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Please only print out pages 1-8 for your records and to complete the questions and

evaluation. Please review the Power Points from this document. If you would like a
print out of this Enduring Material, Please contact Lori Graham (x4050) or Jayne
Sheehan (x4052). Thank you!

Dear Physician:

Physician education/training for a review of pain management is now available. This will
involve:

A. Complete the self-learning module that is attached.

This is approved for 4 CME Category I credit.

Instructions for completion include:


1. Review information in the booklet
2. Complete the written exam.
3. Complete evaluation.
4. Return written exam and evaluation form to Jayne Sheehan.
5. Upon receipt of required paperwork, a certificate of completion will be
sent to P. Eppinger in the Medical Staff office in order to pursue
credentialing of this service on your behalf. A copy will be sent to you
only if requested.
6. J. Sheehan will record the CME credits.

Thank you,

Jayne Sheehan, RN, MSN, CRNP


Director of Professional and Allied Health Education

07/09
rsharesoncmeendmatpainmanagement
ENDURING MATERIAL

JAMESON MEMORIAL HOSPITAL

COMPREHENSIVE REVIEW COURSE IN

PAIN MANAGEMENT FOR NON-SPECIALISTS

COURSE DIRECTOR: VEERAIAH C. PERNI, M.D.,

ASSOCIATE CLINICAL PROFESSOR OF ANESTHESIOLOGY, NEOUCOM.

ORIGINAL PROGRAM DATE: MAY 16, 2009

Chronic pain is a complex disease affecting more individuals than diabetes, heart disease, and cancer
combined. There are approximately eighty million sufferers and it is the most common reason to seek
medical help.

Description:
This four hour comprehensive review course on pain management is intended to describe and define the
various types of pain that a primary care physician is confronted with on a regular basis. The course will
offer methods to proper diagnosis and various aspects of pain management. In order to provide better
outcomes with reduced side effects, the standard of care issues, protocols, schedules, and suggestions on
timely transfer of care issues will be reviewed.

Objectives:
After this course, participants should be able to:
1. Describe the pain definition, classification and methods for understanding of proper diagnosis.
2. Describe the various methods of multidisciplinary pain management, including
alternate, non-traditional methods.
3. Demonstrate understanding of the principles of pharmacologic methods for pain
management, including side effects, abuse, governmental regulations, and accountability.
4. Describe the multiple aspects of interventional pain management techniques.
5. Post written test to evaluate the skills on pain management with 85% as a passing score.
Pain Management

To receive CME credits for this test, you must mark your answers,
complete the evaluation/enrollment information, and return them in
the envelope provided to Jayne Sheehan or Lori Graham.

Accreditation Statement

Jameson Health System is accredited by the Pennsylvania Medical


Society to sponsor continuing medical education for physicians.

This CME activity was planned and produced in accordance with


ACCME Essentials and Standards.

Designation Statement

Jameson designates this educational activity for maximum of 4.0


AMA PRA Category 1 credit(s)™. Physicians should only claim credit
commensurate with the extent of their participation in the activity.

Disclosure Statement

All Faculty and CME Committee do not have any real or apparent
conflict(s) of interest or other relationships related to the content of
this presentation.

We encourage participation by all individuals. If you have a disability,


advanced notification of any special needs will help us better serve
you.

Original date: 05/09


Updated:
Expires: 05/2011
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Questions for Pain Symposia

True or False

1. Prescription opiates has overtaken heroin and cocaine as number


one drug of abuse/addiction in the US.

2. The mid-1990s saw a major rise in the number of new non-medical


users of therapeutics (all Classes).

3. The CAGE questionnaire is an instrument in identifying patient


with potential addiction problems.

4. Pseudoaddiction describes the behavior of chronic pain patients


who have inadequate pain treatment.

Multiple Choice

5. Techniques that help suppress head and facial pain include:


a. Trigeminal Nerve block
b. Sphenopalatine block
c. Cervical Nerve root block
d. All of the above

6. Procedures which diagnose or improve sympathetic mediated pain


include:
a. Stellate injection
b. Lumbar sympathetic block
c. Sphenopalatine block
d. Superior Hypogastric plexus and Celiac Plexus block
e. All of the above

7. Which of the following is an example of neuropathic pain?


a. Cancer Pain
b. Postoperative pain
c. Chronic low back pain
d. Post herpetic neuralgia
8. Which of these treatments is approved for migraine
prophylaxis?
a. Aspirin
b. Lamotrigine
c. Fluoxetine
d. Topiramate

9. Which of the following is NOT involved in fibromyalgia?


a. Long standing pain in 11 of 18 standardized areas
b. Central nociception
c. Rash and hair loss
d. Psychological components

10. Which of the following have demonstrated some efficacy


in treating fibromyalgia?
a. Venlafaxine and selective serotonin reuptake inhibitors
b. Tricyclic antidepressants (TCAS), pregabalin, tramadol
c. Opioids
d. Non-steroidal anti-inflammatory drugs (NSAIDS) and
COX-2 specific inhibitors

11.Anticonvulsants have some efficacy in treating neuropathic


pain. Which of the following is approved for treatment of
post herpetic neuralgia?
a. Carbamazepine
b. Gabapentin
c. Lamotrigine
d. Topiramate

12. TCAs are effective for the treatment of low back pain,
neuropathic pain, and migraine. Which of the following
commonly limits their use?
a. Cost
b. Potential for addiction
c. Formulary restrictions
d. Anti-cholinergic side effects
13. Nonselective NSAIDS are not recommended for preemptive
Analgesia because________________________.
a. they are ineffective
b. prolonged clotting times are a concern
c. no intravenous formulations are available
d. postoperative nausea and vomiting are possible

14. Which of the following is highly suggestive of opioid addiction


in patients?
a. “Lost” prescriptions
b. Evidence of deterioration in work or social life
c. Concurrent alcohol or substance abuse
d. All of these
CME Program Evaluation: Enduring Material (Credits expire May 30, 2011)

Evaluation must be completed and turned in for certificate.

Program Title: Comprehensive Review Course in Pain Management for Non-Specialists


Speaker/Presenter: Drs. Perni, Monroe, Ranieri, and Wrightson

Learning Objectives: At the conclusion of the presentation, the participant should be able to:

1. Describe the pain definition, classification and methods for understanding of proper diagnosis.
2. Describe the various methods of multidisciplinary pain management, including alternate, non-traditional methods.
3. Demonstrate understanding of the principles of pharmacologic methods for pain management, including side effects, abuse,
governmental regulations, and accountability.
4. Describe the multiple aspects of interventional pain management techniques.
5. Post written test to evaluate the skills on pain management with 85% as a passing score
Please rate the following… Excellent Good Fair Poor
Overall activity…    
Clarity of session content…    
Relevance of content to you…    
Quality of visual aids/handouts…    
Presenter’s overall performance…    
Presenter’s knowledge of subject area…    
Presenter’s presentation skills…    
Presenter’s ability to respond to questions…    
Location of CME activity…    
Statement of changes this program has made on your practice.
Some questions allow for more than one answer.

1. This activity will assist in improvement of:


□ Competence
□ Performance
□ Patient Outcomes

2. I plan to make the following changes in my practice by:


□ Modifying treatment plans.
□ Changing my screening/prevention practice.
□ Incorporating different diagnostic strategies into patient evaluation.
□ Using alternate communication methodologies with patient and families.
□ Other.
□ None. This activity validated current practices.

3. What is your level of commitment to making the changes stated above?


□ Very committed
□ Somewhat committed
□ Not very committed
□ Do not expect to change practice

Both pages of the evaluation must be filled out 1


Created 11/09
4. What are the barriers you face in your current practice setting that may impact patient outcomes?
□ Lack of evidence-based guidelines
□ Lack of applicability of guidelines to current practice or patients
□ Lack of time
□ Organizational or Institutional
□ Insurance or Financial
□ Patient Adherence or Compliance
□ Treatment related to adverse events
□ Other: Explain

5. This activity supported achievement of the learning objectives.


□ Strongly Agree
□ Agree
□ No Opinion
□ Disagree
□ Strongly Disagree

6. The material was organized clearly for learning to occur.


□ Strongly Agree
□ Agree
□ No Opinion
□ Disagree
□ Strongly Disagree

7. The content learned from this activity will impact my practice.


□ Strongly agree
□ Agree
□ No Opinion
□ Disagree
□ Strongly Disagree

8. The activity was presented objectively and free of commercial bias.


□ Strongly agree
□ Agree
□ No Opinion
□ Disagree
□ Strongly Disagree

If you answered Disagree or Strongly Disagree to any of the statements above, please explain your disagreement with
the statement(s) in space below. Any other comments about today’s program can be made here also.

