ACUTE AND CHRONIC PAIN: IDEAS OLD AND NEW John D. Loeser, M.D. February 22, 2019 Benton/Franklin County Medical Society

I have no conflicts of interest or sponsorships to report.

HEALTH CARE IS A SOCIAL CONVENTION HEALTH CARE IS A SOCIAL CONVENTION. NOWHERE IS THIS BETTER DEMONSTRATED THAN THE ROLE OF OPIOIDS IN THE TREATMENT OF ACUTE AND CHRONIC PAIN. SO, WE NOW MUST LOOK AT ALTERNATIVES TO OPIOIDS.

IOM REPORT 2011 116 million adults in U.S. with common chronic pain conditions; $590 to $635 billion annual cost.

WHAT IS PAIN?

An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. “IASP Definition” Pain 1986

THERE IS NO TANK INTO WHICH ONE CAN PLACE A DIPSTICK TO MEASURE PAIN.

Pain requires consciousness; it is an emergent property of the human brain. 8 8

MALINGERING IS A VERY RARE DISEASE. ALL PAIN IS REAL. MALINGERING IS A VERY RARE DISEASE.

CONCEPTS ARE IMPORTANT FOR DIAGNOSIS, TREATMENT AND MEASUREMENT

TYPES OF PAIN Transient Pain Acute Pain Chronic Pain

TRANSIENT PAIN Elicited by the activation of nociceptors in the absence of tissue damage. It is ubiquitous in everyday life and rarely a reason to seek health care. Relevant only to procedural pain, this is not a major issue in clinical medicine. It has, however, been the subject of most experimental pain paradigms in man and animals until very recently.

ACUTE PAIN Elicited by injury to the body and activation of nociceptive transducers at site of damage. Local injury alters the characteristics of nociceptors, their central connections, and the autonomic nervous system in the region. Healing of damaged tissue occurs with restoration of normal nociceptor function. Common medical problem: health care can block pain and facilitate healing.

ACUTE PAIN IS USUALLY DUE TO TISSUE DAMAGE AND IS NOCICEPTIVE. NOCICEPTION CAN PERSIST FOR DAYS, MONTHS OR EVEN YEARS.

REMOVING THE SOURCE OF NOCICEPTION CAN CURE THE PAIN ACUTE PAIN CAN PERSIST OVER LONG PERIODS OF TIME AND NOT BECOME “CHRONIC” Degenerative arthropathy of knee or hip Unrecognized infection Unhealed fracture REMOVING THE SOURCE OF NOCICEPTION CAN CURE THE PAIN

“Nature heals, and doctors get the credit”. THE SECRET OF ACUTE PAIN MANAGEMENT “Nature heals, and doctors get the credit”. Voltaire

MANAGING NOCICEPTIVE PAIN REDUCE THE TISSUE DAMAGE BLOCK THE NOCICEPTION FROM REACHING THE CONSCIOUS CENTRAL NERVOUS SYSTEM HASTEN THE HEALING PROCESSES

MANAGING NOCICEPTIVE PAINS-1 Physical measures Rest Massage Graded exercise Stimulation (electrical, mechanical, chemical Cold or heat

MANAGING NOCICEPTIVE PAINS -2 Psychologic measures Distraction Virtual reality Coping skills Stress management Education Cognitive/Behavioral Therapies

MANAGING NOCICEPTIVE PAINS-3 Pharmacologic measures Non-steroidals Opioids Anticonvulsants Muscle relaxants Benzodiazepines Ketamine Clonidine Cannabinoids Topical agents

PAIN PERPETUATED BY CENTRAL PROCESSES CHRONIC PAIN BETTER DESCRIBED AS PAIN PERPETUATED BY CENTRAL PROCESSES

CHRONIC PAIN Triggered by injury or disease Perpetuated by factors other than those that started the pain Body unable to heal because of nerve injury or loss of body part Stress, affective, and environmental factors likely to play a large role.

CHRONIC PAIN Not well managed by Cartesian concepts. Requires a bio-psycho-social model. May be induced by CNS changes in response to injury that are not reversible even though healing occurs. Modulation can be detrimental or beneficial, hence role for psychological therapies.

MANAGING CHRONIC PAINS Centrally acting drugs Education Physical measures Psychological strategies

Doctors pour drugs, of which they know little, for diseases of which they know less, into patients—of which they know nothing. Voltaire

RAPID RETURN TO NORMAL ACTIVITIES Bed rest is bad for your health.

Recommend a gradual and progressive increase in physical activities on a quota system. Never “…let pain be your guide”.

Educate the patient: HURT AND HARM ARE NOT SYNONYMS.

PASSIVE THERAPIES ARE OF LITTLE VALUE.

Recommendation: Self-care and education Provide patients with evidence-based information about their expected course, advise patients to remain active, and provide information about effective self-care options. 31

TYPES OF CHRONIC PAIN Associated with cancer Associated with nerve injury Associated with systemic illness Unknown causation Palliative care and chronic pain

Anything you know that works for acute pain is likely to harm a patient with chronic pain. The only thing they have in common is the four letter word, pain.

Acute and chronic pain share only the four-letter word, “pain Acute and chronic pain share only the four-letter word, “pain.” Their pathogenesis and treatments are dissimilar. Confounding acute and chronic pain leads patients into clinical disasters.

The Opioid Epidemic Unique to the United States Prescription opioid excesses contributed Mortality has shifted from oxycontin to heroin laced with fentanyl Role of illegal marketing of oxycontin Role of inadequate education of physicians about pain and opioids

WHAT HAS THE AMERICAN OPIOID EPIDEMIC BROUGHT US? GUIDELINES AND REGULATIONS: FEDERAL, STATE, LOCAL, HOSPITAL

WA State Opioid Prescribing Rules “Inappropriate” rx: nontreatment, undertreatment, overtreatment and continued use of ineffective therapies. All prescribers must register with WA PDMP. Must inform patients of risks and benefits of opioids whenever prescribed. Never opioids with benzodiazepines, etc CME: 1 hour per lifetime for acute pain and 4 hours for chronic pain rx

OPIOID RULES DO NOT APPLY TO: Inpatients Procedural pre-medications Patients with cancer pain End-of-life care, hospice, palliative care

OUTPATIENT PRESCRIPTIONS Aim for 3 days or less of opioids Never more than 7 days without documentation At 6 weeks must assess misuse or abuse At 12 weeks, mandatory consultation, naloxone “Legacy patient” has a 3 month grace period for tapering

DO NOT LOSE SIGHT OF THE PHYSICIAN’S PRIMARY ROLE: THE RELIEF OF PAIN AND SUFFERING.

BERTRAND RUSSELL VISITED THE DENTIST WITH A TOOTHACHE “Where does it hurt?” the dentist asked. 42 42

“In my mind,” the philosopher replied “In my mind,” the philosopher replied. “Does anybody believe that a tooth (or a back) is capable of hurting?” 43 43

THANK YOU