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Chronic Pain in the ED Martin Huecker Hugh Shoff Chronic Pain in the ED Martin Huecker Hugh Shoff

Summary • • Case Pathophysiology of Pain Acute vs Chronic Epidemiology Treatment Barriers / Summary • • Case Pathophysiology of Pain Acute vs Chronic Epidemiology Treatment Barriers / Challenges Guidelines Future considerations

Case • 35 year old white male with chronic neck pain related to degenerative Case • 35 year old white male with chronic neck pain related to degenerative disc disease • Surgery 3 years ago, has been on Oxycontin 40 bid with hydromorphone po tid for breakthrough pain • Presents in 10/10 pain, has run out of his home medications • Visiting family in your town

Pathophysiology • Nociceptive versus • Nociceptive: Noxious stimulus • Neuropathic: altered CNS signal processing Pathophysiology • Nociceptive versus • Nociceptive: Noxious stimulus • Neuropathic: altered CNS signal processing

Acute vs Chronic Pain • Acute pain has “identifiable pathologic condition” and warns the Acute vs Chronic Pain • Acute pain has “identifiable pathologic condition” and warns the individual of injury or illness. • Acute becomes chronic when the pain pattern persists after the insult has resolved. • Transition is complex with obvious physiologic and psychosocial aspects. • Likely related to treatment efforts in the acute phase

Chronic Pain • “Continues beyond the usual recovery period for an injury or illness Chronic Pain • “Continues beyond the usual recovery period for an injury or illness … continuous or come and go” – American Chronic Pain Association • “adversely affects the function or well-being of the patient, attributable to any non-malignant etiology” – American Society of Anesthesiologists • “pain and disability far out of proportion to the peripheral stimulus. ” • Schofferman

Chronic Pain • Either: – Not related to tissue injury, or – Tissue injury Chronic Pain • Either: – Not related to tissue injury, or – Tissue injury not expected to resolve, past the time of normal resolution, expected to progress

Recurrent Pain • • Subset of Chronic Pain Is not constant in nature, waxes Recurrent Pain • • Subset of Chronic Pain Is not constant in nature, waxes and wanes Back pain, migraines, sickle cell, IBD Treatment approach different – treat like acute pain with goal of preventing future episodes

Chronic pain of malignancy • Similar to acute pain due to ongoing nociceptive stimulus Chronic pain of malignancy • Similar to acute pain due to ongoing nociceptive stimulus • Similar to chronic pain due to duration and psychobehavioral components

Chronic Pain Patients • 1. Exacerbation of chronic pain • 2. Untreated chronic pain Chronic Pain Patients • 1. Exacerbation of chronic pain • 2. Untreated chronic pain / gap in treatment (our case) • 3. Acute pain in the patient already being treated for chronic pain

Epidemiology • 42 -78% of ED visits are for painful conditions • Of these, Epidemiology • 42 -78% of ED visits are for painful conditions • Of these, as much as 40% have underlying chronic pain conditions • Opioid abuse is the fastest-growing drug abuse problem in the United States • Opioid overdose deaths: – 1999: 4030 -- 2008: 14, 800 • 2 nd highest injury death after MVA, greater than cocaine and heroin combined

More Statistics • 710 mg person enough to supply every american with 5 mg More Statistics • 710 mg person enough to supply every american with 5 mg hydrocodone Q 4 H • EM 3 rd highest specialists in number of opioid prescriptions in 10 -30 year olds • Deaths from overdose have led to statewide opioid prescribing guidelines • Recommended by the 2011 Prescription Drug Abuse Prevention Plan from the White House Office of National Drug Control Policy

Chronic Pain • 24 million adults with chronic pain visit the ED annually • Chronic Pain • 24 million adults with chronic pain visit the ED annually • 12 million visits due to acute exacerbations of chronic pain syndromes • 11% to 20% of ED patients have chronic pain • 89% of Americans have pain once a month • 15% severe pain monthly • >65 yo, 55% have pain daily

Definitions • Allodynia: pain from a stimulus that is not normally painful • Hyperalgesia: Definitions • Allodynia: pain from a stimulus that is not normally painful • Hyperalgesia: Pain out of proportion to a noxious stimulus

Neuropathic Pain • Due to nerve injury • Most of the neuropathic pain syndromes Neuropathic Pain • Due to nerve injury • Most of the neuropathic pain syndromes are included in the Complex Regional Pain Syndrome

Complex Regional Pain Syndrome • CRPS • Type 1: No nerve injury • Type Complex Regional Pain Syndrome • CRPS • Type 1: No nerve injury • Type 2: Known nerve injury