Please print your name Specialty

Both pages of the evaluation must be filled out 2


Created 11/09
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Pain Management for Non-Specialists
“Introduction to Pain Management”
Presented by:
Veeraiah C. Perni, M.D.
Director of Anesthesiology,
Jameson Memorial Hospital
Associate Professor of Clinical Anesthesiology
Northeastern Ohio Universities
College of Medicine
{ I, Veeraiah C. Perni do not have any
conflicts of interest in relation to
this presentation.
Evolution of Pain Medicine

{ Pre- 20th Century

{ 20th Century Pain Management

{ Revolution in Pain Management

{ Recent Development
Recent Developments in Pain Management

{ Local anesthetic supplements


{ Novel applications of opiates
{ Non-opioid pharmacologic agents
{ On-demand, patient-controlled
analgesia
{ Multi-model analgesia
{ Regional analgesia techniques
{ Pain as a “fifth vital sign”
{ Future of Pain Medicine
Introduction to
Pain Management Cont’d
{ Epidemiology of Chronic pain

● Chronic Pain- a public health problem

● 30% of US population has chronic pain

● Prevalence of chronic pain increases


with age

● Estimated economic cost for chronic


pain at $100 billion per year
{ Inadequacies in the treatment of pain

● Pain not taken seriously by the


physician

● Doctor’s lack of knowledge of chronic


pain

● Inadequate Pain management


{ Barriers to appropriate Pain Management

● Inadequate medical education

● Healthcare system not recognizing


pain relief as a quality of life priority

● Therapy related side effects

● Compliance and regulatory issues

● Increased life expectancy leads to


increase in painful chronic medical
condition
{ Barriers to appropriate Pain Management
Cont’d
● 50% of elderly living at home and 80% at long
term care facilities have persistent pain

● Physical and psychological toll leading to


depression

● Non-adherence to analgesics exacerbates pain

● Shift the goal of pain treatment to functional


improvement from decreased suffering

● Patients on combination treatments fare best


{ Common sources of pain in the elderly

● Musculoskeletal - arthritic fractures

● Neuropathic - Diabetic, post herpetic


neuralgia
● Visceral pain - Constipation, urinary
Retention, CAD
● Metabolic - Vitamin D deficiency,
osteoporosis, Paget’s
Disease

● Other - Fibromyalgia, cancer, PVD,


dental
Rickie K. Monroe,M.D.
Staff Anesthesiologist
Jameson Memorial Hospital
I, Rickie K. Monroe, do not have any
conflicts of interest in relation to
this presentation.
` Goal is painless or nearly painless surgery

` Anesthesiologist are committed to explore


mechanisms for acute postoperative pain
Quantifying clinical postoperative pain

` Visual analogue scale(VAS) or verbal score

` Recovery room nurses and floor nurses use


this score to quantify acute pain

` Most adult patients can report a verbal pain


score using the range “0” for no pain “10” as
the worse pain imaginable.
` After nearly all surgeries, pain with activities
is much greater than at rest!

` Pain with activities persist much longer after


most surgery than pain at rest.
` Parenteral opiods have limited effects on pain
after surgery only decreasing the baseline
pain at rest

` In general, the only group of drugs that


consistently reduces pain responses is local
anesthesics
` Epidural analgesia decreases pain with
activities

` Continuous regional analgesic techniques like


femoral nerve blocks and brchial plexus block
decrease activity pain!
` International Association for the Study of Pain
defines pain as: “unpleasant sensory and
emotional experience associated with actual
or potential tissue damage or described in
terms of such damage”

` Pain is subjective and emotional experience


` Pain implies perception of a number of
biochemical and physiologic processes

` We treat pains of different types because they


vary remarkable in response and effective
drugs depending on the type of pain being
treated.
` Peripheral noxious stimulus stimulates
specialized receptors on small myelinated
and unmyelinated fibers (A gamma , C fibers)

` Excitatory molecules are released in spinal


cord dorsal horn

` Excited neuron sends signals supraspinally


where sensory information is integrated and
perceived as pain
` Various reflexes are also excited including
activation of sympathetic nervous system

` Regulation takes place by descending


excitatory and inhibitory pathways
` Signifies the presence of a noxious stimulus
that produces actual tissue damage

` Implies a properly working nervous system

` Associated with autonomic hyperactivity, i.e.


hypertension, tachycardia, sweating

` Short-lived
Pain from : 1. Recent Surgery
2. Recent Injury
3. Medical Illness

` Can be managed immediately

` Usually gets better in short time


Copyright © 2003 American Society of Anesthesiologists. All rights reserved
` VISERAL COMPONENT –internal organs heart
,liver intestine

` SOMATIC COMPONENT-involving skeletal


muscle
` METHOD OF TREATMENT

` NSAID’S
` Opioids

Side effects:
` Intense sedation
` Respiratory Depression
` Urinary retention
` Inhabition of bowel function
Regional Anesthesia
1. Continuous epidural infusion of local anesthetic

2. Spinal administration of morphine(Duramorph)


or Fentanyl(Sublimaze)

3. Peripheral nerve block with local anesthesic


(Marcaine, Naropin)

4. NSAIDS act to inhibit inflammatory-related pain


` “ Do not mix pain prescription drugs with
over-the –counter pain relievers without
consulting your doctor”
Non-aspirin Pain Relievers

` Acetaminophen (Tylenol)

` Dosing (325 -1000 mg po Q4-6hr)

` Can relieve headaches and minor pain


Nonsteroidal Anti-inflammatory drugs

` Inhibit the synthesis of prostaglandins

` Prostaglandins mediate components of the


inflammatory response including fever, pain
and vasodilatation.
NSAID’S

` Aspirin (Anacin, Bayer) 325-650 mg po Q 4 prn

` Coated or Buffered Aspirin (Ascripton , Bufferin)

` Aspirin with Acetaminophen (Excedrin)

` Diclofenac (Voltaren)- CV risk, 50 mg po BID-


TID
NSAID’s
` Ketoprofen (Orudis) 75 mg po TID

` May increase risk of serious and potentially fatal


cardiovascular thrombotic event,MI, and stroke

` Used to reduce swelling and irritation as well as


pain

` Limit no more than 10 days without talking to


doctor
Naproxen (Aleve)
`Over the counter, 250-500mg po q 12 hr
` Used to relieve pain, inflammation and fever

` Finding which drugs work is a trial & error


process

` There is no “magic bullet”


` We try different drugs or combinations until we
arrive at what is optimal
` Individual treatment
NSAID’s
` Side Effects
1. Induced asthma
2. Renal impairment

3. Reduced platelet aggregation with bleeding


risks
4. Risks of peptic ulcer disease

5. Edema

6. Hypertension
Cylo-oxygenase (COX) inhibitors
` Are effective analgesics in both inflammatory
and surgical conditions
` Decrease opiod reqirements by 30%-50%

` There is a central site of action

` Increased risk for cardiovascular events such


as MI and stroke : (Vioxx) rofecoxib , (Bextra)
valdecoxib
` Pain is severe
` Work on nerve cell’s pain receptors
` Controversial for chronic pain
` There is risk of addiction, the risk is
decreased if used appropriately
` Combining medications lets physicians
reduce the amount of narcotics
` Commonly administered to treat surgical pain

` Should be administered for treatment of


moderate to severe postoperative pain

` Opioids in the setting of chronic pain


management have guidelines in all 50 states
` Dispensing physicians should become familiar
with the guidelines and maintain appropriate
documentation of compliance

` Treatment agreement between the physician and


patient are vital!!!

