Summary of Chronic Pain Management Strategies. Lecture for Medical Students, University of Ottawa

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CPM 2 Wrap Up
• Chronic Pain
Presented by: Claudia Gomez, MD. FRCPC. April 27, 2018.
uOttawa.ca
Faculté de médecine | Faculty of Medicine

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Faculty Disclosure of Conflict of
Interest
I do not have any affiliation (financial or otherwise) with a
pharmaceutical, biotechnology, medical device, hospital or
research equipment/supply industry that could be perceived as
a direct/indirect conflict of interest as defined in policy
interactions between the Faculty of Medicine and the
Pharmaceutical, Biotechnology, Medical Device, and Hospital
and Research Equipment and Supply Industries.

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Social Media Disclosure
You may only access and use this PowerPoint presentation
for educational purposes.
You may not post this presentation online or distribute it
without the permission of the author.
Find this presentation at slideshare
Twitter: @cpaolag

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Objectives CPM 2
At the end of the presentation, the student will be able to:
1. List the essential components of a chronic pain history.
2. Describe the validated tools used to assess chronic pain
patients (e.g. Brief Pain Inventory, McGill Pain
Questionnaire, DN4, Opioid Risk Tool, CAGE-AID
questionnaire).
3. List the expectations from the College of Physicians and
Surgeons of Ontario when prescribing opioids for chronic
non-malignant pain.
4

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4. List the major classes of medications used to treat
chronic pain and describe their site of action,
mechanism of action and possible side effects (e.g.
NSAID’s (cox-1 and cox-2), acetaminophen, tricyclic
anti-depressants, selective norepinephrine reuptake
inhibitors, anti-convulsants, opioids, and
cannabinoids).
5. Define opioid tolerance, opioid dependence and opioid
addiction.

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PAIN HISTORY
 P – Palliative/Provocative
 Q – Quality
 R – Radiation (and location)
 S – Severity
 T– Timing
Sleep, mood, side effects of
current medications (bowels,
sedation...)
BPI, DN4, Opioid Risk tool,
CAGE-AID
Past Medical Hx
Addiction(s)
Past Surgical Hx
Meds: Including previous
pain medications -
effectiveness vs SE’s
Allergies
Social History
Work
Insurance

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BRIEF PAIN INVENTORY
 Excellent documentation of Pain & Analgesia (response
to trial medication)
 Can trend over time the VAS, location, descriptors
 Documentation of Activity & Function
 Documentation of Adverse Effects
 Documentation of Affect
 Easily filled in by most patients

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DN4 QUESTIONNAIRE
 One tool that can be used to diagnose the type of pain
is the “DN4” criteria for neuropathic pain.
 This is a test that uses 7 questions based on history and
3 questions based on physical examination. If there are
4 points or more, this is suggestive of neuropathic pain.
 It is a validated tool that has been shown to be
sensitive (82.9%) and specific (89.9%) for neuropathic
pain.

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CAGE-AID
CAGE-AID Questions:
1. In the last 3 months, have you felt you should cut down or stop drinking
or using drugs? Yes No
2. In the last 3 months, has anyone annoyed you or gotten on your nerves
by telling you to cut down or stop drinking or using drugs? Yes No
3. In the last 3 months, have you felt guilty or bad about how much you
drink or use drugs? Yes No
4. In the last 3 months, have you been waking up wanting to have an
alcoholic drink or use drugs? Yes No
Each affirmative response earns one point. One point indicates a possible
problem. Two points indicate a probable problem.

