EVP
11.05.2006, 19:53
Primer on Pain Management CME/CE
Disclosures
Charles P Vega, MD University of California - Irvine
Introduction
Pain, both acute and chronic, is 1 of the most common reasons that patients visit their family physician. Over 8 hours of continuing medical education (CME) was dedicated to this important subject at the American Academy of Family Physicians (AAFP) 2005 Scientific Assembly. The speakers enlightened the audience on some of the unique aspects of diagnosing and treating pain.
Perspectives on Chronic Pain
During their CME activity on the first day of the Assembly, Heidi Pomm, PhD, Behavioral Science Director, St. Vincent's Family Medicine Residency Program, Jacksonville, Florida, and Penny Tenzer, MD, Vice Chair and Residency Director, Department of Family Medicine and Community Health, University of Miami School of Medicine, Miami, Florida, explained that pain is now considered the "fifth vital sign" by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).[1] This fact implies that pain should be measured regularly in every patient. Dr. Tenzer advocated for the "HAMSTER" model as a means to assess and follow pain:
H -- History
A -- Assessment (including patient's function, psychological state, and use of medications)
M -- Mechanism of pain
S -- Social and psychological factors
T -- Treatment
E -- Education
R -- Reassessment
To follow pain over time, Dr. Tenzer recommends use of paper or verbal pain scales; numeric scales can help rate the degree or intensity of the pain; and caricature representation of the human body can be used for children or patients with developmental disabilities.
Neuropathic Pain
While nociceptive pain, defined as pain in response to noxious stimuli, is common and may result in significant morbidity, neuropathic pain is considered more frustrating for patient and physician alike. According to Dr. Tenzer, this is partly because neuropathic pain "is the symptom, not the disease." Neuropathic pain is often chronic, and the pain is caused by damage to the neurologic system itself. In addition, many patients experience windup of peripheral nerve roots (when more nerves become involved following repetitive stimuli) and central sensitization (dorsal root ganglions become more easily excited after multiple episodes of pain). Chronic neuropathic pain is difficult to treat, says Dr. Tenzer, because it is mediated by "some of the toughest receptors to treat," including the central N-methyl-D-aspartate receptor.
First-line treatment options for patients with neuropathic pain include gabapentin, lidocaine patches, tramadol, tricyclic antidepressants, and opioid analgesics. Dr. Tenzer suggested some tips for using opioid analgesics, including use of oral medications whenever possible and beginning with a low dose. When titrating these medications to achieve pain control, she recommends using the model of insulin dosing in diabetes. Thus, the physician should add up a daily total of short-acting pain medications used by a patient and then convert this total into an equivalent amount of daily long-acting opioids. While the bulk of analgesia should be delivered through long-acting agents, patients should also have short-acting medications available for breakthrough pain. Finally, the possibility of addiction to narcotics was put in context -- Dr. Pomm noted that "less than 1% of patients who need opioids for pain become addicted."
Dr. Tenzer cautioned against the routine use of meperidine because its metabolites can cause seizures. She also recommended not using propoxyphene because of lower efficacy than other opioids,[2] and discouraged the use of mixed agonist/antagonist opioid medications.
Comorbid Conditions
Depression, anxiety, and sleep disturbances commonly occur with chronic pain, mandating attention and treatment in their own right.[3] Dr. Pomm emphasized that pain is both a sensory and an emotional experience and that "you can't take one [away] from the other." She noted that psychiatric disorders actually predispose patients to chronic pain and decrease patients' functionality when they have pain.
Given the severity and frequency of mood disorders associated with such pain, she believes that "rational polypharmacy" using analgesics along with adjuvant medications is the best course of action. Tricyclic antidepressants, for example, have proven efficacy in treating multiple causes of chronic pain, including diabetic neuropathy, postherpetic neuralgia, migraine and tension headaches, and fibromyalgia.[4,5] These medications can also improve mood, although Dr. Tenzer noted that tricyclic antidepressants as prescribed for pain do not require the higher dose necessary to control depression. Dr. Tenzer recommended starting at the lowest possible dose and titrating upward every few days as tolerated by the patient. Side effects still limit the usefulness of tricyclic antidepressants for chronic pain, but splitting the dose between morning and evening may help tolerability. Desipramine and nortriptyline incur fewer side effects than amitriptyline.[6] Selective serotonin-reuptake inhibitors (SSRIs),which are associated with fewer adverse effects, have a mixed record in the treatment of chronic pain. They do, however, play a role in treating comorbid depression in patients with chronic pain.[7]
Treating Chronic Pain: Beyond Medications
Given the nature of the problem, medication alone is frequently not enough to relieve chronic pain. In a 3-hour session, Robert Bonakdar, MD, Director of Integrative Pain Services and Co-Chair, Scripps Green Hospital Pain Management Committee, Scripps Center for Integrative Medicine, La Jolla, California, and David C. Leopold, MD, Director of Integrative Medical Education and Director of the Integrative Medicine Weight Management Program, Scripps Center for Integrative Medicine, La Jolla, California, led the audience through a review of nonpharmacologic treatment of pain.[6] They noted that 40% of individuals with chronic back pain seek nonpharmacologic treatment.[8] Most of these patients desire alternative therapy because they are dissatisfied with traditional care. Drs. Bonakdar and Leopold described the most popular and effective alternative pain treatments, reviewing the evidence for their efficacy.
