1. Current Concepts and Strategies
in Pain Management
Raymond G. Tatevossian, MD
Chair, Pain &Palliative Care Committee, PSJMC
Clinical Assistant Professor of Anesthesiology,
USC Keck School Medicine

2. Lecture Objectives
• Current Understanding Of Pain
Mechanisms
• Current Treatment Strategies
• Medication Update
• Controversies Surrounding Opioids
• Prudent Opioid Prescribing
• Advanced Interventional Techniques

3. Pain: The Statistics
• 2nd leading cause of medically related lost
work days
• $100 billion/year cost to US economy
• 42% adults experience daily pain
• 50% of population see a doctor with “Pain”
as the chief complaint
• 66% of US veterans report persistent pain
attributable to military service

4. Is All Pain “Bad?”
The Gift of Pain by Dr. Paul Brand
• “The Beloved Enemy”
• Pain is evolutionarily necessary for survival
– Acute pain is protective

5. The “Gift” of Pain--an Example
• Mycobacterium leprae
– Disfigurement
• Infectious processes or
painlessness?
• The Cat Test
– Sensory Neuropathy
http://bhavanajagat.files.wordpress.com/

6. Classification of Pain
Acute Chronic
• Generally protective • Generally no useful fnctn.
• Relieved when healing • Persists after healing
complete complete
• Short duration • Long duration
• Predictable pathology • Unpredictable Pathology
• Predictable prognosis • Unpredictable prognosis
• Tx with analgesics • Tx multidisciplinary

7. Chronic Pain Conditions
Neuropathic Pain: Nocioceptive Pain:
•CRPS 1 and CRPS 2 • Osteoarthritis
•Chronic abdominal pain
•Chronic pelvic pain
Mixed Pain:
•Diabetic neuropathy
•Malignant pain
•HIV neuropathy
•Chronic headache
•Phantom limb pain
•Fibromyalgia
•Arachnoiditis
•Failed back surgery syndrome
•Post herpetic neuralgia
•Post thoracotomy pain
•Trigeminal neuralgia
•Degenerative disc disease

8. Factors Contributing to
Chronic Pain
“Chronic Pain Load”
• Intensity of injury
• Duration of injury
• Repetitiveness of injury
• Chronicity of underlying disease
• Genetic predisposition
– BH4 enzyme production
• Other factors:
- Psychological
- Socioeconomic
- Cultural

9. Mechanisms of Pain: Neuroplasticity
How does a Chronic Pain State Develop?
• Peripheral Sensitization
- Injury causes release of
“sensitizing soup”
- Reduction in threshold and
increase response of nocioceptors
• Central Sensitization
- Membrane excitability, synaptic
recruitment and decreased
inhibition
- Uncoupling of pain from
peripheral stimuli
http://www.aafp.org/afp/2001

10. Treatment: Multiple Options

11. Traditional Step Approach
http://www.nationalpainfoundation.org/images/Impla
ntableTherapy

12. Multimodal Pain Management

13. Goals of Treatment
• Reduce pain
• Increase activity level
• Improve quality of life
• Pre-emptive analgesia
• Stay within “Therapeutic
Window”
– Avoid undertreatment
– Avoid toxicity
• How?
– Synergism with Meds
• Morphine + Gabapentin
– Apply multimodal pain
strategies when possible

14. Analgesic Medication Update
FDA Advisory Panel Recs/Trends:
• Acetaminophen- ↓ max daily dose, ↓
max single dose
• Vicodin, Percocet - ban in current form
• Propoxyphene (Darvocet)- push for
phased withdrawal
Abuse Deterrent Opioids:
• Morphine ER+ Naltrexone (Embeda)
• Oxycodone IR+ Naltrexone (Oxytrex)
• Oxycodone IR + Niacin (Acurox)

15. Emerging Analgesic Medications
• IV Acetaminophen
(Paracetamol)
– opioid sparring, phase 3
completed
• Tapendatol (Nucynta)
µ-opioid agonist, NE reuptake
inhibitor
↓ GI effects, ER phase 3
• Hydromorphone Extended
Release (Exalgo)
– FDA approved 3/1/2010,
awaiting REMS

16. Opioids--The Evolving
Controversy
Past: Decreased Scrutiny
• 1990: Pain becomes “fifth vital sign”
• 1990: Intractable Pain Act
– “no physician or surgeon shall be subject to disciplinary action …
for prescribing controlled substances for intractable pain”
• Medical Board CA defines under treatment of pain as
“inappropriate prescribing”
• Bergman vs Chin: $ 1.5 million dollars awarded for under
treatment of pain
• 2000-2005 a 35-50% increase in opioid prescribing

