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

2. Who treats chronic pain? Chronic pain specialists Acupuncturists Chiropractors PCP’s 2% 7% 40% 52% Bruer B, et al, Southern Medical Journal, 2010; 103:738-747 MacFarlane GJ, Rheumatology 2012; 51:1707- 1713 Gross AR, Spine 2004; 29:1541-1549 (Cochrane Review – neck pain) Rubinstein SM, Spine 2013; 38:E158-E177 (Systematic rev : Spinal Manipulative Therapy)

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

4. 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.

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

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

7. Acute, neuropathic pain ► Migraine, herniated disk

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

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

12. Psychogenic component

14. ► Musculoskeletal symptoms and non-REM sleep disturbance in patients with "fibrositis syndrome" and healthy subjects. ► Moldofsky, et al, Psychosomatic Medicine, 1975, 37 (4): 341-351.

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

16. ► ► Smith et al. The effects of sleep deprivation on pain inhibition and spontaneous pain in women. Sleep. 2007.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.

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

19. How patients feel

20. What patients want

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

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

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

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

25. 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

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

28. 3 Circumstances to Use Opioids ► Moderate to severe pain ► Patient has already failed other therapies ► Other therapies (NSAIDs) are contraindicated

29. Opioids ► Which patients should NOT use opioids?

31. Informed Consent for Opioids

33. Documentation ► How NOT to get in trouble with the DEA

34. 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

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