Chronic pain management

Dr. Ankit Gajjar

 IASP Definition of Pain

“Pain is an unpleasant sensory

and emotional experience
associated with actual or potential
tissue
damage or described in
terms of such damage.”
IASP Defination of chronic
pain

Pain without apparent biological value

that has persisted beyond the normal
tissue healing time usually taken to be
3 months and that affect the function or
well being of the patient
Chronic pain may be:
1) Non malignant
a)inflamatory
b)musculoskeletal
c)neuropathic
2) Malignant
3) chronic pain
syndrome
 Physiology of Pain Perception
Injury Brain

 Transduction
 Transmission Descending

 Modulation Pathway

Peripheral Dorsal
 Perception Nerve Root
Ganglion

 Interpretation Ascending
Pathways
 Behavior C-Fiber

A-beta Fiber Dorsal

Horn
A-delta Fiber
Spinal Cord
5
 Gate Control Theory
(Melzack & Wall, 1965)
A gate in the substantial gelatinosa of the dorsal horn can be open or
closed, blocking pain information.
The gate can be closed by descending signals from the brain, or
by the balance of activity in A-beta fibres (large myelinated) and
C fibres (small non-myelinated)
 A-beta fibres produce touch sensations
 C fibres produce dull diffuse pain.

Greater activity in A-beta fibres closes the gate, greater activity in C

fibres opens it.
 Other factors influencing the gate include
 Attention

 Emotional & Cognitive factors

 Physical factors

Some forms of analgesia, e.g. TENS & acupuncture, might be

accommodated within gate control theory.
 Opening & Closing the Gate
Factor Opens Closes
Physical injury medication
agitation
Emotional anxiety relaxation
stress
frustration optimism

depression happiness
tension
Behavioural rumination enjoyable activities
(Cognitive) boredom complex tasks
distraction
social interaction
Domains of Chronic Pain
Quality of Life Psychological
Physical functioning Morbidity
Ability to perform Depression
activities of daily Anxiety, anger
living Sleep disturbances
Work Loss of self-
Recreation esteem

Social Socioeconomic
Consequences
 Marital/family
Consequences
 Healthcare
relations
 Intimacy/sex costs
ual  Disability
activity
 Lost workdays
 Evaluation of chronic pain

 Describing pain only in terms of its

intensity is like describing music only
in terms of its loudness
Multidimensional Classification of Pain

IASP expert multi-axial classification of chronic pain

Axis I : Regions
Axis II :
Axis III : Systems
Axis : Temporal Characteristics
IV : Patient’s Statement of Intensity
Axis V Etiology
Example:
Mild postherpetic neuralgia of T5 or T 6; 6 months’ duration = 303.22e
Axis I: Thoracic region
Axis II: Nervous system (central, peripheral, or autonomic); physical
disturbance/dysfunction
Axis III: Continuous or nearly continuous, fluctuating severity
Axis Mild severity of 1 to 6 months
IV: Trauma, operation, burns, infective, parasitic (one of
 PAIN HISTORY
 Description: severity, quality, location,
temporal features, frequency, aggravating &
alleviating factors
 Previous history
 Context: social, cultural,
emotional, spiritual factors
 Meaning
 Interventions: what has been tried?
 Pain Intensity Rating Scales
 Visual Analogue Scale (VAS)