Manual Medicine
According to Dr. Leopold, the main goal of manual therapy, whether applied through a chiropractor, doctor of osteopathy, or massage therapist, is "to achieve maximal synchrony of form and function of the system as a holistic unit." Practitioners of manual medicine seek to relieve tendons that are inappropriately shortened and under stress secondary to chronic pain. In 2 study of 459 patients receiving osteopathic manipulative maneuvers (OMMs), OMMs were associated with improved pain and mobility, especially in women. Patient satisfaction with OMMs was high.[7]
Although not proven scientifically, Dr. Leopold reported that, in his clinical experience, manual medicine is most effective for low back pain, cervicalgia, headache, and piriformis pain. He believes that its greatest benefit lies in reducing time to heal and in decreasing medication use. However, he cautioned that patients must be involved in their own care and perform home exercises to derive the most benefit from manual medicine techniques. Regarding traditional vs manual medicine for pain, Dr. Leopold encourages physicians not to feel compelled to necessarily choose 1 over the other, explaining that he prescribes both at the same time.
Electrostimulation
Several types of treatment are categorized as electrostimulation:
Transcutaneous electrical nerve stimulation (TENS)
Neuromuscle electrical stimulators (NMES)
Interferential stimulation
Laser therapy
Electromagnetic field therapy.
While Dr. Bonakdar reports that electrostimulation is "a poor evidence-based therapy," he does recommend it as a means to treat pain from osteoarthritis, carpal tunnel syndrome, low back pain (especially with muscle spasm), and fibromyalgia. He prefers newer methods, like NMES and laser, over older methods, such as TENS. The lack of scientific evidence on these methods partially results from high heterogeneity of the research. A recent Cochrane Review, however, concluded that TENS has value for the treatment of osteoarthritis of the knee because, despite the heterogeneity of the 7 studies included in the analysis, the treatment was superior to placebo.[9]
Acupuncture
Acupuncture has been used to manage several types of pain in non-Western countries for over 2500 years. Dr. Bonakdar now feels that, compared with other "alternative" treatments for pain, acupuncture has won the greatest acceptance among Western physicians. How it works seems to involve multiple mechanisms:
Stimulation of localized electrothermal changes
Modification of the central transmission of pain signals
Enhanced release of endorphins
Dr. Bonakdar described 2 studies strongly supporting the use of acupuncture for chronic headache and osteoarthritis.[10,11]
Disclosures
Charles P Vega, MD University of California - Irvine
Introduction
Pain, both acute and chronic, is 1 of the most common reasons that patients visit their family physician. Over 8 hours of continuing medical education (CME) was dedicated to this important subject at the American Academy of Family Physicians (AAFP) 2005 Scientific Assembly. The speakers enlightened the audience on some of the unique aspects of diagnosing and treating pain.
Perspectives on Chronic Pain
During their CME activity on the first day of the Assembly, Heidi Pomm, PhD, Behavioral Science Director, St. Vincent's Family Medicine Residency Program, Jacksonville, Florida, and Penny Tenzer, MD, Vice Chair and Residency Director, Department of Family Medicine and Community Health, University of Miami School of Medicine, Miami, Florida, explained that pain is now considered the "fifth vital sign" by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).[1] This fact implies that pain should be measured regularly in every patient. Dr. Tenzer advocated for the "HAMSTER" model as a means to assess and follow pain:
H -- History
A -- Assessment (including patient's function, psychological state, and use of medications)
M -- Mechanism of pain
S -- Social and psychological factors
T -- Treatment
E -- Education
R -- Reassessment
To follow pain over time, Dr. Tenzer recommends use of paper or verbal pain scales; numeric scales can help rate the degree or intensity of the pain; and caricature representation of the human body can be used for children or patients with developmental disabilities.
Neuropathic Pain
While nociceptive pain, defined as pain in response to noxious stimuli, is common and may result in significant morbidity, neuropathic pain is considered more frustrating for patient and physician alike. According to Dr. Tenzer, this is partly because neuropathic pain "is the symptom, not the disease." Neuropathic pain is often chronic, and the pain is caused by damage to the neurologic system itself. In addition, many patients experience windup of peripheral nerve roots (when more nerves become involved following repetitive stimuli) and central sensitization (dorsal root ganglions become more easily excited after multiple episodes of pain). Chronic neuropathic pain is difficult to treat, says Dr. Tenzer, because it is mediated by "some of the toughest receptors to treat," including the central N-methyl-D-aspartate receptor.
First-line treatment options for patients with neuropathic pain include gabapentin, lidocaine patches, tramadol, tricyclic antidepressants, and opioid analgesics. Dr. Tenzer suggested some tips for using opioid analgesics, including use of oral medications whenever possible and beginning with a low dose. When titrating these medications to achieve pain control, she recommends using the model of insulin dosing in diabetes. Thus, the physician should add up a daily total of short-acting pain medications used by a patient and then convert this total into an equivalent amount of daily long-acting opioids. While the bulk of analgesia should be delivered through long-acting agents, patients should also have short-acting medications available for breakthrough pain. Finally, the possibility of addiction to narcotics was put in context -- Dr. Pomm noted that "less than 1% of patients who need opioids for pain become addicted."
