Chronic Non-Malignant Pain Pearls

1.  Risk assess before prescribing (OART).

2.  Establish opioid agreement before prescribing (renew annually).

3.  Establish treatment goals and adjust them over time.  What is the realistic, practical goal for this medicine?
4.  Have opioid alternatives been used?
     A.  Joint injections.
     B.  Muscle relaxants.
     C.  Neuropathic pain mess.
     D.  TCAs and antidepressants (SNRIs).
     E.  Local and topical treatments.
     F.  NSAIDs and acetaminophen.
5.  Avoid use of BDZs with opioids.
6.  Psych consult for psychiatric co-morbidities.
MED >100 = 9x increase risk of death.  Our clinic cutoff is 90-100 MEDs.
– If going to stay at >100 MEDs, refer to pain specialist or CSC.
– pain referral before 120 MEDs
– psychiatric referral for all psych co-morbidities
– Use Pain Assessment and Documentation Tool and Brief Pain Inventory (Forms on intranet).
Tapers:
– 10% weekly or
– 1/3, then 1/3 monthly down to 20-25% original dose…

Types of Chronic Pain

The ICSI work group identified four types of pain: neuropathic, muscle, inflammatory, and mechanical/compressive pain. Treatment depends on the type of pain. Because patients’ pain may have more than one mechanism, physicians should determine the relative contribution of each mechanism to the total pain and treat accordingly. If the diagnosis is uncertain, referral to a pain subspecialist may be warranted.

NEUROPATHIC PAIN

Neuropathic pain, which is usually described as a burning or shooting/stabbing pain, is caused by damage to or dysfunction of the nervous system. Examples include sciatica, diabetic peripheral neuropathy, trigeminal neuralgia, and postherpetic neuralgia. Patients with diabetes and persistent pain are likely to have neuropathic pain, as are patients who develop pain after a stroke. Physical findings that point to neuropathic pain are numbness in the pain territory, sensitivity to a non-noxious stimulus (e.g., light touching, rubbing), or coolness of the skin in pain territory. Research suggests that fibromyalgia is a centrally mediated neuropathic pain syndrome and may be considered a type of neuropathic pain.

MUSCLE PAIN

Chronic muscle pain is common, and generally does not prevent patients from performing daily activities. Skeletal muscle pain is one common cause of chronic pain. Myofascial pain, which is common in patients seen in pain clinics, is regional muscle soft tissue pain usually involving the neck, shoulders, arms, low back, hips, and lower extremities. If muscle pain is not properly diagnosed, it can lead to poor treatment outcome, delayed recovery, or ineffective and unnecessary surgery.

INFLAMMATORY PAIN

Examples of inflammatory pain include arthritis, infection, tissue injury, and postoperative pain. Clinical features may include heat, redness, swelling at the site of pain, and a history of injury or inflammation.

MECHANICAL/COMPRESSIVE PAIN

Patients with mechanical/compressive pain typically experience aggravated pain during activity and temporary relief during rest. Neck and back pain are often related to muscle or ligament strain or sprain, degeneration of disks or facets, or osteoporosis with compression fractures. Mechanical/compressive pain may be identified by history and radiologic findings, such as fractures, obstructions, dislocations, or compression of tissue by tumor, cysts, or bony structure.
_______________________________________________________________
Clinical Question:
Is opioid analgesic treatment effective in
patients with low back pain?

Bottom Line:
Effective pain control in
patients with low back pain (LBP) is still elusive. Approximately half of
all patients with LBP who take an opioid analgesic will stop treatment
because of ineffectiveness or adverse effects. Patients staying the course
will experience, on average, a small decrease in pain relative to patients
who take placebo (similar to the benefit from nonsteroidal
anti-inflammatory drugs) and will not have improved function. (LOE = 1a)
Reference:
Shaheed CA, Maher CG, Williams KA, Day R, McLachlan AJ.
Efficacy, tolerability, and dose-dependent effects of opioid analgesics for
low back pain a systematic review and meta-analysis. JAMA Intern Med
2016;176(7):958-968.
Synopsis:
To identify randomized controlled trials that enrolled patients
with nonspecific LBP, published in any language, and evaluated an opioid
analgesic, these researchers searched 5 databases including Cochrane
CENTRAL, as well as reference lists of identified studies. Two reviewers
independently selected studies for inclusion and 2 reviewers independently
extracted the data and evaluated study quality. They retrieved 20 studies
with an enrollment of 7295 patients; all but one study enrolled patients
with chronic LBP. The length of studies was 12 weeks or less. Most of the
studies were of moderate to high quality. Based on 13 studies with
moderate-quality evidence, opioids reduced pain in the short term, though
the mean difference in pain scores was minimal (mean difference: 10.1 on a
scale of 0 – 100). This effect size is similar to that for nonsteroidal
anti-inflammatory drugs versus placebo for LBP in a prior Cochrane Review.
Overall, opioid treatment did not produce clinically important pain relief
compared with placebo (ie, a mean difference in pain scores of at least
20), even with doses as high as 240 mg morphine per day. Half of the
studies had more than 50% of the enrolled patients drop out, either because
of adverse effects or lack of effectiveness. The patients who dropped out
were not considered in the estimates of treatment benefit, meaning that the
actual overall likelihood of benefit is even smaller in clinical practice.
Low-quality studies of disability did not show a reduction in disability
using either the Oswestry Disability Index or the Roland Morris Disability
Questionnaire. Study results were homogeneous, but there was some evidence
of publication bias.
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