 Numerical Rating Scale

0 10
Worst pain
No pain
maginable

 Categorical Scale
None (0) Mild Moderate (5 – 6) Severe (7 – 10)
(1 – 4)
 Medication(s) Taken
 Dose
 Route
 Frequency
 Duration
 Efficacy
 Adverse effects
 Physical Exam In Pain Assessment
Inspection / Observation
“You can observe a lot just by watching”
 Overall impression… the “gestalt”?
 Facial expression: Grimacing; furrowed brow; appears
anxious; flat affect
 Body position and spontaneous movement: there may be
positioning to protect painful areas, limited movement due
to pain
 Diaphoresis – can be caused by pain
 Areas of redness, swelling
 Atrophied muscles
 Gait
 Myoclonus – possibly indicating opioid-induced
 Physical Exam In Pain Assessment
Palpation
 Localized tenderness to pressure or percussion
 Fullness / mass
 Induration / warmth
 Psychological evaluation
 Goal of psychological evaluation is to determine the
contribution of affective, cognitive behavioral factors to
the perception and report of pain.
 Diagnostic imaging techniques:
Radiography
Ultrasonography
Doppler
CT scan
MRI
 Pain in Children
 Children feel pain just as intensely
 Keeping parents informed, as part of the “team” is
important
 Anticipatory guidance helps children to cope with
pain more effectively
 Careful calculations for dosing adjustments is
vital
 Dosages are usually based on child’s weight
 Children can use a faces scale for pain assessment
Evaluation of pain in children
 PAIN
TREATMENT
 Modified WHO Analgesic Ladder
Proposed 4th Step

The WHO Ladder

 Pharmacotherapy

Analgesics
 Nonopioids
 Adjuvant Analgesics
 Opioids
 Opioid Therapy: Drug Selection

Short-Acting Opioids
- Morphine
- Oral transmucosal fentanyl
- Tramadol

Long-Acting Opioids
- Transdermal Fentanyl
- Methadone
- Extended-release morphine
- Oxycodone
Opioid Therapy: Drug Selection

Advantages of Long-Acting Opioids:

- Fewer peaks and troughs

- Sustained pain relief
- Dosed less often, improved adherence
-Potentially improved patient satisfaction and quality
of life
Opioid Therapy:
Prescribing Principles
- Drug Selection: Elements to Consider
Severity of pain, previous exposure, availability,
patient’s preference, renal/liver function, cost
- Dose to Optimize Effects
Fixed schedule (or around-the-clock) vs as-
needed dosing;
rescue doses
- Treat Side Effects
Goal: balance between analgesia and side effects
- Manage the Poorly Responsive Patient
Opioid Therapy: Dosing
- By-the-clock (fixed-schedule) dosing with long-
acting opioid plus an “as-needed” short-acting
“rescue” opioid (usually 5%–15% of total daily
dose, q 2-3 h prn)

-Baseline dose increases: 25%–100% or

equal to “rescue” dose use

- Increase “rescue” dose as baseline

dose increases
Opioid Therapy:
Route of Administration

- Oral / Transdermal

- Rectal

- Parenteral (IV, SC)

- Intraspinal (epidural,
intrathecal)
Opioid Titration

- Dose titration over time is key to successful opioid

therapy
-There is no ceiling dose for pure-agonist opioids.
Titrate dose upward for maximum pain relief with
acceptable side effects
- Consider rescue medication for breakthrough pain
-Responsiveness of an each patient to each drug
varies
- If a patient does not respond well on one
opioid, it
is important to try another (opioid rotation)
Opioid Therapy: Patient Selection

-Thorough Evaluation
_pain history
_physical exam
coexisting conditions
- Review of Previous
Medical/Pain History
_any psychological
disturbances
_chronic pain history
- Substance Abuse
History (including
alcohol)
Opioid Therapy:
Monitoring Outcomes
Monitoring the 4 A’s

1.Analgesia (pain relief)

2.Activities of Daily Living (psychosocial
functioning)
3.Adverse Effects (side effects)
4.Aberrant Drug-Taking (addiction-
related
outcomes)
Opioid Therapy: Managing the
Poorly Responsive Patient
If dose escalation increases adverse effects
- Side-effect management
-Pharmacologic strategy to lower opioid
requirement
_spinal route of administration
_add nonopioid or adjuvant analgesic
- “Opioid rotation”
_nonpharmacologic strategy to lower opioid
requirement
Opioid Therapy: Managing the
Poorly Responsive Patient
Opioid Rotation
-Based on large intra-individual variation in
response to different opioids
-Reduce equianalgesic dose by 25%–50% with
provisos:
_reduce less if pain severe
_reduce more if medically frail
_reduce less if same drug by different route
_reduce transdermal fentanyl less (no cutback from
equianalgesic dose)
reduce methadone more: 75%–90%
Opioid Therapy:
Managing Side Effects

