SustainedCurrents

PeripheralNociceptive

Fibers

Transient Activation

ACUTEPAIN

1Woolf CJ et al. Ann Intern Med. 2004;140(6):441-451; 2Petersen-Felix S et al. Swiss Med Wkly. 2002;132(21-22):273-278; 3Woolf CJ. Nature.1983;306(5944):686-688; 4Woolf CJ et al. Nature. 1992;355(6355):75-78.

Surgeryor InjuryCauses

Inflammation

Figure 1. Long-Term Consequences of Acute Pain: Potential for Progression to Chronic Pain1-4

SustainedActivation

PeripheralNociceptive

Fibers

Sensitization

CHRONIC PAIN

CNSNeuroplasticity

Hyperactivity

Structural Remodeling

Figure 2. Pain Can Affect All Aspects of a Person’s Life

Social Consequences1

• Marital/family relations

• Intimacy/sexual activity

• Social isolation

Socioeconomic Consequences1

• Health care costs/ utilization

• Disability• Lost workdays

Functional Status1,2

• Physical functioning• Ability to perform

activities of daily living• Work• Recreation

Psychological Morbidity1-3

• Depression• Anxiety, anger• Sleep disturbances• Loss of self-esteem• Post-traumatic stress

disorder

1AGS Panel on Persistent Pain in Older Persons. J Am Geriatr Soc. 2002;50(6 suppl):S205-S224; 2Becker N et al. Pain. 2000;84(2-3):203-211; 3Fishbain DA et al. Clin J Pain. 1997;13(2):116-137.

All diminish function and quality of life.

Figure 3. Vicious Cycle of Uncontrolled Pain

Pain

Altered Functional

Status

Decreased Mobility

AvoidanceBehaviors

Social Limitations Diminished

Self-Efficacy

Figure 4. ACP/APS Guidelines for LBP

• Recommendation 1: Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories: non-specific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain (strong recommendation, moderate-quality evidence).

ACP, American College of Physicians; APS, American Pain Society; LBP, low back pain.Chou R et al. Ann Intern Med. 2007;147:478-491.

• Recommendation 2: Clinicians should not routinely obtain imaging or other diagnostic tests in patients with non-specific LBP (strong recommendation, moderate-quality evidence)

• Recommendation 3: Clinicians should perform diagnostic imaging and testing for patients with LBP when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination (strong recommendation, moderate-quality evidence)

• Recommendation 4: Clinicians should evaluate patients with persistent LBP and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) (strong recommendation, moderate-quality evidence)

• Recommendation 5: Clinicians should provide patients with evidence-based information on LBP with regard to their expected course, advise patients to remain active, and provide information about effective self-care options (strong recommendation, moderate-quality evidence)

• Recommendation 6: For patients with LBP, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. Clinicians should assess severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy (strong recommendation,moderate-quality evidence). For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs

Figure 5. ACP/APS Guidelines for LBP

ACP, American College of Physicians; APS, American Pain Society; LBP, low back pain.Chou R et al. Ann Intern Med. 2007;147:478-491.

Figure 6. Pain Assessment: History• Injury; inciting event • Temporal features⎯onset, duration• Intensity• Topography⎯location, radiation• Quality⎯burning, sharp, dull, shooting, etc• Exacerbating/alleviating factors• Associated symptoms• Previous therapies⎯medications, physical therapy, surgery• Functional impact⎯mobility, activities of daily living, exercise,

sleep• Evaluation/treatment for depression• Prior diagnostic studies reviewed• Goals/expectations reviewedChou R et al. Ann Intern Med. 2007;147:478-491.

1Chou R et al. Ann Intern Med. 2007;147:478-491; 2Bigos S et al. Acute Low Back Problems in Adults. Rockville, MD: Agency for Health Care Policy and Research (AHCPR); 1994.

