pubmed/25994041

Head Ache & LBP Predict FMS https://www.ncbi.nlm.nih.gov/pubmed/26772544

Comorbid Pain in FMS is the Norm Fibromyalgia Fibromyalgia Fibromyalgia Low Back Pain Low Back Pain Head Ache https://www.ncbi.nlm.nih.gov/pubmed/22364327

Central Sensitivity Spectrum Disorders https://www.ncbi.nlm.nih.gov/pubmed/17350675

Overlapping Chronic Pain Conditions https://www.ncbi.nlm.nih.gov/pubmed/27586833

Prescribers are Poor at Diagnosing Central Pain Syndromes 23% Sensitivity N = 312, 240 FMS+ https://www.ncbi.nlm.nih.gov/pubmed/23071343

Prescribers are Poor at Diagnosing Central Pain Syndromes 27% Specificity N = 4M https://www.ncbi.nlm.nih.gov/pubmed/27281286

Prescribers are Poor at Diagnosing Central Pain Syndromes “You cannot guess at the extent of fatigue, unrefreshed sleep, cognitive problems, multiplicity of symptoms, and extent of pain without a detailed interview. The new criteria obligate you to pay careful attention to the patient if you want to diagnose fibromyalgia.” Fredrick Wolfe https://www.ncbi.nlm.nih.gov/pubmed/20461781

Diagnosing Central Sensitivity Spectrum Disorders Pain in many body regions. 2. Higher current and lifetime history of chronic pain in several body regions. 3. Multiple somatic symptoms (e.g., fatigue, memory difficulties, sleep problems, mood disturbance) 4. Negative Affect, dispositional pessimism, pain catastrophizing. (Stable trait vs transient state) 5. More sensitive to other sensory stimuli (e.g., bright light, loud noises, odors, other sensations in internal organs) 6. 1.5 to 2x more common in women. 7. Strong family history of chronic pain. 8. High self-reported pain & distress (VAS/NPS/PSD/PCS) 9. Pain triggered or exacerbated by stressors. 10. Peak prevalence of FMS age 30-59 (working-age).* 11. Essentially normal physical examination +/- diffuse tenderness. https://www.ncbi.nlm.nih.gov/pubmed/26266995

2016 FMS Survey Questionnaire 96% Sensitivity, 92% Specificity https://www.ncbi.nlm.nih.gov/pubmed/21285161

Pain Catastrophizing Scale Moderate Risk 20-29 High Risk > 30 https://www.ncbi.nlm.nih.gov/pubmed/11289089

Elevated PCS Predicts Abuse https://www.ncbi.nlm.nih.gov/pubmed/23618767

Elevated PCS Predicts Abuse https://www.ncbi.nlm.nih.gov/pubmed/24612286

Elevated PCS Predicts Abuse https://www.ncbi.nlm.nih.gov/pubmed/23809983

Why Is Dx’ing FMS/CSS Important? It is opioid unresponsive. Once opioids are started FMS/CS patients are exquisitely sensitive to withdrawal symptoms & thus hard to taper. Guessing at the Dx makes for poor inter-rater reliability. Prognosis: Untreated it does not improve with time. When present amid other CNP conditions – HA, LBP, etc. – it is likely to be the primary source of morbidity. Patient expectations for treatment are often unrealistic. Provider satisfaction/comfort with care is low.

FMS Is Opioid Unresponsive https://www.ncbi.nlm.nih.gov/pubmed/26975749

Natural Hx of FMS N = 1,555 11yr f/u https://www.ncbi.nlm.nih.gov/pubmed/21765102

Natural Hx of FMS N = 76 2yr f/u https://www.ncbi.nlm.nih.gov/pubmed/28077978

Natural Hx of FMS N = 1,644 https://www.ncbi.nlm.nih.gov/pubmed/23710561

FMS is the Primary Source of Morbidity in Mixed Pain States N = 383, 76 FMS+ https://www.ncbi.nlm.nih.gov/pubmed/27049402

FMS is the Primary Source of Morbidity in Mixed-Pain States N = 156, 25 FMS+ https://www.ncbi.nlm.nih.gov/pubmed/28182837

FMS is the Primary Source of Morbidity in Mixed Pain States https://www.ncbi.nlm.nih.gov/pubmed/28229811

Patient Expectations In FMS https://www.ncbi.nlm.nih.gov/pubmed/19732374

Provider Satisfaction https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4070226/figure/Fig1/

Sample Case

Joyce Joyce is a 45y/o woman who recently moved from CA to Jackson, County to retire. Her past medical history is significant for a work related back injury for which she was medically retired. She now receives SSD and seeks to establish care with you for primary care needs as well as pain management. Her medication regimen consists of Lisinopril for HTN. She is requesting “Percocet” for pain.

Joyce 10 >13 = FMS >13 = FMS 7 17

Joyce 4 4 3 4 3 4 4 3 4 4 3 4 4 48/52 >30 Abnl

Evidence-Based Treatments of FMS Evidence Level Patient Education 1A Graded Exercise CBT Tricyclics SNRI’s Gabapentenoids NSAIDS 5D Opioids https://www.ncbi.nlm.nih.gov/pubmed/28077978

Centralized Pain Pt Handout https://www.painscience.com/articles/central-sensitization.php

Evidence-Based Treatments for FMS https://www.youtube.com/watch?v=pgCfkA9RLrM

Evidence-Based Treatments for FMS https://fibroguide.med.umich.edu/

Evidence-Based Treatments for Pain Catastrophizing

Evidence-Based Treatments for Pain Catastrophizing https://web.stanford.edu/class/msande271/onlinetools/LearnedOpt.html

Resources 2016 Fibromyalgia Survey Questionnaire https://www.slideshare.net/101N/2016-fibromyalgia-survey-questionnaire Evidence-Based Treatments for FMS, Dr. Clauw JAMA http://www.slideshare.net/101N/fibromyalgia-clinical-review Daniel Clauw, MD Youtube Video for patients https://www.youtube.com/watch?v=pgCfkA9RLrM&t=6s Sample Centralized Pain Patient Handout http://www.slideshare.net/101N/central-sensitization-70569194 List of non-opioid alternatives for chronic non-cancer pain http://www.slideshare.net/101N/nonopioid-alternatives-for-chronic-noncancer-pain

paul.coelho@salemhealth.org