` An understanding of tolerance(increasing amount


of drug needed to produce the same effect) ,or
physical dependence(abrupt cessation of drug
will lead to a withdrawl syndrome) as opposed to
addiction(where drug is used for reasons other
than pain relief)
` Respiratory ` Paralytic ileus
depression ` Dependence, abuse
` CNS depression ` Respiratory arrest
` Hypotension ` Bradycardia
` Syncope ` Muscle rigidity
` Shock ` Cardiac arrest
` Seizures
` Codeine ` Morphine

` Fentanyl ` Oxycodone
` Morphine (MS ` Oxycontin(oxycodone)
Contin)(15-30 mg po -2 times more potent
q8-12hrs) than morphine
` Dosage
` Avinza – once daily (10,15,20,30,40,60,80
dosing(30,45,60,75,90 ER)
,120 ER) ` No active metabolites
` Methadone - ` Used in opioid tolerant
inexpensive mu patients
agonist
` Duration 6-8 hours
` 2-4 times more potent
than morphine
` Morphine-like
drugs prescribe d
to treat acute pain ` Hydrocodone with
or cancer pain acetaminophen
(Vicodan, Lortab,
Norco)

` Acetaminophen
with codeine
(Tylenol#3,etc.)
` Duragesic transdermal skin patch- narcotic
treatment for moderate to severe chronic pain
` Fentanyl delivery for 72 hours
` 25 mcg/hr patch ~60 mg per day morphine

` Actiq (Transmucosal 200 mcg times 1 Q 30


minute intervals)

` Fentora (buccal 100 mcg times 1 Q 30 minute


intervals)
` Fast acting medications containing fentanyl
` Used for cancer patients who have breakthrough
pain
` Respiratory ` Cardiac arrest
depression
` Circulatory
` Respiratory arrest collapse

` Bradycardia,severe ` Paralytic ileus

` Dependence,abuse
` Allows patient to self administer an analgesic
agent
` Incremental dose, lockout interval, maximum
dose mg/hr and optional basal rate
` Preferred to use incremental dose of opioid
with short lockout interval to allow frequent
dosing ie, morphine 1.5 mg Q 8 min ; 12
mg/hr max.
` Basal rate usually used only following
extensive and extremely painful surgery
` Has been demonstrated to result in improved
patient satisfaction due to decreased delay in
treatment
Ultram(Tramadol)

` Non-narcotic drug that works on opiate


receptors

` Indicated for moderate to severe chronic pain

` Less risk of addiction


` Dosing (50-100mg po q 4-6 hr prn)
Characteristics Drug
` Relieve certain pain ` Amitriptyline
` Elavil
` Available only by ` Pamelor
prescription ` Norpramin
` Used to help sleep better
` Cancer pain, nerve
` Adjust levels of brain
chemicals( Serotonin, pain from diabetic
Norepinephine) neuropathy, post-
` Lower doses than that to herpetic neuralgia
treat depression
Cymbalta
9 Dosing 60 mg po qd
9 Serotonin and norepinephrine reuptake
inhibitor

9 FDA approved for treatment of Diabetic


Neuropathy and Fibromyalgia
¾ Help some patients described as having “
shooting “ pain by decreasing abnormal
painful sensations
` Still unclear as to how they control pain

` Post- herpetic neuralgia from shingles

¾ Tegretol (200-400 mg po bid)


` Gabapentin (Neurontin) (300-600 mg po tid)
` Pregabalin (Lyrica) (100-300 mg po bid-tid)
` Neuaxial delivery of drugs will result in lower
doses of medications need than systemic
delivery
` Should result in less opiod related side effects
Copyright © 2003 American Society of Anesthesiologists. All rights reserved
I. Pruritis I. Sensory or motor
II. Urinary retention block sensation
III. Hypotension II. Respiratory
depression
1) Superficial infection

2) Epidural abscess

3) Epidural hematoma
` Group of nerves or single nerve causing pain

` Typically using local anesthetic


Interventional Pain Medicine:
Blocks and Procedures

Thomas A Ranieri MD, FIPP


Disclosures
„ I, Thomas Ranieri, do not have any
conflicts of interest in relation to this
presentation
Pain Physicians
„ Fellowship Training in Interventional
Techniques
„ Certifications:
„ “Special Qualifications” ABA
„ Diplomat American Board of Pain Medicine
„ Fellow of Interventional Pain Practice
„ Diplomat of American Board of
Interventional Pain Medicine
Purpose of Injection/infusion
Therapy
„ Diagnostic
„ Therapeutic
„ Prognostic
„ Preemptive
Timeline
1. History and Physical
2. Data acquisition and review
3. Diagnostic testing
4. Physical and Behavioral Medicine Evaluation
(Addictionology?)
5. Pharmacologic Intervention
6. Diagnostic/Prognostic/Therapeutic injections
(Precision Localization)
7. Neuroablative Techniques
8. Neuroaugmentive Techniques (SCS,PNS,DAS)
9. Functional Restoration
10. Gainful Employment
Trigeminal Ganglion
Block/Neurolysis
„ Indications „ Contraindications
„ Trigeminal Neuralgia „ Local Infection
„ Cluster Headaches „ Sepsis
„ Ocular Pain „ Coagulopathy
„ Cancer Pain
„ Surgical Anesthesia
Anatomy
Fluoroscopic Position
Cervical Nerve Root
„ Indications „ Contraindications
„ A-A & A-O joint pain „ Local Infections
„ Occipital Headaches „ Coagulopathies
„ C/S radiculalgia „ Vertical Metastasis
„ Upper Cervical Pain „ Suboccipital
craniotomy
Anatomy
Fluoroscopic Image
Sphenopalatine Ganglion Block
„ Indications „ Contraindications
„ SPG Neuralgia „ Infection
„ Trigeminal Neuralgia „ Coagulopathy
„ Headaches „ Relative
„ Atypical Facial Pain „ Altered anatomy ie
„ Herpes Zoster surgery, infection or
Ophthalmicus genetic variations
„ Cancer
Anatomy
Fluoroscopy
Sphenopalatine Block
Stellate Ganglion Block
„ Indications „ Contraindications
„ Raynaud’s Disease „ Anticoagulant
„ Arterial Embolism „ Pneumothorax &
„ Meniere`s disease Pneumonectomy on
„ Herpes Zoster the contralateral side
„ Post-traumatic „ Recent Cardiac
syndrome (CRPS I & Infarction
II, Sudeck’s Disease) „ Glaucoma
„ Pulmonary Embolism „ Bradycardia
Anatomy
Stellate Block
Atlanto-Occipital Block
„ Occipital Headaches
„ Pain on rotation when performed
protraction or retraction
„ Contraindications:
„ Local Infection
„ Coagulopathy
„ C/S instability
Anatomy
A-O Block
Atlanto-Axial Block
„ Indications:
„ Occipital Headaches – sub-occipital region
„ C1-C2 Hypomobility
„ Contraindications:
„ Infections
„ Surgical Fusion
„ Cervical Surgery
„ Relative:
„ Arnold Chiari
„ Mets to the Cervical Corpus
„ Dens Fracture
„ Bleeding disorder
Anatomy
A-A Block
Cervical Facets
„ Indications:
„ Whiplash Injuries
„ Mechanical Neck Pain
„ Cervical Sprain/Strain
„ Cervicogenic Cephalgia
„ Contraindications:
„ Infections
„ Coagulopathy
Anatomy
Cervical Facets
Cervical Discogram
„ Indications:
„ Persistent neck and arm pain
„ Equivocal Findings on MRI
„ Prior to Cervical Fusion
„ S/P Fusion to ID transitional levels
„ Cannot distinguish between scar and recurrent disk
„ Contraindications:
„ Infection
„ Bleeding
„ Immunocompromised
Anatomy
Cervical Discography
T2 and T3 Sympathetic Blocks
„ Indications include upper extremity SMP
and Vascular disease
„ Contraindications:
„ Absolute: Infection, bleeding & sepsis
„ Relative: Thoracic aneurysm and
Respiratory Insufficiency
Anatomy
Thoracic Sympathetic Block
Other Blocks and Procedures
„ Intercostals – Injections/Cryo/RFL
„ Thoracic – facets, disco, epidurals, SNRB –
blocks/RFL/Discectomy
„ Suprascapular – blocks and RFL
„ Lumbar – Epidurals, SNRB, Disco,
Facets/RFL/Annuloplasty/Perc-D
„ Endoscopic Discectomy
„ Percutaneous Facet Fusion
„ Celiac and Splanchnic N Blocks/lysis/RFL
Disk Procedures
„ Symptomatic Disk Disruption
„ IDET
„ Biaculoplasty, Disk-it, Stereotactic Disk
Lesioning
„ Intervertebral Disk Displacement
„ Nucleoplasty - C/S, T/S, L/S
„ DeKompressor – C/S, T/S, L/S
„ SED – C/S, L/S, T12-L1 disk
IDET
Nucleoplasty
Nucleoplasty
Biaculoplasty
Stereotactic Radiofrequency Disk
Lesioning
DeKompressor
Dekompressor
Endoscopic Discectomy
„ Patient – Monitored Anesthesia Care
„ Patient has failed all conservative
measures
„ Patient prefers not to undergo open
discectomy
„ Does not burn any bridges
Transforaminal Lumbar
Discectomy (SED)
SED Procedure
YES Scope
TruFuse
„ Facet Mediated Pain
„ Failed all conservative measures
including RFL
„ Burns NO bridges
„ Patients receive general anesthesia
„ Addresses underlying problem
Indications
„ Isolated Facet based back pain
„ Minor instability
„ Adjunct to motion limiting devices
„ Augment posterior stabilization
„ Contraindications
„ Trauma, High Grade instability, Spondylolysis
and Grade 2 or higher Spondylolisthesis
Trufuse Allograft Bone Dowels
Vertebral Augmentation
„ Indications – VCFx due to osteoporosis,
Tumor, angiomas
„ Contraindications – infection, coagulopathy,
vertebra Plana, Retropulsion, non-
visualization
„ Kyphoplasty – Balloon Tamp cavity creation,
endplate elevator and PMMA delivery
„ Vertebroplasty – PMMA delivery
Vertebroplasty
Kyphoplasty
Epiduroscopy
„ Epidural steroid injections in patients
with previous surgery
„ Lysis of perineural adhesions
„ Puncture and aspiration of synovial
cysts and CSF inclusion cysts
„ Irrigation of spinal canal after and
extruded or sequestered disk fragment
Epidural Fibrosis
Procedure
Images
Spinal Cord Stimulation
„ Indications:
„ Failed Back
„ Peripheral Vascular Disease and ischemic pain
„ CRPS
„ Post-Herpetic Neuralgia
„ Visceral Pain – Angina, thoracic or AAA
„ Deafferentiation
„ Torticollis, MS and Cerebral Palsy
„ Peripheral Nerve Stimulation
SCS
„ Demonstrated relief with the temporary
electrode ( 50% or greater)
„ Cleared by Behavioral Medicine
„ Failed all Measures including surgical
„ Not addicted or in litigation
Drug Administration System
• Indications:
– Pain type and generator appropriate
– Demonstrated opioid responsiveness
– No untreated psychopathology
– Demonstrated relief with trial catheter
DAS
• Exclusion Criteria:
– Aplastic Anemia and systemic infection
– Known allergies to the materials in the implant
– Known allergies to the medicines considered
– Active intravenous drug use
– Psychosis or dementia
Intrathecal Drug Administration
DAS
Summary
• Interventions are performed to identify,
treat and ablate pain generators
• In depth knowledge of fluoroscopic
anatomy is necessary
• Each individual case presents its own
problems relative patients own intentions
i.e. secondary gain, depression,factitious
• Each case must pass the “Yo Mama” test
Proper Opiate Prescribing
Guidelines