Figure 7. Acute Low Back Pain “Red Flags”1,2

• History of cancer• Age >50 years with other signs/symptoms or risk factors• Fever, intravenous drug use, recent infection• Urinary retention, multiple level motor deficits• Osteoporosis, steroid use• Possible fracture• Abdominal pulsating mass• Significant weakness, progressive weakness (cauda equina syndrome)

Confirmation of red flag conditions may require: • Laboratory testing [complete blood count/erythrocyte sedimentation rate/C-

reactive protein/urinalysis, and prostate specific antigen when appropriate]• Medical imaging [lumbosacral radiographs/computed tomography/magnetic

resonance imaging]• Test results may indicate need for emergent surgical referral

Figure 8. Pain Assessment• Physical Examination:

− Structural assessment of affected area− Comprehensive neurological exam⎯posture, gait, muscle strength,

sensation, deep tendon reflexes, and other pertinent tests− Other surveillance testing⎯urine toxicology screen

• Diagnosis:− Supported by objective findings− Imaging/diagnostic tests

• Treatment Plan:− Instructions on lifestyle modifications: weight loss, regular exercise,

good sleep hygiene; other self management resources (eg, www.theacpa.org)

− Medication adherence/side effects discussed− Pain contract/consequences for violating discussed − Follow-up

McCarberg B, Stanos S, D’Arcy Y, eds. Back and Neck Pain. New York, NY: Oxford University Press; 2012.

Drug Net benefit Level of evidenceAcetaminophen Small to moderate Fair

Antiepileptic medicationsa

Small (for gabapentin in patients with radiculopathy only)Unable to estimate topiramate

Fair for gabapentina

to poor for topiramatea

Benzodiazepinesa Moderate FairNSAIDs Moderate Good

Opioids and tramadolb Moderate Fair

SNRIs N/Ac N/Ac

Skeletal muscle relaxants Moderate (for acute LBP only) Good

Systemic steroidsa No benefit Good

Tricyclicantidepressantsa

Small to moderate (for chronic LBP only) Good

Figure 9. Pharmacologic Interventions

NSAIDs, nonsteroidal anti-inflammatory drugs; SNRI, serotonin-norepinephrine reuptake inhibitors.aThese agents are not FDA-approved for the treatment of LBP; bTramadol is approved for the short-term management of acute pain; cClinical studies of this class for the treatment of LBP were not available at the time of the writing of the ACP/APS guidelines; Chou R et al. Ann Intern Med. 2007;147(7):478-491.

• Heat (level II)/cold packs• Physical therapy (2-6 sessions in sub-acute)• Exercise (individualize plan)⎯yoga, progressive

muscle relaxation• Acupuncture• Transcutaneous electrical nerve stimulation • Cognitive-behavioral therapy • Spinal manipulation• Multidisciplinary treatment programs (back schools,

education, counseling) • Back braces and supports have not been found to be

clinically effective

Figure 10. Non-Pharmacologic Modalities: ACP/APS Guideline 7

Chou R et al. Ann Intern Med. 2007;147:478-491.

Figure 11. Integrating Non-Pharmacologic Therapies into the Treatment Plan

• Benefit of non-pharmacologic interventions (including complementary and alternative medicine) is usually enhanced when combined with pharmacologic strategies1

• Integrate systematically in a multimodal approach – May be effective alone for some types of pain or low-intensity pain

(<4/10)• Assessment is key

– Have past treatments been successful? If not, why not?– What is he/she willing to try next?

• Some complementary therapies not covered by insurance– Is he/she able to pay out of pocket? Are pharmaceutical company

programs available to subsidize cost?

1American Geriatrics Society Panel on the Pharmacological Management of Persistent Pain in Older Persons. J Am Geriatr Soc. 2009;57(8):1331-1346.

The following factors predict chronicityof pain, poor patient outcome and psychosocial distress:• Belief system• Comorbidities• Affective factors• Waddell’s signs• Affect, behavior, beliefs, social, work

Figure 12. Yellow Flags

Nicholas MK et al. Phys Ther. 2011;91(5):737-753.

Figure 13. Self-Report Assessment Tools

• Brief Pain Inventory (BPI)1

• Faces Pain Scale2

• Functional Pain Scale (FPS)3

• Iowa Pain Thermometer4

• Numeric Pain Intensity Scale5

• Pain Disability Index (PDI)6

• Patient Health Questionnaire (PHQ)7

• Short Form–McGill Pain Questionnaire (SF-MPQ)8

• Verbal Descriptor Scales (VDS)9

• Visual Analog Scale (VAS)5

1Cleeland CS, Ryan KM. Ann Acad Med Singapore. 1994;23(2):129-138; 2Hicks CL et al. Pain. 2001;93:173-183;3Gloth FM 3rd et al. J Am Med Dir Assoc. 2001;2(3):110–114; 4Herr K et al. Pain Med. 2007;8(7):585-600; 5Acute Pain Management Guideline Panel. Acute Pain Management: Operative or Medical Procedures and Trauma, Clinical Practice Guideline. AHCPR Publication No. 92-0032. Rockville, MD: Agency for Healthcare Research & Quality; 1992:116-117; 6Tait R et al. Arch Phys Med Rehabil. 1987;68(7):438-441; 7Patient Health Questionnaire (PHQ) Screeners web site. Available at http://www.phqscreeners.com; 8Melzack R. Pain. 1987;30(2):191-197; 9Le Resche L et al. J Dent Res. 1988;67(1):33-36.