Common
Constipation
Somnolence, mental clouding

Less Common
- Nausea - Sweating
- Myoclonus - Amenorrhea
- Itch - Sexual dysfunction
- Urinary retention - Headache
 Opioid-Induced Neurotoxicity(OIN)
 Neuropsychiatric syndrome
 Cognitive dysfunction
 Delirium
 Hallucinations
 Myoclonus/seizures
 Hyperalgesia/allodynia
 OIN: Treatment
 Opioid rotation
 Reduce opioid dose
 Hydration
 Circadian modulation
 Psychostimulants
 Tolerance
 Reduced potency of analgesic effects of
opioids following repeated
administration, i.e., increasing doses are
necessary to produce pain relief
 Related to opioid receptor regulation
 Less common in pts with cancer pain
 Often reason pts “save” opioids
until terminal phase
 Dependence
 Physical dependence: normal response
to chronic opioid administration
 Evident with opioid withdrawal:
yawning, sweating, tremor, fever,
increasesd HR, insomnia,
muscle/abdominal cramps, dilated pupils
 Avoided by decreased dose 20-30%/day
Addiction

- Psychological dependence
- “A pattern of drug use characterized by a
...craving for opioids...manifest...[by]
compulsive drug-seeking behavior
leading to...overwhelming involvement
in use and procurement of the drugs.”
PSEUDO-ADDICTION:
 Physical dependence confused
with psychological dependence
 Pain-relief seeking, not drug-
seeking
 When right dose used, patient functions
better in life, whereas opposite true with
the true addict
 To help diffentiate: one MD controls the
drug under a specific contract with pt.,
Nonopioid Analgesics:
Acetaminophen

- Minimal anti-inflammatory effect

-Fewer adverse effects than other nonopioid
analgesics
- Adverse effects:
_renal toxicity
_risk of hepatotoxicity at high doses;
_increased risk with liver disease or chronic
alcoholism
- No effect on platelet function
Nonopioid Analgesics:
NSAIDS
Mechanisam of action:
- Inhibit both peripheral and central cyclo-
oxygenase, reducing prostaglandin formation

- 2 isoforms of COX
_COX-1: Constitutive, physiologic
_COX-2: Inducible, inflammatory
Nonopioid Analgesics:
NSAIDS
- Major recent advance: COX-2 selective NSAIDS
-COX-2 selective inhibitors have better GI safety
profile; no change in platelet function
-Drug selection should be influenced by drug-
selective toxicities, prior experience, convenience,
cost
-Great individual variation in response to different
drugs
-Use with caution in patients with renal
insufficiency, congestive heart failure or volume
overload
 Adjuvant Analgesics
Adjuvant Analgesics for Neuropathic Pain
CLASS EXAMPLES
Anticonvulsants gabapentin, valproate, phenytoin,
carbamazepine, clonazepam,
topiramate, lamotrigine
Antidepressants amitriptyline, desipramine, nortrip-
tyline, paroxetine, citalopram, others
Local Anesthetics mexiletine

Corticosteroids dexamethasone, prednisone

α-2 Adrenergic Agonists tizanidine
NMDA-Receptor Agonists dextromethorphan, ketamine
Topicals lidocaine, lidocaine/prilocaine, capsaicin
Miscellaneous baclofen, calcitonin
Adjuvant Analgesics:
Anticonvulsants
Common Characteristics
- Most clinical experience: gabapentin, carbamazepine, phenytoin,
valproate, clonazepam
- Limited data on efficacy of newer anticonvulsants
-Used as an analgesic, dosing schedule is similar to anticonvulsant
indication
- Large inter-/intra-individual variability in analgesic response
Gabapentin
- Usual first-line drug for neuropathic pain
- Favorable safety profile
- Positive controlled trials in PHN/diabetic neuropathy
- No controlled studies in cancer patients
- Usual starting dose 100-300 mg/day
- Titration to identify responders/nonresponders
-Usual effective dose 600-3600 mg/day; higher doses sometimes
beneficial
 Pregabalin
 Very similar to gabapentin
 More reliable oral absorption
 Slightly different side effect profile
 Doses: 75-300mg BD
Adjuvant Analgesics:
Antidepressants

