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

2. I have no conflicts of interest or sponsorships to report.

3. 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.

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

5. WHAT IS PAIN?

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

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

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

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

10. CONCEPTS ARE IMPORTANT FOR DIAGNOSIS, TREATMENT AND MEASUREMENT

11. TYPES OF PAIN
Transient Pain
Acute Pain
Chronic Pain

12. 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.

13. 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.

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

15. 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

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

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

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

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

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

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

23. 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.

24. 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.

25. MANAGING CHRONIC PAINS
Centrally acting drugs
Education
Physical measures
Psychological strategies

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

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

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

29. Educate the patient:
HURT AND HARM
ARE NOT SYNONYMS.

30. PASSIVE THERAPIES ARE OF LITTLE VALUE.

31. 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

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

33. 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.

34. 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.

36. 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

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

38. 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

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

40. 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

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

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

43. “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

44. THANK YOU