An Approach to Chronic Pain in Primary Care

June 2017Jill Schneiderhan MD, AIHMClinical InstructorUniversity of Michigan Department of Family Medicine

Objectives• Articulate the different pathophysiological

mechanisms that lead to chronic pain. • Describe the components of a well rounded

treatment plan for a variety of chronic pain conditions.

• Give the rationale for choosing from the treatment modalities with the strongest evidence for improving function and decrease pain in chronic pain conditions.

Overview• Why talk about chronic pain?

• Intertwined with the opioid epidemic• There is a high incidence in the general

population• It is multi-factorial and difficult to treat• A majority ends up in primary care settings• Lack of multidisciplinary treatment option• Dissatisfaction

Condition Number of Sufferers Source

Chronic Pain 100 Million Americans Institute of Medicine of The National Academies[1]

Diabetes 25.8 million Americans(diagnosed and estimated undiagnosed)

American Diabetes Association [2]

Coronary Heart Disease(heart attack and chest pain)Stroke

16.3 million Americans

7.0 million Americans

American Heart Association [3]

Cancer 1.9 million Americans American Cancer Society

1. Dzau, V.J. and P.A. Pizzo, Relieving pain in America: insights from an Institute of Medicine committee. JAMA, 2014. 2. American Diabetes Associations. http://www.diabetes.org/diabetes-basics/statistics 3. AHA Statistical Update Heart Disease and Stroke Statistics—2011 Update A Report From the American Heart Association Circulation. 2011. 4. American Cancer Society. http://www.cancer.org/cancer/cancerbasics/cancer-prevalence

Managing Chronic Pain

Solid Relationship

Appropriate Plan

ImprovedPain

Model for Approaching Chronic Pain

Doctor –Patient

Relationship

Cause of Pain

Multifaceted Treatment

Plan

Goals

Step One: Cement the Relationship

Doctor –Patient

Relationship

Cause of Pain

Multifaceted Treatment

Plan

Goals

Physician Patient Interaction

Physician Patient Interaction• Where to heart of the issue starts• Centers around communication• Patient’s feel positively about pain management

• If they feel cared for by doctor• Feel listened too• Even in the setting of decreased or refused

pain medication

Matthias, M. S. et al. Eur J Pain, 2015.

Physician Patient Interaction• Over emphasis on role of opioids• Physicians have been drafted into the

political/legal “war on drugs”• What starts out as caring and desire to help can

turn into fear of medical board repercussions and of “creating addicts”

• Physicians struggle between feeling like they are tasked with “catching addicts” or alternatively bargaining with patients over how little pain medication they can live with

Nicolaidis, C. Pain Medicine, 2011.

Physician Patient Interaction• Care for the patient

• Does not mean “saying yes”

• Means determining what is causing the most problem and developing a treatment plan to address

Partnership

Doctor as placebo• Using yourself as a treatment• Listen, empathize, and educate• Patient’s express decreased pain with improved

understanding of pain physiology1

• Studies that show patients had more improvement when physicians were positive vs. negative in setting of unexplained illness2

1. Van Oosterwijck, J., et al. Clin J Pain, 2013. 2. Thomas, K. B. British medical journal (Clinical research ed.), 1987.

Step Two: Determine Cause of Pain

Doctor –Patient

Relationship

Cause of Pain

Multifaceted Treatment

Plan

Goals

Step Two: Determine Cause of Pain• Goal is to place pain in one of three categories

• Peripheral Tissue Damage• Central Neuropathic Pain (“Centralized Pain)• Mixture of Both

• How do we get there?• By doing a good work up• By getting to know our patient

Pathophysiology• Our current paradigms for diagnosing and

treating chronic pain are antiquated

• Degree of damage or inflammation ≠ level of pain

• Disparity ≠ psychogenic factors

Pathophysiology• Neurobiological factors increase or decrease

sensitivity to pain, and

• Operative in all chronic pain states

• Central factors play a prominent role in most chronic pain

• Therefore we need to modify our paradigm

Neurotransmitters

Aglin K, Clauw DJ. Rhem Dis Clin North Am 2009: 35 233-251

Clinical Characteristics of Centralized Pain

• Typically characterized by:• Multifocal pain (use Brief Pain Inventory or a Body Map)• Higher current and lifetime history of pain• Multiple other symptoms:

• Fatigue• Memory difficulties• Sleep disturbances• Sensory Hypersensitivities

Clinical Characteristics of Centralized Pain• 1.5-2 X more common in females

• Strong familial/genetic underpinnings1

• Take a family history of pain

• Triggered or exacerbated by stressors2

• Generally normal physical examination except for diffuse tenderness and nonspecific neurological signs3

1. Kato K, et al. Psychol Med. 2008. 2. Aglin K, Clauw DJ. Rhem Dis Clin North Am 2009. 3 Watson NF, et al. Arthritis Rheum 2009.