Treatment • Pain subjective, therefore determination of success and failure can be difficult • Treatment • Pain subjective, therefore determination of success and failure can be difficult • Pharmacologic Therapies • Nonpharmacologic

Pharmacologic • NSAIDs – Nonselective COX, COX-2 inhib • Acetaminophen • Opioids – Agonists, Pharmacologic • NSAIDs – Nonselective COX, COX-2 inhib • Acetaminophen • Opioids – Agonists, agonist-antagonists • Nonanalgesics • Local Anesthesia

NSAIDs • No abuse potential • GI and Renal side effects may be prohibitive NSAIDs • No abuse potential • GI and Renal side effects may be prohibitive • Valuable augmentation to opioids

Acetaminophen • • Safe in less than 3 grams per day dosing No GI Acetaminophen • • Safe in less than 3 grams per day dosing No GI side effects No renal injury concern Hepatotoxic

Opioids • Role well established in ACUTE pain • Analgesic effect AND altered emotional Opioids • Role well established in ACUTE pain • Analgesic effect AND altered emotional response to pain • Controversial in Chronic pain • Concerns: respiratory suppression, dependence, diversion • Can be used in acute exacerbations of chronic pain • Should be prescribed for chronic conditions in concert with pain management physician with pain contract

Nonanalgesics • • Skeletal Muscle Relaxants Anti-depressants Anticonvulsants NMDA receptor antagonists Nonanalgesics • • Skeletal Muscle Relaxants Anti-depressants Anticonvulsants NMDA receptor antagonists

Non-Pharmacologic • • Transcutaneous Electrical Nerve Stimulation Physical Therapy Hypnosis Acupuncture Non-Pharmacologic • • Transcutaneous Electrical Nerve Stimulation Physical Therapy Hypnosis Acupuncture

System Barriers / Challenges • • • Time Limitations Limited Priority Frequent Flyers Insurance System Barriers / Challenges • • • Time Limitations Limited Priority Frequent Flyers Insurance No PCP

Physician Barriers • • Annoyance Fear of addiction / bad intentions Belief in pathology Physician Barriers • • Annoyance Fear of addiction / bad intentions Belief in pathology Diversion Reluctance to prescribe Exaggeration / Manipulation Futility

Pseudoaddiction • Patient behaviors occurring when pain is undertreated • Intense focus on obtaining Pseudoaddiction • Patient behaviors occurring when pain is undertreated • Intense focus on obtaining analgesics – Patient can appear to be “drug-seeking” • Unlike “drug-seeking, ” resolves with adequate treatment / relief of pain

Drug-Seeking Behavior • • • Exaggeration of pain Very susceptible to bias Patient deserves Drug-Seeking Behavior • • • Exaggeration of pain Very susceptible to bias Patient deserves benefit of doubt Multidisciplinary approach Prescription monitoring programs

Opioid Prescription • Guidelines • Monitoring Systems Opioid Prescription • Guidelines • Monitoring Systems

Example Chronic Pain Treatment Guidelines • Definitive management is NOT the EP’s role • Example Chronic Pain Treatment Guidelines • Definitive management is NOT the EP’s role • Rescue, Referral • Treat pain aggressively, promptly, appropriately • Thorough physical exam • Expect exaggerated avoidance, emotion, allodynia, nondermatomal distribution, autonomic manifestations

Example Chronic Pain Treatment Guidelines • Look for fear, worry, “catastrophizing, ” suppression, distraction, Example Chronic Pain Treatment Guidelines • Look for fear, worry, “catastrophizing, ” suppression, distraction, depression • Multimodal treatment • Avoid prolonged immobolization, return to work early • Multimodal pain clinic • Minimize stress, depression

ACEP: Drug Monitoring Programs • 41 states, 7 more in the process • Level ACEP: Drug Monitoring Programs • 41 states, 7 more in the process • Level C • Programs MAY identify patients at high risk of diversion and doctor shopping • No proven decrease in mortality or abuse

Monitoring Programs • Since 1930 s • Computerized in 1990 s • 2002 Harold Monitoring Programs • Since 1930 s • Computerized in 1990 s • 2002 Harold Rogers Prescription Drug Monitoring Program, US DOJ • 2005 National All Schedules Prescription Electronic Reporting Act • State-based, limited interstate communication thus far

Monitoring Programs • Useful tool in recognizing and intervening upon patients involved in substance Monitoring Programs • Useful tool in recognizing and intervening upon patients involved in substance abuse • Emergency Physicians received little training • Maintain therapeutic stance – Beneficence, Nonmaleficence • Avoid despair and hostility

KASPER • Kentucky All Schedule Prescription Electronic Reporting System • KASPER is a reporting KASPER • Kentucky All Schedule Prescription Electronic Reporting System • KASPER is a reporting system designed to be: – A source of information for practitioners and pharmacists. – An investigative tool for law enforcement.