17. Opioids--The Evolving
Controversy
Present: Increased Scrutiny
• Most common class of medication prescribed
– 800% increase in 10 years
• Fatal opioid poisonings have tripled 1999-2006
• Food & Drug Administration Act (2007)
– Creation of REMS for new and existing drugs
• McLellan and Turner, Annals On Internal,
Editorial, Jan 2010
- “prescribing opioids at high doses is both dangerous amd
questionable”
- White House Office of National Drug Control Policy

18. Opioids--The Evolving
Controversy
Future:
• Goals
– Avoid undertreatment AND avoid abuse
• Know appropriate prescribing stratagies
– immediate release vs. sustained release formulations
– neuropathic vs nocioceptive pain
– malignant vs. chronic non-cancer pain
– Urine toxicology screen
– Opioid contract/Prescription monitoring

19. Strategic Opioid Prescribing
Prescription Monitoring Opioid Contract
• CURES (CA) • Call it “Opioid Consent”
• Pharmacists, physicians, • Discuss risks and
and law enforcement benefits of opioids
officials • Educational
• Real time, S II – IV • Establish rules of
• https://pmp.doj.ca.gov/pm prescribing
preg

20. Intrathecal Drug Delivery
Systems
AKA: Pain pump
Mechanism of Action:
• Drug delivered directly to the
intrathecal space
Drugs:
• Morphine
• Baclofen
• Ziconotide (Prialt®)
http://www.medtronic.com/IN/images/intro_intrathecal1.gif
• Bupivicaine
• Clonidine
• Ketamine

21. Intrathecal Drug Delivery
Systems
PROS CONS
• Short reversible trial • Short reversible trial
• Delivery of drug ∀ ↓opioid benefit with
directly to the site of time (40% failure with
action time)
• 1mg IT Morphine = • Contraindications to
300 gm oral Morphine placement
• Cancer Pain: ↓pain, • Complications
↓toxicity, ↑survival (granuloma)
6mo

22. Spinal Cord Stimulation
• Production of electrical
field over dorsal columns
by epidurally placed
electrodes
• Gate Control Theory
– Gate exists in dorsal horn that governs pain
signal transmission
– Closing gate decreases pain
• Parasthesia produced
over painful body area

23. Spinal Cord Stimulation
Grade A Evidence
• Failed Back Surgery
• Arachnoiditis
Grade B Evidence
• CRPS I
• CRPS II
Other Indications
• Phantom limb, post herpetic
neuralgia, spinal cord injury
www.medscape.com

24. References
1. Arthritis Foundation. (2000) Pain in America. http://www.arthritisfoundation.org
2. American Pain Foundation. http://www.painfoundation.org.
3. National Institutes of Health. NIH Guide: New Directions in Pain Research: Bethsea.1998.
4. Brand P and Yancey P. The Gift of Pain. Michigan: Zondervan Publishing House, 1997.
5. Turk D. Pain Hurts-Individuals, Significant Others, and Society. APS Bulletin. 2006;16:1.
6. Payne J. Pain medications: What you need to know about acetaminophen, darvon, and darvocet. US News
and World Report 2009.
7. Jamison R and Clark D. Opioid Medication Management:Clinician beware. Anesthesiology 2010; 112:777-8.
8. Tucker K. Promoting good pain management in california. California Health Law News 2004;22:1-4.
9. McLellan T. Chronic noncancer pain management and opioid overdose: Time to change prescribing
practices. Annals of Internal Medicine 2010;152:123-4.
10. http://cdc.gov/nchs/data/databriefs/db22.htm
11. http://www.painmed.org/pdf/rems_comments.pdf
12. Cousins M, Carr D, et al. Neural blockade in clinical anesthesia and pain medicine. New York: LWW,
2009.
13. American Society of Anesthesiologists Task Force on Chronic Pain Management. Practice guidelines for
chronic pain management: an updated report by the ASA. Anesthesiology 2010;112:810-33.
14. Gilron I, Bailey J, et al. Morphine, gabapentin, or their combination for neuropathic pain. NEJM
2005;352:1324-34.
15. Smith T, Staats P, et al. Randomized clinical trial of an implantable drug delivery system compared with
comprehensive medical management for refractory cancer pain:impact on pain, drug-related toxicity, and
survival. J of Clinical Oncology. 2002;20:4040-9.
16. Barolat G, Massaro F, et al. Mapping of sensory responses to epidural stimulation of the intraspinal neural
structures in man. J. Neurosurg 1993;78:233-239.