John D. Wrightson, M.D. FAAPMR

Board Certified in Physical Medicine,


Rehabilitation & Pain Management
I, John D. Wrightson, do not have any
conflicts of interest in relation to this
presentation.
Proper Opiate Prescribing
Guidelines
™ When is prescribing appropriate?

™ What information is necessary before prescribing?

™ What are the laws regarding prescription narcotic


use?

• For Physicians?
• For Patients?
Proper Opiate Prescribing
Guidelines
™ What are the differences between dependence, tolerance,
addiction and pseudo-addiction?
™ How should the patient taking long-term opiate medication for
chronic non-malignant pain be managed?
• Treatment options?
™ What are the requirements necessary to either discontinue
prescription narcotic use or discharge a patient for either abuse
or diversion?
Proper Opiate Prescribing
Guidelines
When is prescribing appropriate?
y Acute pain : Pain that comes on quickly, can be severe,
but lasts a relatively short time. As opposed to chronic
pain.
y Chronic pain: Pain (an unpleasant sense of discomfort)
that persists or progresses over a long period of time. In
contrast to acute pain that arises suddenly in response to
a specific injury and is usually treatable, chronic pain
persists over time and is often resistant to medical
treatments.
y Pitfall: How can physicians be certain that a patient’s
pain is legitimate and that the painful condition warrants
the use of narcotics?
Proper Opiate Prescribing
Guidelines
What information is necessary before prescribing?
y More important for patient’s requiring chronic
opiate management.
y What does the patient’s history & physical
examination show?
y What is documented in diagnostic testing records?
y What documentation is appropriate? (Above, plus
pharmacy records, urine drug screen)
Proper Opiate Prescribing
Guidelines

™ What are the laws regarding prescription narcotic


use?
• For Physicians?
• For Patients?
Proper Opiate Prescribing
Guidelines
The Tenets of Lawful Prescribing
¾ A lawful prescription for a controlled substance
must be:
9 Issued for a legitimate medical purpose

9 By an individual practitioner acting in the usual


course of his or her professional practice.
9 Physician-patient relationship exists.

9 Documented in the medical records.


Proper Opiate Prescribing
Guidelines
Summary of Federal Law

™ Federal law does not preclude the use of opioid’s as analgesics for
legitimate medical purposes, including treating chronic pain and
treating pain in addicts.

™ Federal law does prohibit the use of opioids to maintain an


addicted state without special registration as an NTP
Proper Opiate Prescribing
Guidelines
y Patient responsibilities:
9 Take medication as prescribed
9 Do not share medication
9 Do not accept medications from other people, physicians
9 Essentially, adhere to pain management agreement
Proper Opiate Prescribing
Guidelines
™What are the differences between dependence,
tolerance, addiction and pseudo-addiction?
y Dependence
y Tolerance

y Addiction

y Pseudoaddiction
Proper Opiate Prescribing
Guidelines

Dependence: refers to a state


resulting from chronic use of a drug
that has produced tolerance and
where negative physical symptoms
of withdrawal result from abrupt
discontinuation or dosage reduction.
Proper Opiate Prescribing
Guidelines

Tolerance: decrease in
susceptibility to the effects
of a drug due to its continued
administration.
Proper Opiate Prescribing
Guidelines
yADDICTION: drug addiction, a condition
characterized by an overwhelming desire to continue
taking a drug to which one has become habituated
through repeated consumption because it produces a
particular effect, usually an alteration of mental
status. Addiction is usually accompanied by a
compulsion to obtain the drug, a tendency to increase
the dose, a psychologic or physical dependence, and
detrimental consequences for the individual and
society.
y Mosby's Medical Dictionary, 8th edition. © 2009,
Elsevier.
Proper Opiate Prescribing
Guidelines
y Pseudoaddiction: Pattern of drug seeking behavior
of pain patients receiving inadequate pain
management that can be mistaken for addiction
y Cravings and aberrant behavior
y Concerns about availability
y “Clock-watching”
y Unsanctioned dose escalation
**Can be distinguished from true addiction in that
the behaviors resolve when pain is effectively
treated.
Proper Opiate Prescribing
Guidelines
™How should the patient taking long-term opiate
medication for chronic non-malignant pain be
managed?
y Monthly evaluations
y Random urine drug screens & pill counts
y Pain Management Agreement
y Opiate Informed consent
Proper Opiate Prescribing
Guidelines
™How should the patient taking long-term opiate
medication for chronic non-malignant pain be
managed?
• Treatment options?
9 Poly-pharmacy, inclusive of NSAIDS, muscle relaxants,
anti-convulsants, anti-depressants (TCA’s, SSRI’s,
SNRI’s), opiates, etc…
9 Physical therapy
9 Occupational therapy
9 Psychiatric therapy
9 Cognitive-behavioral therapy
9 Surgical intervention
Proper Opiate Prescribing
Guidelines
™ What are the requirements necessary to either
discontinue prescription narcotic use or discharge a
patient for either abuse or diversion?
y Repeated phone calls to the office requesting early
narcotic refills.
y Unusual excuses to explain loss, theft or damage to
narcotic medication.
y Tainted urine drug screens.
Proper Opiate Prescribing
Guidelines
Continued discharge criteria:
y Incorrect pill count
y Evidence of Doctor Shopping
Proper Opiate Prescribing
Guidelines
™ Physician obligation to patient:
If discontinuing opiates only:
9 letter outlining to the patient of such necessity

9 Offer patient the opportunity to attend rehab

If discharging a patient:
9 Letter of discharge if patient being released from
practice
9 Offer patient opportunity to attend rehab
9 One month supply of discharge or withdrawal medication
Proper Opiate Prescribing
Guidelines
Conclusion:
It is often appropriate and necessary to prescribe
narcotic based medications. As long as these
guidelines are adhered to, physicians may
prescribe them without fear of disciplinary action
or prosecution.
Chronic Intractable Pain and
Opioids:
Relieve suffering
Avoid addiction
Limit liability
Thomas A Ranieri MD, FIPP, DABIPP
Allied Pain Treatment Centers
Disclosures
„ I, Thomas Ranieri, have no conflict of interest in
relation to this presentation.
Prescribing Controlled Drugs
A Question of Balance
“The under-prescribing of controlled drugs
for acute, chronic and malignant pain, and
(perhaps) anxiety is extremely widespread
and contributes to significant patient
morbidity.”

1988 AMA/White House Symposium


Prescribing Controlled Drugs:
A Question of Balance
“The over-prescribing of controlled
drugs contributes to societal substance
abuse, iatrogenic dependence, increased
morbidity, and a risk management
nightmare.”