KASPER • Access to KASPER: – Prescribers for medical treatment of a current or KASPER • Access to KASPER: – Prescribers for medical treatment of a current or prospective patient, – Dispensers for pharmaceutical treatment for a current patient, – Law enforcement officers for a bona fide drug-related investigation, – Commonwealth's attorneys and assistant Commonwealth's attorneys, county attorneys and assistant county attorneys, – Licensure boards for an investigation of a licensee, – Medicaid for utilization review on a recipient, – A grand jury by subpoena, and – A judge or probation or parole officer administering a drug diversion or probation program.

Border State Prescription Monitoring Programs • • • Indiana PMP (INSPECT) Illinois PMP Ohio Border State Prescription Monitoring Programs • • • Indiana PMP (INSPECT) Illinois PMP Ohio PMP (OARRS) Tennessee PMP Virginia PMP West Virginia PMP (RXData. Track)

House Bill One • Legislation in state of KY, first of its kind • House Bill One • Legislation in state of KY, first of its kind • Mandatory registration with KASPER • Mandatory use of KASPER when prescribing Schedule II, Schedule III with hydrocodone, and specified Schedule IV medications • Certain Exceptions include administration in the ED, inpatient setting, cancer, end of life care

ACEP: Low Back Pain Level C No obvious benefit to opioid or non-opioid Risk ACEP: Low Back Pain Level C No obvious benefit to opioid or non-opioid Risk of opioid Therefore physician should attempt nonopioid except in severe or refractory pain • No more than three to seven days of medication • •

ACEP: New-onset acute pain: Schedule II vs III • Level B – For “short-term ACEP: New-onset acute pain: Schedule II vs III • Level B – For “short-term relief of acute MSK pain” physicians may prescribe either • Level C – “Inadequate” evidence of any superiority of Schedule II over Schedule III

ACEP: Opioids In Acute Exac of Noncancer Chronic Pain • Level C: • Physicians ACEP: Opioids In Acute Exac of Noncancer Chronic Pain • Level C: • Physicians should avoid prescribing of opioids for patients with acute exacerbations of chronic non-cancer pain • Lowest possible dose and duration • Honor pain contracts

Future • Patient satisfaction as a metric? • HCAHPS survey and reimbursement • Additional Future • Patient satisfaction as a metric? • HCAHPS survey and reimbursement • Additional state or federal legislation similar to House Bill 1 • Additional state opioid prescribing guidelines similar to those in Washington, New York, etc

References • • • Miner, JR, Paris, PM, Yealy, DM. (2009). Pain Management. In References • • • Miner, JR, Paris, PM, Yealy, DM. (2009). Pain Management. In Rosen’s Emergency Medicine – Concepts and Clinical Practice (7 th Edition, pp. 2410 -2428). Mosby Hansen, GR. Management of Chronic Pain in the Acute Care Setting. Emerg Med Clin N Am. 23 2005; 307338. Cantrill, SV, et al. Clinical Policy: Critical Issues in the Prescribing of Opioids for Ault Patients in the Emergency Department. Ann Emerg Med. 2012; 60: 499 -525 Baker, K. Chronic Pain Syndromes in the Emergency Department: Identifying Guidelines for Management. Emergency Medicine Australasia. 2005; 17: 57 -64 Todd, KH. Pain and Prescription Monitoring Programs in the Emergency Department. Ann Emerg Med. 2010; 56: 24 -26 Todd, KH, et al. Chronic or Recurrent Pain in the Emergency Department: National Telephone Survey of Patient Experience Western Journal of Emergency Medicine. 2010; 11: 408 -415 Wilsey, BW, et al. Chronic Pain Management in the Emergency Department: A Survey of Attitudes and Beliefs. Pain Management 2008; 9: 1073 -1080 KASPER Kentucky All Schedule Prescription Electronic Reporting System. http: //www. chfs. ky. gov/os/oig/KASPER. htm Kentucky House Bill 1. http: //www. kbml. ky. gov/NR/rdonlyres/DFFF 4843 -1343 -4468 -9574 C 9 BE 26 CE 48 CF/0/House. Bill 1. pdf