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The Pain Spiral

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Realistic goals
 30 – 50% pain
reduction is realistic
 Total pain relief is
unrealistic
 Ideal: reduced pain,
improved function
with minimal side
effects.
- Pain relief
- Function
- Adverse
effects

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Managing Pain and Function
Self
Management
Psychosocial
Medical:
Pharmacologic
Interventional
Physical
Rehabilitation

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The pharmacotherapy of chronic pain:
A review (Lynch & Watson 2006).
https://www.hindawi.com/journals/prm/2006/642568/abs/
 NSAID’s
 Acetaminophen
 Anti-Convulsants
 Anti-Depressants: TCA’s, SNRI, SSRI
 Opioids
 Cannabinoids
 Alpha-2-agonists
 Neuroleptics
 Muscle Relaxants

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Neuropathic Pain Treatment
Pharmacological management of chronic neuropathic pain:
revised consensus statement from the Canadian Pain Society
Pain Res Manag Vol 19 No 6 November/December 2014
https://www.hindawi.com/journals/prm/2014/754693/abs/
Gabapentinoids ↔️ TCA ↔️ SNRI
Tramadol ↔️ Opioid Analgesics
Cannabinoids
Fourth-line agents*
Consider adding
additional agents
sequentially if partial
but inadequate pain
relief*
*Topical lidocaine (second line for postherpetic neuralgia), methadone, lamotrigine,
lacosamide, tapentadol, botulinum toxin

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What is the CPSO opioid strategy?
 Facilitate safe and
appropriate opioid
prescribing by
physicians to
patients,
 Protect patient
access to care,
 Reduce risk to both
patients and the
public.
Decision-making
framework
 Do I prescribe opioids to
this patient?
 How will I safely prescribe
opioids to this patient?
 What is my exit strategy?

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What to do before prescribing an
opioid?
• Complete thorough assessment to understand the pain
problem to make an informed decision about opioids as a
reasonable treatment choice.
• Consider screening tools to help identify patients at risk of
opioid misuse or addiction.
• Manage expectations by setting function-improvement and
pain-reduction goals with patient. These become the
outcomes for measuring opioid effectiveness.
• Ensure informed consent by reviewing with the patient:
potential benefits, risks, side effects, and complications of
opioid therapy

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6 “A”s of documentation for opioids
• Analgesia: (BPI, PQRST)
• Activity level: Improvements in activity level/function
• Adverse effects: Nausea, sedation, constipation, etc.
• Adherence and Accurate medication log
– Adhering to treatment plan?
– Evidence of addictive behavior?
– have them bring in there pill bottles and see if the correct
number of pills remain
– If on a opioid patch: all patches (i.e., Fentanyl/Butrans)
should be returned to the pharmacy in order to get refills,
write this on their script
• Affect (mood)
– Any change in mood?

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Prescription monitoring system
Unexpected result Possible explanations Actions for the physician
1 UDS negative for
prescribed opioid
False negative
Non-compliance
Diversion
Repeat test using chromatography; specify the drug of interest (e.g. oxycodone
often missed by immunoassay).
Take a detailed history of the patient’s medication use for the preceding 7 days
(e.g., could learn that patient ran out several days prior to test)
Ask patient if they’ve given the drug to others.
Monitor compliance with pill counts.
2 UDS positive for
non-prescribed
opioid or
benzodiazepines.
False positive.
Patient acquired opioids
from other sources (double-
doctoring, "street").
Repeat UDS regularly.
Ask the patient if they accessed opioids from other sources.
Assess for opioid misuse/addiction (See Recommendation 12).
Review/revise treatment agreement
3 UDS positive for
illicit drugs (e.g.,
cocaine, cannabis).
False positive.
Patient is occasional user or
addicted to the illicit drug.
Cannabis is positive for
patients taking dronabinol
(Marinol®), THC:CBD
(Sativex®) or using medical
marijuana.
Repeat UDS regularly.
Assess for abuse/addiction and refer for addiction treatment as appropriate
Ask about medical prescription of dronabinol, THC:CBD or medical marijuana
access program.
4 Urine creatinine is
lower than 2-3
mmol/liter.
Patient added water to
sample.
Repeat UDS
Consider supervised collection or temperature testing
Take a detailed history of the patient’s medication use for the preceding 7 days
Review/revise treatment agreement.
5 Urine sample is cold Delay in handling sample
(urine cools within minutes).
Patient added water to
sample.
Repeat UDS, consider supervised collection or temperature testing
Take a detailed history of the patient’s medication use for the preceding 7 days
Review/revise treatment agreement.