1988 AMA/White House Symposium


Number of U.S. Treatment
Admissions and Emergency
Department Mentions for
Narcotic Painkillers, 1995-2002
110,000
Emergency
100,000 Department
90,000 Mentions

80,000
70,000 Treatment
60,000 Admissions

50,000
40,000
30,000
1995 1996 1997 1998 1999 2000 2001 2002
Unintentional Drug Poisoning
Paulozzi et al. – Pharmacoepidemiol Drug Saf. 2006 15(9):618-627
„ Average Mortality Increased
„ 5%/year from 1979-1990
„ 18%/year from 1990-2002
„ Opioid poisoning vs. Cocaine, Heroin from 1999-2002
„ 91% inc. with Opioids
„ 33% inc. with Cocaine
„ 12% inc. Heroin
„ 2002 Statistics
„ 32% Methadone
„ 54% other opioids
„ 13% synthetic Opioids
Number of new non-medical
users of therapeutics

(NSDUH,
2002)
Drug Abuse: An Epidemic
„ Current illicit drug use in 2006(1 mo. Prior to survey) NSDUH Survey
„ Among Populations aged 12 or older
„ 20.4 million Americans or 8.3% of population
„ Nearly 8,000 initiates per day
„ Among population aged 12 o 17
„ 9.8% of population
„ Among population aged 18 or older
„ 18.5 million current users
„ 13.4 million (74.9%) employed part or full time
„ Lifetime use – 111.8 million
„ Past year – 35.8 million
„ Illicit drug use other than marijuana
„ Life time 72.9 million
„ Past year 21.3 million
„ Current 9.6 million
Chronic intractable pain: the
clinical challenge

„ Be aware of the “Heart Sink” patient.


„ Remain within your area of expertise.
„ Utilize Interventional Pain Medicine to validate
complaint (Injection and/or Differential infusions)
„ Stay grounded in you role:
„ COMFORT ALWAYS

THEN…..
„ CURE SOMETIMES
Prescribing Controlled Drugs
The Doctors
„ Pitfalls
„ “I just don’t prescribe any controlled drugs in my
practice”
„ “If patients abuse their medications, that is their
problem not mine”
„ “I only prescribe controlled drugs in extreme
situations, and only if pushed”
Chronic Pain Management:
decisions regarding chronic opioid
therapy

„ What are the indication for considering chronic


opioids in chronic pain syndromes?
„ Indication – patient specific and disease specific
„ Contraindications
Indications for possible chronic
opioids
THE FIVE QUESTIONS
„ Is there a clear diagnosis?
„ Is there documentation of an adequate work-up?
„ Is there impairment of function?
„ Has non-opioid multi modal therapy failed?
„ Are contraindications to opioid therapy ruled out?
„ Begin opioid therapy…Document! Monitor!
„ Avoid poly-pharmacy
Contraindications to chronic
opioid prescribing
„ Allergy to opioid medications ~ relative
„ Current addiction to opioids ~ ?absolute
„ Past addiction to opioids ~ ?absolute
„ Current /past addiction, opioids never involved
~ relative, ??absolute if cocaine
„ Severe COPD ~ relative
Prescription Drug Abuse
The Drugs
„ All euphoria producing drugs (EPD’s) have
abuse and dependence producing potential
„ Sedative-hypnotics / Stimulants / Opioids
„ Totally DIFFERENT classes
„ What do they have in common?

„ Acute release of DOPAMINE from the VTM to


the frontal cortex
Chronic pain management:
ruling out addiction
„ Perform an AUDIT and CAGE.
„ Ask family or sig. other the f-CAGE.
„ Perform one or more toxicology tests.
„ Inquire of prior physicians re: use of controlled
prescriptions (f-CAGE).
„ If history of current or prior addiction, ever
abused opioids?
Screening for Addiction: the
CAGE and f-CAGE
„ CAGE = Cut down on use? Comments by
friends and family about use that have annoyed
you? Embarrassed bashful or guilty re: behaviors
when using? Eye-openers to get started in the
mornings?
„ F-CAGE = Ask the patient’s significant other
the CAGE about the patient’s use of alcohol,
drugs or controlled prescriptions.
Assessment of Addiction
„ Differentiate between misuse, abuse and
addiction behaviors
„ Distinguish between primary addictive disease
and pain under-treatment
„ Refer when needed- Addictionology, Psychiatry
and Interventional Pain (validation)
TERMS
Tolerance: The development of a need to take increasing
doses of a medication to obtain the same effect;
tachyphylaxis is the term used when this process
happens quickly.
Dependence: The development of substance specific
symptoms of withdrawal after the abrupt stopping of a
medication; these symptoms can be physiological only
(i.e., absence of psychological or behavioral maladaptive
patterns).
TERMS
Addiction: The development of a maladaptive pattern of
medication use that leads to clinically significant
impairment or distress in personal or occupational
roles. This syndrome also includes a great deal of time
used to obtain the medication, use the medication, or
recover from its effects; loss of control over medication
use; continuation of medication use after medical or
psychological adverse effects have occurred.
Terms
„ “Pseudo-addiction”
„ Definition: Patients with severe unrelieved pain
become intensely focused on obtaining relief, and can
mimic aspects of drug seeking (aberrant) behavior.
(Haddox, 1990)
„ This behavior should resolve when adequate pain relief is
provided, without evidence of loss of control, escalation,
binging, etc.
„ Pseudoaddiction is a pseudo-diagnosis (ASIPP -2008)
Tips for prescribing of chronic
opioids
„ Factor in tolerance (already on opioids).
„ Start low/go slow (not already on opioids).
„ Slow release, long acting preparations.
„ Fixed dosing, avoid prn’s.
„ Avoid opioids for “breakthrough” pain.
„ Avoid poly-pharmacy involving controlled
drugs!!!
Prescription Drug Abuse
Drugs to Avoid & Alternatives
„ Controlled drugs to avoid prescribing
„ Side effect
„ meperidine, propoxyphene, butalbital

„ Narrow toxic/therapeutic

„ secobarbital, pentobarbital, meprobamate,


ethchlorvynol
„ Lack of efficacy

„ carisoprodol (Soma), propoxyphene


Prescription Drug Abuse
Drugs to Avoid & Alternatives
„ ALTERNATIVES:
„ Meperidine = any other CII medication!
„ Butalbital = DHE / compazine / tramadol / etc

„ Sedative Hypnotics = any benzodiazepine

„ Soma = baclofen / skelaxin / flexeril / etc

„ Propoxyphene = other opioids / NSAIDS (cox I or


II) / acetaminophen / tramadol
Documentation when initiating a
chronic opioid treatment plan
„ Identify a clear diagnosis
„ Document an adequate work-up.
„ Ensure that non-opioid therapy failed or is not
appropriate (treatment rationale).
„ Identify anticipated outcome (treatment goal).
„ Strongly consider an opioid agreement.
„ Consult a physician with expertise in the organ system
involved.
Rules Governing Prescription of
Opiates
„ State of Ohio Medical and Pharmacy Boards
„ Cannot prescribe opiates to an addict with Chronic pain unless the
patient is under the care of an addictionologist
„ Patients being prescribed opiates for a documented Chronic pain
diagnosis must also be evaluated and treated by Psychiatry and/or
Clinical Psychologist
„ Must adhere to the state medical rules governing controlled substance
prescription
Rules
„ These rules do not apply when prescribing
non-narcotic medication for chronic pain
Rules
„ Documentation of improvement of function ADLs,
employment, volunteering exercise
„ Documentation of patient compliance and non-
diversion
„ Documentation the patient is not an addict
„ Specialist can assume the care but is usually a
consultant
„ Evaluate progress toward treatment objectives
What are the Rules?
„ Documentation of Pathology
„ Validation of complaint by more than one source i.e.
consultants
„ Identify and document pain mechanism
„ Prescribe amounts within the PDR’s Recommendation
„ Documentation of continued need
„ Use mostly long acting medications unless
contraindicated
Diagnostics
„ Laboratory
„ Imaging and Nuclear Studies
„ Neurophysiologic
„ Neural Scan, EMG/NCV, Autonomic
„ Vascular Studies
„ Diagnostic Injections
„ Validation
„ Identification
„ Suppression
„ Prognostic
„ Reduction of Inflammation
Purpose of Injection Therapy
„ Augment healing – steroids/ PFP is coming
„ Promote normal physiology – Synvisc/PFP
„ Enhance central modulation – 10%NACL/Phenol
„ Validation of Pain complaint
„ Identify Pain mechanism and pathway
„ Limit consumption of psychoactive substance
„ Augment and enhance rehabilitation
Monitoring strategy when
prescribing chronic opioids
„ Document functional improvement.
„ Titrate opioids to improved function.
„ Monitor medications (pill counts).
„ Avoid non-planned escalation.
„ Monitor for scams (controlled drug consent)
„ Perform occasional toxicology tests.
„ Document, document, document!
Prescription Drug Abuse
Scams #1
„ Spilled the bottle
„ The dog ate it
„ Lost the prescription
„ Washed in laundry
„ Medications stolen
„ Left somewhere
„ The Pharmacist “shorted” me
Prescription Drug Abuse
Scams #2
„ Physician heal thyself
„ Oh, by the way
„ You are the only one who understands...
„ Rx lifting/altering
„ Late calls/cross coverage
„ John Hancock/“Dear Doctor”
Dealing with Scams
Principles
„ Cops vs Docs attitudes
„ No offense but...
„ Learn to recognize common scams – USE A
CONTROLLED DRUG CONSENT!
„ Just say no (and mean it)
„ Turn the tables
Emergency contraindications to
continued controlled drug prescribing
(above all, first do no harm)
„ Altering a prescription = FELONY
„ Selling Rx. drugs = DRUG DEALING
„ Accidental/intentional overdose = DEATH
„ Threatening staff = EXTORTION
„ Too many scams = OUT OF CONTROL
Emergency contraindications to continued
controlled drug prescribing
(above all, first do no harm)
„ What is a physician to do?
„ 1) Identify the contraindicated behavior.
„ 2) Show where agreement was broken.
„ 3) State that prescribing is inappropriate.
„ 4) Educate about withdrawal symptoms.
„ 5) Instruct to go to the E.R. if withdrawal.
„ 6) Offer care with out Rx, and/or referral.
Signs and symptoms of opioid
withdrawal
„ HEENT, CV, GI, MS, Neuro/Psych.
„ HEENT- dilated pupils, lacrimation, rhinorrhea,
yawning
„ CV- tachycardia, hypertension
„ GI- nausea, vomiting, diarrhea, abd. cramps
„ MS- piloerection, diaphoresis, myalgias,
arthralgias, bone pains
„ N/P-insomnia, anxiety, headache, dysphoria
Pain Patient on
Chronic Opioids + New Physician