- Evidence is best for tricyclics

- SSRI/atypical antidepressants better tolerated

-Proven efficacy for all types of neuropathic pain,

but often preferred for continuous dysesthesias

-Analgesic doses for tricyclics is usually less than

the antidepressant dose
 Antidepressants in
Neuropathic Pain Disorders*
 Multiple mechanisms of action
 Randomized controlled trials and meta-analyses
demonstrate benefit of tricyclic antidepressants
(especially amitriptyline, nortriptyline, desipramine)
for postherpetic neuralgia and diabetic neuropathy
 Onset of analgesia variable
 analgesic effects independent of antidepressant

activity
 Improvements in insomnia, anxiety, depression
 Desipramine and nortriptyline have fewer adverse
effects
 Tricyclic Antidepressants
 Action: Mixed ( 5-HT &/ Norad at synapse)
 Indication:
 All NP treatment (except SCI, PLP, HIV)

 NNT: overall = 3.1, central = 4.0, periph =

2.3
 PHN prevention: 50%  if used for 90days

 SE: dizzy, sedation, anticholinergic

 NNH minor = 5, NNH major = 16

 Doses
 Amitriptylline 10-25mg nocte, max 100mg

 Nortriptylline (?less sedating) same doses

Adjuvant Analgesics:
Corticosteroids
- Shown to improve pain, appetite, nausea,
malaise, quality of life in cancer patients
-In the cancer population, indicated for
refractory neuropathic pain, and other
indications: bone pain, bowel obstruction,
capsular pain, lymphedema, headache
-In non-cancer pain, long-term use is limited to
inflammatory conditions
- Usual drugs are prednisone and
dexamethasone
Adjuvant Analgesics:
α-2 Adrenergic Agonists
- Evidence of nonspecific analgesic effects
-Established analgesic effect of epidural
clonidine in neuropathic cancer pain

-Tizanidine usually better tolerated (starting

dose 1-2 mg/day; usual maximum dose up to 40
mg/day)
Adjuvant Analgesics:
NMDA-Receptor Antagonists

-N-methyl-D-aspartate receptor involved in neuropathic

pain

-Commercially-available drugs in the U.S.: ketamine,

dextromethorphan, amantadine
_Ketamine: dissociative anesthetic; can be used p.o. or
IV/SC infusion
_Dextromethorphan: antitussive; starting dose 120
mg/day; maximum daily dosage one gram
_Amantadine: starting does 100 mg b.i.d.
 Topical analgesics
 1) NSAIDS
 2) LA
 3) Capsaicin

Other adjuvants
1)anti emetics
2)laxatives
 Topical vs Transdermal
Drug Delivery Systems
Topica Transderma
(lidocaine
l patch 5%) (fentanyl
l patch)

Peripheral tissue activity Systemic activity

Applied directly over painful Applied away from painful
site Insignificant serum levels site
Systemic side effects unlikely Serum levels
necessary
 Lidocaine Patch 5%
 Lidocaine 5% in pliable patch
 Up to 3 patches applied once daily directly
over painful site
 12 h on, 12 h off (FDA-approved label)
 recently published data indicate 4 patches (18–
24 h) safe
 Efficacy demonstrated in 3 randomized controlled trials on
postherpetic neuralgia
 Drug interactions and systemic side effects unlikely
 most common side effect: application-site sensitivity
 Clinically insignificant serum lidocaine levels
 Mechanical barrier decreases allodynia
 Calcitonin
 Action: uncertain
 Indication: PLP, CRPS, ?other NP
 SE: N/V, flushing, dizzy, allergy
 Skin prick test advised
 Dose: 100 IU in 100ml saline over
1hr
 Pre-treat with anti-emetics
 Repeat daily for 3 days
“In deciding whether opioids are
indicated…, it is more appropriate to
determine whether opioids reduce pain,
improve function in valued life roles,
and result in overall enhancement of
well-being, without posing unacceptable
risks or side effects, than to make the
decision based solely on a diagnosis.”
Non-Pharmacological Pain
Management

