1. 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

2. 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.

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

4. 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.

5. 1990 FMS

6. Portenoy Portenoy/Foley
US Overdose Deaths
Peak Incidence of Prescription OD 45-54
Portenoy Recants
2012
Portenoy Portenoy/Foley
1986
Porter & Jick
1980

7. Variation in Opioid Rx’ing for FMS 2007-2009
Peak Incidence of Prescription OD 45-54

8. 35% of FMS Pt’s Receive SSDI
Disabled Medicare Beneficiaries Rx’d Opioids

9. FMS Patients Report High Pain Levels In Spite of High Dosages

10. Opioids In FMS: Once Started Seldom Stopped
N = 100K, 60% Received Opioids.

11. Opioids In FMS: Once Started Seldom Stopped
N = 64K, 44% Received Opioids.

12. 30 Day Supply & Risk of COT 20% will remain on opioids at 3yrs.

13. 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

14. 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.

15. 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

16. 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%

17. Prevalence of LBP & HA in FMS

18. Prevalence of FMS in cLBP 42%
Chance Alone: .3 x .05 = 1.5%

19. Prevalence of FMS in Migraineurs 56%
Chance Alone:
.2 x .05 += 1%

20. Head Ache & LBP Predict FMS

21. Comorbid Pain in FMS is the Norm
Fibromyalgia
Fibromyalgia
Fibromyalgia
Low Back Pain
Low Back Pain
Head Ache

22. Central Sensitivity Spectrum Disorders

23. Overlapping Chronic Pain Conditions

24. Prescribers are Poor at Diagnosing Central Pain Syndromes
23% Sensitivity
N = 312, 240 FMS+

25. Prescribers are Poor at Diagnosing Central Pain Syndromes
27% Specificity
N = 4M

26. 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

27. 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)
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 (working-age).*
11. Essentially normal physical examination +/- diffuse tenderness.

28. 2016 FMS Survey Questionnaire
96% Sensitivity, 92% Specificity

29. Pain Catastrophizing Scale
Moderate Risk 20-29
High Risk > 30

30. Elevated PCS Predicts Abuse

31. Elevated PCS Predicts Abuse

32. Elevated PCS Predicts Abuse

33. 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.

34. FMS Is Opioid Unresponsive

35. Natural Hx of FMS N = 1,555 11yr f/u

36. Natural Hx of FMS N = 76 2yr f/u

37. Natural Hx of FMS
N = 1,644

38. FMS is the Primary Source of Morbidity in Mixed Pain States
N = 383, 76 FMS+

39. FMS is the Primary Source of Morbidity in Mixed-Pain States
N = 156, 25 FMS+

40. FMS is the Primary Source of Morbidity in Mixed Pain States

41. Patient Expectations In FMS

42. Provider Satisfaction

43. Sample Case

44. 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.

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

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

47. Evidence-Based Treatments of FMS
Evidence Level
Patient Education 1A
Graded Exercise
CBT
Tricyclics
SNRI’s
Gabapentenoids
NSAIDS 5D
Opioids

48. Centralized Pain Pt Handout

49. Evidence-Based Treatments for FMS

50. Evidence-Based Treatments for FMS

51. Evidence-Based Treatments for Pain Catastrophizing

52. Evidence-Based Treatments for Pain Catastrophizing

53. Resources 2016 Fibromyalgia Survey Questionnaire
Evidence-Based Treatments for FMS, Dr. Clauw JAMA
Daniel Clauw, MD Youtube Video for patients
Sample Centralized Pain Patient Handout
List of non-opioid alternatives for chronic non-cancer pain