Are chronic opioids appropriate?

YES! UNSURE NO
Re-document: Physical Dependence vs Addiction: Educate patient
Chemical dependence on need to
Diagnosis discontinue opioids
screening
Work-up
Toxicology tests
Treatment goal Emergency?
Pill counts
Functional status ie: overdoses
Monitor for scams selling meds
Reassess for altering Rx
Monitor Progress: appropriateness
Pill counts
NO!
Function YES! 3-month self taper
Refill flow chart (document in chart)
Occasional urine Discontinue opioids OK
toxicology Instruct patient on 10-week structured taper
Adjust medications withdrawal symptoms OK
Watch for scams Tell to “go to ER” Discontinue opioids at
if withdrawal symptoms end of structured taper
Opioid w/d treatment options
„ Gradual self taper over three months**
„ 10 week structured taper**
„ Abrupt discontinuation and detoxification
„ Methadone
„ Clonidine
„ Buprenorphine
„ Tramadol
„ Ultra-Rapid Opiate Detoxification – Consent &
Compliance
** = non-emergency patient with a legitimate pain diagnosis.
Chronic intractable pain: the
clinical challenge
„ Be aware of the “Heart Sink” patient.
„ Remain within your area of expertise.
„ Stay grounded in you role
„ Utilize Interventional Pain Physician for
Diagnostic/Differential - Injections/Infusions
„ FIRST….DO NO HARM
„ THEN…..
„ CURE SOMETIMES
„ COMFORT ALWAYS
Pain Management for
the Non-Specialist

Presented by:

Veeraiah C. Perni, M.D.


Director of Anesthesiology
Jameson Memorial Hospital
z I, Veeraiah C. Perni do not have any
conflicts of interest in relation to this
presentation.
Practical Pain Management for
Non-Specialists
z Target clinical specialty
z Guideline objectives
z Assessment /Evaluation
z Management/Rehabilitation/Treatment
z Chronic low back pain: ACP/APS
recommendations
z Special focus on Cancer pain and palliative
medicine
z Tips on referrals to pain specialist
z How to get paid for Pain Management
Target Clinical Specialty
z Family Practice
z Internal Medicine
z Pediatrics
z Physical Medicine and Rehabilitation
z Psychology
z Surgery
z Hospitals/Allied Health Personnel
Guideline Objectives
z Chronic Pain; scope/definition
z To improve by bio-psychosocial
assessment
z The target is management not elimination
z Multidisciplinary team approach; the
primary care physician as team leader
z The goal of treatment is to improve
function through fitness and healthy
lifestyle
z To improve the effective use of
medications and interventional techniques
Key Points in the History of the
Chronic Pain Patient
z Pain location, intensity, quality, onset,
duration, effects of pain, and pain relief
z A general history and physical exam are
essential
z A history of depression or other
psychopathology
z Past or current physical, sexual, or
emotional abuse
z A history of chemical dependency
z Patient self report is remarkable
Other Methods of Assessment
z Diagnostic Testing
- There is no diagnostic test for chronic pain
- Plain radiography – musculoskeletal pain
- CT/MRI for spine pathology
- CT Myelography for pts. considered for surgery
- Electromyography / nerve conduction studies for
LMN dysfunction, nerve or nerve root pathology
or myopathy
z Functional Assessment
z Pain Assessment Tools
Determination of Biological
Mechanism of Pain
z Pain classification and types of pain
- Neuropathic Pain
- Muscle Pain
- Inflammatory Pain
- Mechanical/compression pain
z Decades ago, all chronic pain was treated
similarly
z Mechanism – specific treatment
z Pain usually has more than one mechanism
Neuropathic Pain
z Cause – damage or dysfunction of the
nervous system
- sciatica from nerve root compression
- diabetic peripheral neuropathy
- trigeminal / Post herpetic neuralgia

z Clinical Features
- the setting; the first clue
- the distribution; follows the nerve distribution
- the character; burning, shooting, stabbing
- findings of physical examination: numbness,
coolness, and allodynia
Muscle Pain
z Causes
- muscle pain of chronic pain
- fibromyalgia syndrome and,
- myofascial pain syndrome
z Common Clinical Features
- sore, stiff, aching, painful muscles
- fatigue, poor sleep, depression, headache,
and irritable bowel syndrome
- acute muscle pain occasionally
- pain related disability is a challenge to the
health care system
z Fibromyalgia Syndrome
- Widespread musculoskeletal disease

z Myofascial Pain Syndrome


- regional muscle and soft tissue pain
- trigger points refer pain
- Widespread musculoskeletal disease
Inflammatory Pain
z Causes
- Tissue Injury, postoperative, osteo-arthritic
pain, infection
- same as nociceptive pain
- inflammatory chemicals stimulate primary
sensory nerves and carry information to the
spinal cord