1. Anaesthesiological therapies

A) nerve blocks
a) diagnostic
b) therapeuti
c

B) continuous
catheter
technique
a) epidural
Interruption of Pain Signal and
Anesthetic Intervention

- Neuro-Axial Drug Delivery System

- Neural Blockade
Neuro-Axial Drug Delivery System

- Indication:
- Route:1-Epidural
2-Intrathecal (external vs internal pump)
3-Regional Plexus Catheter
Neurostimulatory therapies

A) Spinal cord stimulation (SCS)

B)Transcutaneous electrical nerve

stimulation (TENS)
Surgical therapies
- Rarely use as a primary treatment such as in
neuroma Because of availibility of new therapy
and risk of surgical complication, surgery is
rarely use nowdays….

- Radiation therapy

- Chemotherapy

- behavioral changes
Neurolytic procedures

- Celiac plexus
- Superior hypogastric plexus
- Ganglion impar
- Posterior root
Spinal Cord Stimulation
- Spinal cord stimulation (SCS) is a safe and effective therapy
_in use for over 35 years
_has helped thousands of people find pain relief
- Implantable Pulse Generator is implanted under the skin
_Leads are then placed under the skin next to the spinal cord
_Signals sent to spinal cord create paresthesia, masking the pain
-Reversible procedure – surgically implanted device can be
removed
- When is SCS appropriate?
_For severe and long-lasting neuropathic pain
_When other treatments are not working well
Precision™ is the first
long-lasting, rechargeable
Spinal Cord Stimulation
(SCS) system.
Small - half the size of
other SCS systems
Only system with
independent current
control allows clinician to
better control pain
coverage
Can cover multiple pain
areas simultaneously
Maintains therapeutic
stimulation patterns
regardless of impedance
Preparing the Patient for Test
Stimulation
-Position and
sedate the
patient

-Mark interspinous
intervals with
fluoroscopy

-Mark desired
entry level
Percutaneous Lead Placement
- Insert Touhy needle
-Confirm needle
location with
fluoroscopy and
loss of resistance
- Introduce
guidewire
- Insert lead
Confirm lead location
with fluoroscopy
Dual Lead Placement

- Insert second
needle one level
below/contralateral
to first

- Place lead tips at

same level or
staggered
Intraoperative Screening
-Connect lead and
screener
-Goal of matching
stimulation to pain
pattern
-Test by trying
different electrode
combinations and
polarities
Test Stimulation:
Partial Percutaneous Lead Implant

-Least invasive
initial approach
-Preferred test
stimulation
for surgical
leads
- Lead secured
to skin
-Allows for test
stimulation
Optimizing SCS Therapy

- Patients can test SCS Therapy prior to

permanent implantation
- Trial SCS
-Incision is made to place a lead in
the epidural space near the spinal cord
- External trial stimulator is
connected,
producing the paresthesia
-Patient is awake while a computer to
guides the pain-masking signals to
provide optimal pain relief
-Patient wears the remote-controllable
system on a belt for 5-14 days
Optimizing SCS Therapy (cont)
- Implanting a permanent
device
If the SCS Trial goes well,
the permanent SCS
device will be implanted
- Programming the
SCS
Doctor steers the signal as
patient says where it feels best
For people with complex
pain, or pain in multiple
locations, the Precision
system offers
the ability to deliver pain-
masking signals to up to four
locations
Psychological therapy
- Also called MIND BODY THERAPIES
-Psychological factors are important contributor to
the intensity of chronic pain and disability associated
with chronic pain..
-There may be a vicious cycle between pain and
stress…
- Some indications:
- relavant somatisation
- depressive disorder
- drug abuse
- inadequate coping
Familial Involvement and
Functioning
- Supportive

- Over solicitous

-Impact on family
functioning and roles

- Entrenched family
models
Physical Therapy
-Passive modalities used in
moderation

-Functional outcomes emphasized

over pain reduction

-Goal should be to make the

patient independent in a
maintenance exercise
program
Other ways to
control Pain
- Acupuncture

- Distraction

- Meditation

- Massage

- Hypnosis
Can we offer this ?