Figure 14. Racial/Ethnic Disparities in Pain Care

• Racial/ethnic minorities report greater pain severity, disability, and vulnerability to psychosocial problems (depression, PTSD, anxiety) than whites1-4

• Despite having greater pain severity, minorities are less likely to receive pain medications:− African Americans have a 66% greater chance of not receiving pain

medications for extremity fractures compared with whites5

− Hispanics are twice as likely not to receive analgesics for extremity fractures compared with whites (55% vs 26%)6

• Minorities are less likely to have access to pain management services and treatment, and to have their pain underestimated by health care providers7-9

− Pharmacies in minority communities are more than 50 times less likely to stock sufficient supply of opioids than white communities regardless of income level7,8

− African Americans are twice as likely to have their pain underestimated9

1Green CR, Hart-Johnson T. J Natl Med Assoc. 2010;102(4):321-331; 2Carey TS et al. J Pain. 2010;11(4):343-350; 3Ndao-Brumblay SK, Green CR. J Natl Med Assoc. 2005;97(10):1369-1377; 4Green CR et al. J Pain. 2004;5:171-182; 5Todd KH et al. Ann Emerg Med. 2000;35(1):11-16; 6Todd KH et al. JAMA. 1993;269(12):1537-1539; 7Green CR. J Pain. 2005;6(10):689-699; 8Morrison RS et al. N Engl J Med. 2000;342(14):1023-1026; 9Staton LJ et al. J Natl Med Assoc. 2007;99(5):532-538.

Figure 15. Factors Contributing to Racial/Ethnic Disparities in Pain Care

1American Pain Foundation. Topic Brief: Pain Management and Disparities. A Policymaker’s Guide to Understanding Pain and Its Management. November 2008; 2Anderson KO et al. Cancer. 2002;94(8):2295-2304; 3McAuliffe L et al. J Adv Nurs. 2009;65(1):2-10; 4Anderson KO et al. Cancer. 2000;88:1929-1938.

Patients Clinicians

• Beliefs about pain1

• Stoicism2

• Fear of judgment andreluctance to report pain2

• Poor adherence2

• Delay in seeking care and refusal to take medications2

• Poor access to care and low socioeconomic status1

• Inadequate pain assessment4

• No “objective” measures3

• Concern of drug seeking2

• Time constraints4

• Lack of pain management training3

Culture1

Language1

Side effects2,4

Fear of addiction2

Poor patient-provider

communication1

Figure 16. Differing Response to Analgesia

• Acute post-operative pain1

• Cancer pain2

• Elderly3

• Women4

• Ethnic minorities5,6

− Genetic factors related to race/ethnicity may affect analgesic drug absorption, metabolism, elimination, and response

1Werner MU et al. Anesthesiology. 2004;100:115-119; 2Vielhaber A et al. Hematol Oncol Clin North Am. 2002;16:527-541; 3Pergolizzi J et al. Pain Pract. 2008;8(4):287-313; 4Fillingim RB, Gear RW. Eur J Pain. 2004;8(5):413-425; 5Johnson JA. J Pharm Sci. 1997;86:1328-1333; 6Sibille KT et al. Pain Med. 2011;12(7):1076-1085.

Figure 17. Differing Coping Strategies Among Racial/Ethnic Minorities

• African Americans and Hispanics with chronic pain are more likely to use prayer/religion and diverting attention as coping strategies1,2

• Many minority patients rely on complementary and alternative pain treatments and take analgesics only when pain is severe3,4

• African American patients are more likely to use external coping strategies that are associated with increased depression and disability5

1Katz JN et al. BMC Musculoskelet Disord. 2011;12:78; 2Cano A et al. J Pain. 2006;7(7):459-468; 3Anderson KO et al. Cancer. 2002;94:2295-2304; 4Juarez G et al. J Cancer Education. 1999;14:168-173; 5Tan G et al. Pain Med. 2005;6:18-28.