z Clinical Features
- heat, redness, and swelling
Mechanical / Compression Pain
z Causes : muscle / ligament strain,
degeneration of discs, facets or
osteoporosis with compression fractures,
fractures, dislocation, obstruction, and
compression by bony tumors
z Same as nociceptive pain
z Aggravated by activity and usually
relieved rest
z Radiology very helpful
Pain Management -Algorithm
z Develop a written plan of care and set
goals using the bio-psychosocial model
z All patients with chronic pain must
participate in an exercise fitness program
z Set personal goals/restructuring life
z Improve sleep, manage stress
z Decrease pain
z Patients want quick fix, not temporary
relief
Treatment Plan for Chronic Pain
z Rehabilitation/functional management
z Psychosocial management
- Depression
- Cognitive – Behavior therapy
z Pharmacologic management
z Interventional management
z Non-pharmacologic management
z Complementary medicine
z Referral to multi-disciplinary pain mgmt.
z Surgery for placement of a stimulator or
pump
Management of Neuropathic Pain
z Eliminate the underlying causes of pain
z Local or regional therapies
- Topical Capsaicin, 3 to 4 times daily
- Lidocain cream or patch
- Transcutaneous electrical nerve stimulator
z Pharmacologic management
- Gabapentin: 300mgs TID (100% Renal)
- Pregabalin: 50-100 mgs TID
- Other Anticonvulsants:
* Carbamazepine
* Oxcarbazepine 150-300 mgs BID
* Topiramate, Lamotrigine, Tiagabine
* Benzodiazepine, Clonazepam
Pharmacologic Management
(cont)- Neuropathic Pain
z Tricyclic antidepressants
- Amitriptyline, Notriptyline, Desipramine,
Imipramine, and others
- Potentiate descending inhibitory pathways
- Pain reduction is independent of effect
on depression
- A screening EKG is required in elderly
z Corticosteroids
- Pain relief through membrane stabilization
and anti-inflammatory effects
- Short term control of neuropathic radicular
pain caused by edema, tumor invading
bone and acute or sub-acute disc herniation
z Opioids
- not known for neuropathic pain but as potent
analgesics
- Methadone and Tramadol are more effective
Management of Muscle Pain
z Physical rehabilitation
z Behavioral management
z Drug therapy
- Pain and sleep
* Tricyclic antidepressants
Nortriptyline low dose
* Cyclobenzaprine
- Depression and Pain
* Duloxetine
- Opioids rarely needed
Inflammatory Pain Management
z Physical rehabilitation
z Behavioral management
z Drug therapy
- Pain and sleep
* Tricyclic antidepressants
Nortriptyline low dose
* Carbobenzaprine (short term)
- Depression and pain
* Duloxetine
- NSAIDS, immunologic drugs, other
depressants
Mechanical / Compressive
Pain Management
z Screen for serious medical pathology and
refer to appropriate specialist
z Physical rehabilitation
z Behavioral management
z Drug therapy
- Tricyclic antidepressants
- NSAIDS
- Other antidepressants
Pharmacologic Management of Pain
Key Points
z A thorough medication history is critical
z Base the choice of medications on type and
severity
z Medications are not the primary focus in managing
pain
z Titrate doses for an optimal balance between
analgesic benefit, side effects, and functional
improvement
z For Opioid therapy:
- use a written Opioid agreement for long-
term therapy
- see the Federation of State Medical
Boards at:
http://www.fsmb.org for complete
information
Non-Opioid Analgesics
Acetaminophen
z To treat mild chronic pain or to supplement
z Lack anti-inflammatory effects
z Do not damage gastric mucosa
z May have chronic renal and hepatic side
effects
z Dose; max 4gms./24 hrs.
z Caution: Patients with liver impairment
Non-Opioid Analgesics,
Non-Steroidal Anti-Inflammatory Drugs
z To treat mild to moderate inflammatory or
non-neuropathic pain
z NSAIDS inhibit prostaglandin synthesis by
blocking the enzyme Cyclooxygenase (COX)
z COX-2 agents have fewer GI symptoms but
higher cardiovascular effects. Use along
with gastroprotective agent; Proton pump
inhibitor (Misoprostol)
z Use caution in patients with risk of bleeding
z Ketorolac not for chronic pain
z NSAIDS have significant opioid sparing
properties and reduce opioid-related side
effects
Use of Opioids in Chronic Pain
z First get familiar with Federation of State
Medical Board documents
z For neuropathic pain, not responding to first line
therapies
z Opioids are rarely beneficial for inflammatory,
mechanical / compressive pain
z Not indicated for chronic headache mgmt.
z Have better therapeutic index and low medical
risks
z Close monitoring is essential and non-compliant
pts. must be referred to pain or addiction
specialist
Tricyclic Anti-Depressants
(TCAS)
z First line for neuropathic pain with insomnia,
anxiety and depression
z Avoid tertiary amines (Amitriptyline,
Imipramine)
z TCAS analgesic effects are with lower doses
z Maximum analgesic effect may take several
weeks to be seen
z Baseline EKG is indicated for pts. at higher
cardiac risk
z Common side effects: sedation, dry mouth,
constipation, and urinary retention
Other Anti-Depressants
z Selective Serotonin re uptake inhibitors
z Less side effects compared to TCAS, but
less efficient for neuropathic pain relief
z Bupropion, Venlafaxine, and Duloxetine
are all efficient against neuropathic pain
z Duloxetine in doses of 60 mgs. BID is
beneficial for fibromyalgia
Anticonvulsant or Antiepileptic
Drugs
z Carbamazepine and Phenytoin:
- effective for neuropathic pain
- Carbamazepine well established for
trigeminal neuralgia
- unwanted CNS side effects
z Pregablin:
- Diabetic neuropathy
- Post herpetic neuralgia
z Oxcarbazepine; good for neuropathic pain

z Gabapentin; excellent for all types of


neuropathic pains. Titrate up gradually

z Lamotrigine; Trigeminal neuralgia, post-


stroke pain and neuropathies of HIV
infection
Topical Agents
z 5% Topical Lidocaine patches; 12hrs on and 12hrs off
- Excellent safety profile
- Post herpetic neuralgia and other
neuropathic pain syndromes
z Capsaicin:
- Depletes the pain mediator substance-P
from afferent nociceptive neurons
- Good for arthritic pain and other neuropathic pain
- Use at least for 6 wks. for benefits
- Side effect – burning; becomes tolerant after a few
weeks
Diagnosis and Treatment
of Low Back Pain

Joint Practice Guidelines from


ACP and APS
Recommendations
z Focused history and physical examination
1. Nonspecific low back pain
2. Back Pain with radiculopathy or spinal
stenosis
3. Low back pain with other spinal cause
z Imaging not required for nonspecific LBP
z Imaging advised for neurological deficits
or other underlying conditions
z Imaging before steroid injections or
surgery
z Advise patients to be active and self-care
options
z First line drugs: Acetaminophen, NSAIDS
z Muscle relaxants for temporary relief of
acute low back pain
z Tricyclic antidepressants for chronic LBP
z Use of opioids in selected patients
z Spinal manipulation for acute LBP, intense
rehabilitation, acupuncture, yoga,
cognitive behavioral therapy for sub-acute
and chronic pain
JAMESON MEMORIAL HOSPITAL
NEW CASTLE, PA 16105

IV PCA - PAIN CONTROL ORDERS


(For Jameson Hospital Medical Staff Only)

Medication □Morphine 1 mg/ml in 0.9% NSS


□HYDROmorphone (Dilaudid) 0.2 mg/ml in 0.9% NSS

□Morphine 5mg/ml (HIGH POTENCY)


□HYDROmorphone (Dilaudid) 0.5mg/ml (HIGH POTENCY)

Initiate the following pain control orders:


SELECT ONE: □ PCA Mode
□ Continuous Mode
□ PCA & Continuous
Typical Ranges
* Consider patient age, renal status, comorbidities and history of
opioid use.
• IV fluids @ ml/hr Morphine HYDROmorphone
• Continuous rate (Delivery): mg/hr
• Loading dose: mg Continuous 1-3 mg/hr 0.2 - 0.5 mg/hr
• PCA dose: mg Loading 1-4 mg 0.3 - 0.5 mg
• Lock out time: minutes. (Typical lock out range PCA dose 0.5- 2 mg 0.2 - 1 mg
10-20 minutes)
• One hour dose limit: mg
• Decreased respiratory rate of less than 8 per min. and/or patient unarousable, administer Narcan 0.04 mg q 1 minute
IV STAT, according to protocol. Then call ordering physician.
• Bolus PRN dose:
• RN may administer a bolus PRN dose of mg once per hour, if needed, until pain relief is achieved.
• Monitor sedation, pain level & vital signs q ½ h for 2 hours, q 1 hr for 2 hours, then q 4 h.
• Continuous Pulse Oximetry - chart q h. If unable to maintain sat above 94%, apply Nasal O2 at 3 liters and
notify physician.
• Notify PCP or ordering physician of inadequate pain relief or persistent nausea.
• Verify all other narcotic medication/sedative orders with physician initiating PCA orders.
• RN must clarify if conflicting orders are present.
• Additional PRN medications:

Physician Date/Time

*Patients in terminal state may be exempt from these monitoring/intervention orders. Physician can cross out
unapplicable orders and initial to eliminate this monitoring.

9/05; Revised 4/09


PHO-1019
JAMESON HEALTH SYSTEM
NEW CASTLE, PA 16105

CONTINUOUS EPIDURAL INFUSION


(Anesthesia Assoc., P.C. Orders ONLY)

Epidural Infusion Only:

• Final concentration: Fentanyl 2 mcg/ml Bupivacaine (0.125%) in 250 ml 0.9% NSS


• Infusion to run @ ml/hr.
• Use yellow striped tubing specifically for Epidural infusion.
• Ambu and Oxygen immediately available.
• Continuous Pulse Oximetry - chart q 1 hrs. Apply nasal O2 at 2 LPM while catheter in place. Call Anesthesia if unable
to maintain sat above 90% and notify PCP or Surgeon.
• Notify anesthesia immediately if patient complains of progressive heaviness in legs or inability to move legs.
• For decreased respiratory rate of less than 8 per minute and/or patient unarousable, administer Narcan 0.04 mg q 1 minute
IV STAT according to protocol, then call Anesthesia and notify PCP or Surgeon.
• Monitor/record respirations q ½ hr x 2 then q 1 hr x 24 hrs. then q 4 hrs.
• Monitor sedation, pain level, and vital signs q ½ hour for 2 hrs and q 1 hr for 2 hrs then q 4 hrs.
• Whenever Epidural dosage increased, reinstate initial monitoring protocol.
• Notify Anesthesia of inadequate pain relief, persistent nausea, sedation level 3 or greater, or respirations less than 8.
Exception: For pts on ventilator - contact physician/service managing ventilator care.
• Hold all other Narcotic medications/sedatives unless ordered by Anesthesia.
• If intubated, Diprivan drip titrated to sedation level of 3 or greater.
• RN must clarify if conflicting orders are present.
• If patient has no IV order from surgeon or primary physician, patient is to have Lactated Ringers at 40 ml/hr.
• Do not begin Lovenox, Coumadin, IV/SQ Heparin until at least 2 hrs. after epidural catheter has been removed
due to risk of epidural hematoma/bleeding.
• If IV/SQ Heparin, Lovenox, or Coumadin ordered, discontinue Epidural catheter and hold dose for 2 hrs following
removal of catheter.
• If air in volumetric infusion set, may disconnect from Epidural catheter, purge air and reconnect to catheter.
• Patient may have:
□ Morphine Sulfate 2 mg IV q 30 min PRN for breakthrough pain for pain level greater than 5 x 2 doses only.
If pain level greater than 5 after 2 doses, notify Anesthesia
OR
□ Dilaudid 0.5 mg IV q 30 min prn up to 4 doses per 4 hr. period
Call Anesthesia if pain level greater than 5 after 4 doses of Dilaudid
• Epidural Bolus prn per Anesthesia.
• □ For nausea, give Zofran 4 mg IV, wait 15 minutes. If nausea/vomiting continues, give Zofran 4 mg IV then
continue Zofran 4 mg IV q 4 hrs prn for nausea/vomiting. Call Anesthesia for persistent nausea/vomiting.
• □ If itching, administer Nubain 5 mg IV. May repeat Nubain 5 mg IV in 15 minutes, once. If itching persists,
notify Anesthesia for further orders.

Physician Date/Time

Revised 7/05; 8/06; 2/07; 4/09


PHO-1005
JAMESON HEALTH SYSTEM
NEW CASTLE, PA 16105

CONTINUOUS PERIPHERAL NERVE/


FEMORAL NERVE/LUMBAR PLEXUS/
SCIATIC NERVE CATHETER ORDERS
(Anesthesia Assoc., P.C. Orders ONLY)

Medication: □ Bupivacaine 0.05% (final concentration) in 250 ml NSS


□ Bupivacaine 0.125% (final concentration) in 250 ml NSS

• Infusion to run at ml/hour on CADD Solis Pain Management Pump.


• Place peripheral nerve catheter infusion pump at the foot of the bed when used in conjunction with
another pain delivery system.
• Use yellow-striped tubing with tag indicating “Bupivacaine Infusion Only”.
• If air in infusion set, may disconnect from the peripheral nerve catheter, purge air and reconnect to
catheter.
• IV Peripheral PCA for 24 hours (see physician Peripheral PCA Order Sheet).
Start: Date Time
Discontinue: Date Time
• Call Anesthesia if patient is experiencing progressive motor block in extremity
• Post-op care: Check site for dislodgement and hematoma, check extremity for circulation, motion and
sensation, and check vital signs: q ½ hour for 2 hours, then q 1 hour for 2 hours, then q 4 hours until
catheter removed.
• Call Anesthesia if catheter dislodges.

Physician Date/Time

Revised 2/07; 4/14/09


PHO-1007
JAMESON HEALTH SYSTEM
NEW CASTLE, PA 16105

IV PCA INFUSION PUMP ORDERS


(Anesthesia Assoc., P.C. Orders ONLY)

PCA ORDERS SHOULD BE ADJUSTED BY ANESTHESIA ONLY

Medication □Morphine 1 mg/ml in 0.9% NSS


□HYDROmorphone (Dilaudid) 0.2 mg/ml in 0.9% NSS
□Fentanyl 10 mcg/ml - * in 0.9% NSS

• CONTINUOUS Rate (Delivery):


• BOLUS (Loading Dose): *Omit Bolus if narcotic given within last hour.
• PCA Dose:
• (Lockout): min
• ONE HOUR LIMIT:
• If pain is not adequately controlled: (pain scale 4 or greater)
PCA dose may be increased to and the 1 hr limit increased to (one time
only)
• If pain level greater than 5 after PCA dose increased one time (pain reassessment), call Anesthesia.
• Monitor sedation, pain level, and vital signs q ½ hour for 2 hrs then q 1 hr for 2 hrs then q 4 hrs.
• Notify Anesthesia if sedation level 3 or greater.
• For decreased respiratory rate of less than 8 per min. and/or patient unarousable, administer Narcan 0.04 mg
IV STAT q 1 minute according to protocol, then call Anesthesia and notify PCP or Surgeon.
• □ For nausea, give Zofran 4 mg IV, wait 15 minutes. If nausea/vomiting continues, give Zofran 4 mg IV
then continue Zofran 4 mg IV q 4 hrs prn for nausea/vomiting. Call Anesthesia for persistent
nausea/vomiting.
• □ If itching, administer Nubain 5 mg IV. May repeat Nubain 5 mg IV in 15 minutes, once.
If itching persists, notify Anesthesia for further orders.
• Continuous Pulse Oximetry - chart q 1 hr. Apply nasal O2 at 2 LPM while PCA in place. Call Anesthesia
if unable to maintain sat above 90% and notify PCP or Surgeon.
• Whenever PCA dosage increased, reinstate initial monitoring protocol.
• Hold all other Narcotic medications/sedatives unless ordered by Anesthesia.
• RN must clarify if conflicting orders are present.
• If patient has no IV order from surgeon or primary physician, patient is to have Lactated Ringers at 40
ml/hr.
• Place PCA infusion pump at the head of the bed when used in conjunction with another pain delivery
system.

Physician Date/Time

Revised 7/05; 8/06; 2/07; 4/09


PHO-1045
JAMESON HOSPITAL
NEW CASTLE, PA 16105

POST-OP PAIN MANAGEMENT


ORDERS AFTER
INTRAOPERATIVE DURAMORPH
(Anesthesia Assoc., P.C. Orders ONLY)

• Patient received mg of intrathecal/epidural Duramorph at (time) intraoperatively.


• Epidural discontinued at: Date Time
• Patient may have:
( ) Morphine Sulfate 1 mg IV q 15 min prn for breakthrough pain up to 5 doses (pain level greater than 5)
*If pain scale still greater than 5 despite prn Morphine, increase Morphine Sulfate to 4 mg IV x 1
dose
*If no relief, notify Anesthesia
( ) a. Until date @ 7:00 a.m.
OR
( ) b. During 18 hours post Duramorph injection. End of 18 hour time frame:
Date Time
OR
( ) Dilaudid 0.5 mg IV q 15 minutes prn up to 4 doses per 4 hour period
*Call Anesthesia if pain level greater than 5 after 4 doses of Dilaudid
( ) a. Until date @ 7:00 a.m.
OR
( ) b. During 18 hours post Duramorph injection. End of 18 hour time frame:
Date Time
• No other IV/IM/PO narcotic for 18 hrs post Duramorph injection unless ordered by Anesthesia.
• Hold all other Narcotic medications/sedatives unless ordered by Anesthesia.
• Notify Anesthesiologist for additional pain orders while Duramorph protocol in effect.
• Monitor/record Respirations q ½ hr x 2, q 1 hr x 24 hrs then q 4 hrs.
• Notify Anesthesia if sedation level 3 or greater.
• Monitor sedation, pain level, and vital signs q ½ hour for 2 hrs then q 1 hr x 2 hrs then q 4 hours.
• For decreased respiratory rate of less than 8 per minute and/or sedation level 3 or greater, administer Narcan 0.04
mg IV STAT q 1 minute according to guidelines, then call Anesthesia and notify PCP or Surgeon.
• Continuous Pulse Oximetry - chart q 1 hr. until the Duramorph protocol completed.
• Apply nasal O2 at 2 LPM for 18 hours following Duramorph injection until Duramorph protocol is completed. Call
Anesthesia if unable to maintain sat above 90% and notify PCP or Surgeon.
• If patient has no IV order from surgeon or primary physician, patient is to have Lactated Ringers at 40 ml/hr.
• May anticoagulate 2 hrs following epidural discontinuation.
• □ For nausea, give Zofran 4 mg IV, wait 15 minutes. If nausea/vomiting continues, give Zofran 4 mg IV then
continue Zofran 4 mg IV q 4 hrs prn for nausea/vomiting. Call Anesthesia for persistent nausea/vomiting.
• □ For itching, administer Nubain 5 mg IV. May repeat Nubain 5 mg IV in 15 minutes, once. If itching persists,
notify Anesthesia for further orders.
• RN must clarify if conflicting orders are present.
• □ Toradol 30 mg IV q 8 hrs x 3 doses if not contraindicated.

Physician Date/Time

Rev. 7/05; 8/06; 2/07; 5/09