Centralized Pain• Not “yes” or “no” – occurs over a wide

continuum• Present in all chronic pain state to some degree

• Diagnostic labels (e.g. FM, IBS, TMJ) are becoming irrelevant1

• Wolfe et al. has shown that degree of fibromyalgia-ness predicts pain intensity, symptoms, and disability over a wide range of rheumatic disorders (RA,OA, regional musculoskeletal pain, FM)2

• Brummett et al. has shown that higher degree of fibromyalgia-ness predicts poor response to surgery, greater post op opioid need and greater chance of being on an opioid 6 months post op3

1. Aglin K, Clauw DJ. Rhem Dis Clin North Am 2009. 2 Wolfe F, Rasker JJ. J Rheumatol 2006. 3 . Brummett CM, et al. Arthritis & rheumatology (Hoboken, NJ). 2015.

Overlap of Central Pain Syndromes

Fig. 1 Overlap between fibromyalgia and related syndromes. GAD, generalized anxiety disorder; HA, headache; OCD, obsessive-compulsive disorder; PTSD, posttraumatic stress disorder.

Aglin K, Clauw DJ. Rhem Dis Clin North Am 2009: 35 233-251.

Evolution from Acute to Chronic Pain

• Central Pain Prone Phenotype• Female, genetically prone, early life trauma, family h/o chronic

pain and mood disturbances, personal h/o centralized pain, cognitions such as catastrophizing, lower mechanical pain thresholds

• Exposure to “stressor” or acute peripheral nociceptive input

• Leads to psychological and behavioral response to pain or stressor

• New or different region of chronic pain

Aglin K, Clauw DJ. Rhem Dis Clin North Am 2009: 35 233-251.

1. Phillips K, Clauw D. Arthritis and Rheumatism 2013; 65(2), 291–302 2. Williams DA et al. J Pain 2009; 10:777-791. 3. AblinK, Clauw DJ. Rheum Clin North Am 2009; 35: 233-51. 4. Diatchenko et al. Hum Mol Gen 2005; 14(1)L 135-143. 5. Kehlet et al. Lancet 2006; 367: 1618-25

Summary• Peripheral Nociceptive Pain

• Tissue Damage occurring• Evidence of such on physical exam and tests

• Central Neuropathic Pain or Centralized component• Dysfunction of nerve/pain regulation pathways• No evidence on exam or tests• Often suggested by symptom course and history

Detailed History and Physical• Cementing the clinician/patient relationship

• A critical component of successful pain management• Trust is an integral part of pain management

• Past Medical History: Current location and nature of pain, History of pain onset, Previous Treatments tried and failed, Effect of pain on physical and psychological functioning

• Screen for co-morbid psych and substance abuse disorders

• Physical Exam: Complete a thorough physical exam yourself – even if many already documented

Educating Your Patient• Need to explain difference between peripheral

(tissue damage) cause and central (problem with the nerves and brain that cause pain to be generated by the nerves themselves)

• Analogy: Imagine pain is music. • Your body is the guitar – peripheral pain is when

the guitar is being strummed louder• Your nervous system is the amplifier – chronic pain

is like the amplifier having the volume turned to 10

Questions?

By artist Anne Félicité

Step Three: Set Achievable Goals

Doctor –Patient

Relationship

Cause of Pain

Multifaceted Treatment

Plan

Goals

Functional Goals• What they are….

• They are about function (not pain intensity)• What does the patient want/need to be able to

DO that they are not able to do currently…because of the pain

• Examples include:• Being able to get through an entire day at work

without going home early• Being able to walk to the grocery• Being able to pick up my grandchild

Functional Goal• Often patient is not thinking about pain from this

perspective

• Looking for short term relief

• Long term conversation with your patient to shift this perspective

Patient’s Attitudes Toward Pain

• Very important in order to set a goal that is realistic

• How does your patient think about their pain?• What do they think is causing it?• Is their cause and what you think the cause is

similar?• How do you get to a middle ground?