Dr. Tenzer cautioned against the routine use of meperidine because its metabolites can cause seizures. She also recommended not using propoxyphene because of lower efficacy than other opioids,[2] and discouraged the use of mixed agonist/antagonist opioid medications.
Comorbid Conditions
Depression, anxiety, and sleep disturbances commonly occur with chronic pain, mandating attention and treatment in their own right.[3] Dr. Pomm emphasized that pain is both a sensory and an emotional experience and that "you can't take one [away] from the other." She noted that psychiatric disorders actually predispose patients to chronic pain and decrease patients' functionality when they have pain.
Given the severity and frequency of mood disorders associated with such pain, she believes that "rational polypharmacy" using analgesics along with adjuvant medications is the best course of action. Tricyclic antidepressants, for example, have proven efficacy in treating multiple causes of chronic pain, including diabetic neuropathy, postherpetic neuralgia, migraine and tension headaches, and fibromyalgia.[4,5] These medications can also improve mood, although Dr. Tenzer noted that tricyclic antidepressants as prescribed for pain do not require the higher dose necessary to control depression. Dr. Tenzer recommended starting at the lowest possible dose and titrating upward every few days as tolerated by the patient. Side effects still limit the usefulness of tricyclic antidepressants for chronic pain, but splitting the dose between morning and evening may help tolerability. Desipramine and nortriptyline incur fewer side effects than amitriptyline.[6] Selective serotonin-reuptake inhibitors (SSRIs),which are associated with fewer adverse effects, have a mixed record in the treatment of chronic pain. They do, however, play a role in treating comorbid depression in patients with chronic pain.[7]
Treating Chronic Pain: Beyond Medications
Given the nature of the problem, medication alone is frequently not enough to relieve chronic pain. In a 3-hour session, Robert Bonakdar, MD, Director of Integrative Pain Services and Co-Chair, Scripps Green Hospital Pain Management Committee, Scripps Center for Integrative Medicine, La Jolla, California, and David C. Leopold, MD, Director of Integrative Medical Education and Director of the Integrative Medicine Weight Management Program, Scripps Center for Integrative Medicine, La Jolla, California, led the audience through a review of nonpharmacologic treatment of pain.[6] They noted that 40% of individuals with chronic back pain seek nonpharmacologic treatment.[8] Most of these patients desire alternative therapy because they are dissatisfied with traditional care. Drs. Bonakdar and Leopold described the most popular and effective alternative pain treatments, reviewing the evidence for their efficacy.
Manual Medicine
According to Dr. Leopold, the main goal of manual therapy, whether applied through a chiropractor, doctor of osteopathy, or massage therapist, is "to achieve maximal synchrony of form and function of the system as a holistic unit." Practitioners of manual medicine seek to relieve tendons that are inappropriately shortened and under stress secondary to chronic pain. In 2 study of 459 patients receiving osteopathic manipulative maneuvers (OMMs), OMMs were associated with improved pain and mobility, especially in women. Patient satisfaction with OMMs was high.[7]
Although not proven scientifically, Dr. Leopold reported that, in his clinical experience, manual medicine is most effective for low back pain, cervicalgia, headache, and piriformis pain. He believes that its greatest benefit lies in reducing time to heal and in decreasing medication use. However, he cautioned that patients must be involved in their own care and perform home exercises to derive the most benefit from manual medicine techniques. Regarding traditional vs manual medicine for pain, Dr. Leopold encourages physicians not to feel compelled to necessarily choose 1 over the other, explaining that he prescribes both at the same time.
Electrostimulation
Several types of treatment are categorized as electrostimulation:
Transcutaneous electrical nerve stimulation (TENS)
Neuromuscle electrical stimulators (NMES)
Interferential stimulation
Laser therapy
Electromagnetic field therapy.
While Dr. Bonakdar reports that electrostimulation is "a poor evidence-based therapy," he does recommend it as a means to treat pain from osteoarthritis, carpal tunnel syndrome, low back pain (especially with muscle spasm), and fibromyalgia. He prefers newer methods, like NMES and laser, over older methods, such as TENS. The lack of scientific evidence on these methods partially results from high heterogeneity of the research. A recent Cochrane Review, however, concluded that TENS has value for the treatment of osteoarthritis of the knee because, despite the heterogeneity of the 7 studies included in the analysis, the treatment was superior to placebo.[9]
Acupuncture
Acupuncture has been used to manage several types of pain in non-Western countries for over 2500 years. Dr. Bonakdar now feels that, compared with other "alternative" treatments for pain, acupuncture has won the greatest acceptance among Western physicians. How it works seems to involve multiple mechanisms:
Stimulation of localized electrothermal changes
Modification of the central transmission of pain signals
Enhanced release of endorphins
Dr. Bonakdar described 2 studies strongly supporting the use of acupuncture for chronic headache and osteoarthritis.[10,11]