Pain Management in Primary Care Kimberly Zoberi, MD Saint Louis University School of Medicine

Who treats chronic pain? Chronic pain specialists Acupuncturists Chiropractors PCP’s 2% 7% 40% 52% Bruer B, et al, Southern Medical Journal, 2010; 103: MacFarlane GJ, Rheumatology 2012; 51: Gross AR, Spine 2004; 29: (Cochrane Review – neck pain) Rubinstein SM, Spine 2013; 38:E158-E177 (Systematic rev : Spinal Manipulative Therapy)

Ways to classify pain ► Acute vs. chronic ► Nociceptive vs. neuropathic ► Psychogenic vs. somatic

Acute vs. Chronic Acute Cause is known Function is protective Increased autonomic activity Short duration, resolves with healing Inflammation, tissue injury Short term upregulation of pain sensitivity Chronic Cause = ? No protective function None Does not resolve with healing None Long term changes including allodynia, hyperalgesia, etc.

Nociceptive vs. Neuropathic ► Nociceptive: Appropriate stimulation of nerve endings leads to signaling ► Neuropathic: Dysfunction of nerve

Acute, nociceptive pain ► Examples? ► Goals of treatment  Heal the injury  Decrease acute pain  Prevent progression to chronic pain ► Strategies

Acute, neuropathic pain ► Migraine, herniated disk

Chronic, nociceptive pain ► Arthritis, cancer ► BOTH ongoing damage and upregulation of nerve impulses ► Remodeling centrally and dorsal horn of spinal cord ► Multimodal treatment

Chronic, neuropathic pain ► Fibromyalgia, IBS ► Not much utility to anti-inflammatories ► Neuromodulating agents are key

Psychogenic component

► Musculoskeletal symptoms and non-REM sleep disturbance in patients with "fibrositis syndrome" and healthy subjects. ► Moldofsky, et al, Psychosomatic Medicine, 1975, 37 (4):

► Sleep deprivation patients looked identical to fibromyalgia patients in mood mood somatic complaints somatic complaints sleep architecture sleep architecture

► ► Smith et al. The effects of sleep deprivation on pain inhibition and spontaneous pain in women. Sleep The effects of sleep deprivation on pain inhibition and spontaneous pain in women. ► ► Kundermann et al. The effect of sleep deprivation on pain. Pain Res Manag. 2004The effect of sleep deprivation on pain.

Source: Sleep and Pain, Lavigne (ed) 2007.

How patients feel

What patients want

Physical therapy Psychotherapy Neuromodulators Sleep regulation Mood regulation NSAIDS/Co-analgesics Narcotics Interventions Behavioral activation Family therapy Anxiety management TENS

General Treatment Strategy ► Acknowledgement of patient’s pain ► Nonpharmacologic treatments  Physical therapy  Exercise  Heat/ice  Coping mechanisms  CBT

Pharmacologic treatment Acetaminophen Adjuvant pain meds NSAIDS +/- mild opioids Short acting Opioids PRN Long Acting Opioids ATC +/- Adjuvant pain meds Continued pain NeuropathicNon-neuropathic ++

Facilitation Substance P Glutamate NGF CCK Inhibition NE/Serotonin Dopamine Opioids GABA Cannabinoids Adenosine

Adjuvant Pain Meds ► Neuromodulators ► Calcium channel agents  Ca needed for afferent pain fibers to synapse  Gabapentin inhibits this ► Sodium channel agents  Na needed for spinal cord neurons to transmit impulses  Topamax inhibits this ► Serotonin/NE reuptake inhibitors

Adjuvant pain meds ► Side effects? ► Which one has NO weight gain?

3 Circumstances to Use Opioids ► Moderate to severe pain ► Patient has already failed other therapies ► Other therapies (NSAIDs) are contraindicated

Opioids ► Which patients should NOT use opioids?

Informed Consent for Opioids

Documentation ► How NOT to get in trouble with the DEA

Initial Assessment ► Onset, duration ► Location, distribution ► Quality, character ► Intensity ► Aggravating and relieving factors ► Associated factors  Mood and emotional distress  Functional impairment ► Associated features  Neurological deficit, hyperalgesia, allodynia ► Previous treatments

Ongoing Assessment (Progress Note) ► 4 A’s ► Analgesia (use a pain scale) ► ADL’s ► Adverse effects ► Aberrant drug related behavior ► Assessment and Plan