Step Four: Develop a Collaborative Treatment Plan

Doctor –Patient

Relationship

Cause of Pain

Multifaceted Treatment

Plan

Goals

Collaborative Treatment Plan• Must be collaborative• Must be in line with cause of pain

• Peripheral Tissue Damage vs. Centralized Neuropathic

• Must help patient work towards their stated functional goal

• Often best accomplished by a multidisciplinary team

Partnership• Physician’s job

• Determine cause of pain and educate patient

• Facilitate the patient’s development of patients self management skills

• Facilitate the development of the care plan

• Be a source of consistent support

Patient Readiness• Need to assess patient readiness to participate in

self management• Pre-contemplative, Contemplative, Changing,

Maintenance• Motivational Interviewing• Active patient participation in plan increases

effectiveness

Treatment in General• Significant advances in understanding of

physiology have not equaled improvement in treatments

• Most treatments overall are poor to fair• Most average around 30% effective in

improving pain (roughly equal to placebo)• Even if a treatment improves pain it rarely

provides concomitant physical or emotional functional improvements

Turk, D. C., et al. The Lancet, 2011.

Peripheral Tissue Damage

• Caused by inflammation and tissue damage• Acute Pain due to Injury• Cancer Pain

• Sometimes: • Osteoarthritis• Rheumatic Diseases

• Anti-inflammatories and opioids responsive

Peripheral Neuropathic• Damage or dysfunction to a peripheral nerve• Diabetic neuropathy• Post-herpetic neuralgic

• Responds to both peripheral and central compounds

Central Neuropathic Pain• Characterized by a disturbance of the central

nervous system’s ability to process pain • A contributing factor in all chronic pain to

varying degrees• Fibromyalgia• Irritable Bowel• TMJ• Headaches – of all variety that don’t have

anatomical cause• Mechanical Low Back Pain

Central Neuropathic Pain• No tissue damage occurring• Not responsive to NSAID’s and opioids1,2

• Neuroactive compounds that alter levels of neurotransmitters most useful medications• SNRI’s and TCA’s3

• Gabapentin and Lyrica4

• Every medication has about 1/3 chance of success

1. Derry S, et al. The Cochrane database of systematic reviews. 2017. 2. Reinecke H, et al. British journal of pharmacology. 2015. 3. Hauser W, et al. CNS drugs. 2012. 4. Harris RE, et al. Anesthesiology. 2013.

Medications

Non-pharmacological

approaches

Doctor-Patient Relationship

Treatment Plan• Behavioral Aspects

• Empowering: Patient assuming active role in managing pain• Behavioral activation: Movement is key component• Self-care: Getting enough sleep, smoking cessation

• Emotional Aspects• Counseling: Addressing fear and stopping Fear-Pain cycle• Education: on relationship between emotions, stress and

pain• Validation: Conveying that you do not think “it is all in their

head”

Non-pharmacologic Approaches• Not Optional!

• Education1

• Exercise – simplest and least expensive approach is patient initiated activity2

• Psychological Care• CBT most studied3

• Mindfulness as effective as CBT (and medication) 3

1. Hauser W, et al. Arthritis and rheumatism. 2009. 2. Geneen LJ, et al. The Cochrane database of systematic reviews. 2017. 3. Cherkin DC, et al. Jama. 2016.

Medications• Neuroactive compounds that alter levels of

neurotransmitters most useful medications• SNRI’s and TCA’s1

• Gabapentin and Lyrica2

• Cyclobenzaprine3

• Has serotonergic properties and results in moderate sleep improvement and moderate pain reduction

• 5mg at night before bed – long term • Naltrexone4

• Small RCTs showing improvement in QOL & decreased pain

• 4.5mg a day (needs to be compounded)

1. Hauser W, et al. CNS drugs. 2012. 2. Harris RE, et al. Anesthesiology. 2013. 3. Arnold LM. Pain Med. 2007. 4. Younger J, et al. Arthritis and rheumatism. 2013.

Summary• Management of Chronic Pain is challenging and

multifaceted• The doctor-patient relationship is the primary

factor that determines improvement • Start with non-pharmacological management

• Not Optional!• Layer in medication when needed

• Central acting agents• Sometime useful for short term activation and

engagement in self management