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Diagnostic criteria for Opioid-Use Disorder*
 Use of an opioid in increased amounts or longer than intended
 Persistent wish or unsuccessful effort to cut down or control opioid use
 Excessive time spent to obtain, use, or recover from opioid use
 Strong desire or urge to use an opioid
 Interference of opioid use with important obligations
 Continued opioid use despite resulting interpersonal problems, social
problems, or both.
 Elimination or reduction of important activities because of opioid use
 Use of an opioid in physically hazardous situations (e.g., while driving)
 Continued opioid use despite resulting physical problems, psychological
problems, or both.
 Need for increased doses of an opioid for effects, diminished effect per dose or
both☨
 Withdrawal when dose of an opioid is decreased, use of drug to relieve
withdrawal, or both☨
*If 2 or 3 items cluster together in the same 12 months, the disorder is mild; if 4 or 5 items cluster, disorder
is moderate; if 6 or more items cluster, disorder is severe. Criteria from DSMMD 5th Ed.
☨If the opioid is taken only as prescribed, this item does not count toward a diagnosis of an opioid-use
disorder.

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Distinguishing Dependence,
Tolerance and Addiction
• Physical Dependence =
symptoms of withdrawal arises if
drug discontinued, significantly
reduced or given antagonist
• Tolerance = more drug needed to
maintain therapeutic effect or loss
of effect over time
• Pseudoaddiction = behavior
suggestive of addiction but due to
non-optimal dosing or dosing
schedule of opiates
• Addiction (psychological
dependence) = psychiatric disorder
characterized by continued
compulsive use of substance
despite harm
Arch Intern Med. 2012;172(17):1342-1343.
doi:10.1001/archinternmed.2012.3212

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Behaviors suggesting prescription drug
abuse
 Multiple prescribers
 Frequent emergency room visits
 Multiple drug intolerances described as “allergies” and
refusal to pursue non-opioid treatments
 Frequent dose escalations and self-dose escalation
 Frequent running out of medication early
 Frequent telephone calls to clinic and early appointments
 Focusing mainly on opioid issues during visits
 Repeated prescription loss with “classic” excuses such as
the dog ate my prescription, the airline lost my baggage,
the medicine was stolen
From: IASP Pain Clinical Updates - New Addiction Criteria: Diagnostic Challenges available at
https://s3.amazonaws.com/rdcms-iasp/files/production/public/FileDownloads/PCU_21-5_web.pdf

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Resources
 2017 Canadian Opioid Prescribing Guidelines:
http://www.cfpc.ca/uploadedFiles/CPD/Opioid%20poste
r_CFP_ENG.pdf
 Opioid tapering template:
https://thewellhealth.ca/opioidtaperingtool
 CPSO statement on appropriate opioid prescribing:
http://www.cpso.on.ca/opioids
 Patient resources: https://www.liveplanbe.ca/pain-
education
 Doc Mike Evans – Best advice for people taking opioid
medications
https://www.youtube.com/watch?v=7Na2m7lx-hU

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Resources
http://www.hqontario.ca/Evidence-to-Improve-Care/Quality-Standards/View-
all-Quality-Standards/Opioid-Prescribing-for-Chronic-Pain
http://www.cfpc.ca/chronic-non-cancer-pain-management-opioid-resources/
https://www.ismp-canada.org/download/OpioidStewardship/opioid-handout-
bw.pdf
https://safemedicationuse.ca/tools_resources/medication_list.html
Canadian Patient Safety Institute (English):
http://www.patientsafetyinstitute.ca/en/toolsResources/Pages/SAFE-Toolkit-
Video-Series.aspx
CPSI (French):
http://www.patientsafetyinstitute.ca/fr/toolsresources/pages/safe-toolkit-video-
series.aspx