Figure 18. Multiple Types of Pain1

1Adapted from Woolf CJ. Ann Intern Med. 2004;140(6):441-451; 2Chong MS, Bajwa ZH. J Pain Symptom Manage.2003;25(5 suppl):S4-S11.

Patients may experience multiple pain states simultaneously2

Examples

• Strains and sprains• Bone fractures• Postoperative

• Osteoarthritis• Rheumatoid arthritis• Tendonitis

• Diabetic peripheral neuropathy

• Post-herpetic neuralgia• HIV-related

polyneuropathy

• Fibromyalgia• Irritable bowel syndrome

Noxious Peripheral

StimuliA. Nociceptive

InflammationB. Inflammatory

Peripheral Nerve Damage

Multiple MechanismsC. Neuropathic

No Known Tissue or Nerve DamageAbnormal Central Processing

D. Noninflammatory/Non-neuropathic

Figure 19. Nociceptive Versus Neuropathic Pain

Nociceptive Neuropathic

Pain descriptiona • Sharp• Dull

• Burning• Tingling• Shooting

Sensory exam Normal range Abnormal

Deep tendon reflex Normal range Abnormal

Strength Normal range +/-

aThese descriptions are general guidelines and not absolutes; aching may be seen with both types of pain.Mahowald ML, Krug HE. Chronic musculoskeletal pain. In: Firestein GS et al, eds. Kelley’s Textbook of Rheumatology , 8th ed. Philadelphia, PA: 2008.

1Gottschalk A, Smith DS. Am Fam Physician. 2001;63:1979-1984; 2Iyengar S et al. J Pharmacol Exp Ther. 2004;311:576-584; 3Morgan V et al. Gut. 2005;54:601-607; 4Reimann W et al. Anesth Analg. 1999;88:141-145; 5Vanegas H, Schaible HG. Prog Neurobiol. 2001;64:327-363; 6Malmberg AB, Yaksh TL. J Pharmacol Exp Ther. 1992;263:136-146; 7Stein C et al. J Pharmacol Exp Ther. 1989;248:1269-1275.

Figure 20. Breaking the Chain of Pain Transmission

5-HT, serotonin; NE, norepinephrine; TCA, tricyclic antidepressant

Fine PG et al. J Support Oncol. 2004;2(suppl 4):5-22; Portenoy RK et al. In: Lowinson JH et al, eds. Substance Abuse: A Comprehensive Textbook. 4th ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2005:863-903.

Figure 21. Multimodal Treatment

Lifestyle changeExercise, weight loss

Strategies for pain and

associated disability

PharmacotherapyOpioids, nonopioids, adjuvant analgesics Interventional

approachesInjections,

neurostimulation

Physical medicine and rehabilitation

Assistive devices, electrotherapy

Psychological support

Psychotherapy, group support

Complementary and alternative

medicineMassage, supplements

Figure 22. Federation of State Medical Boards

• 2004 Model Policy for the Use of Controlled Substances for the Treatment of Pain

• 28 state medical boards have adopted the model policy verbatim, and 10 other states have adopted guidelines with similar language:1. Evaluation of the patient2. Treatment plan3. Informed consent and agreement for treatment4. Periodic review5. Consultation6. Medical records7. Compliance with controlled substances laws and regulations

The Federation of State Medical Boards. Model Policy for the Use of Controlled Substances for the Treatment of Pain. 2004. Available at: http://www.fsmb.org/pdf/2004_grpol_Controlled_Substances.pdf. Accessed February 24, 2012.

Figure 23. Medical Record

• Should contain 10 parts:1. History and physical examination2. Diagnostic tests3. Evaluation and consultation4. Treatment objectives5. Discussion of risks and benefits of treatment6. Informed consent7. Treatment offered8. Medication - type, date, dosage, quantity9. Treatment agreement10. Periodic review

The Federation of State Medical Boards. Model Policy for the Use of Controlled Substances for the Treatment of Pain. 2004. Available at: http://www.fsmb.org/pdf/2004_grpol_Controlled_Substances.pdf. Accessed February 24, 2012.

Figure 24. Monitor Clinical Outcomes: 4 A’s

• Analgesia (pain relief)• Activities of daily living (physical/psychosocial

function)• Adverse side effects• Aberrant drug-taking behaviors

Passik SD et al. Adv Ther. 2000;17:70-80.