CHRONIC PAIN

MANAGEMENT
Michael Marschke, MD
Medical Director of Horizon Hospice

COMMON ETIOLOGIES OF
CHRONIC PAIN
Episodic pain syndromes:
Headaches migraine, tension, cluster
Ischemic episodes claudication, angina,
sickle cell disease
Visceral pain biliary colic, irritable bowel,
pre-menstrual syndrome, renal colic
Somatic pain - gout

COMMON ETIOLOGIES OF
CHRONIC PAIN
Chronic pain syndromes:
Somatic degenerative and inflammatory
arthitis, trauma, vertebral compression
fractures, boney metastases, fibromyalgia
Visceral abdomenal cancers, chronic
pancreatitis
Neuropathic diabetic neuropathy,
phantom limb pain, spinal
stenosis/sciatica, spinal mets, HIV, drug
induced

CHRONIC PAIN IS MULTIFACTORIAL

Psychologic factors depression, anxiety,

somatization
Socioeconomic factors cultural differences,
urban poor, gender
Spiritual factors spiritual suffering, meaning of
pain
Physical factors VERY complex neuroanatomy
creating the pain sensation, from pain receptors
to afferent nerves to spinothalamic tract, to
thalamus to cortex with modulators all along
the way
Therefore best approach is multi-disciplinary

EVALUATION OF CHRONIC
PAIN
GOALS:
Determine etiology to better treat this
pain
Determine if correctable, intractable, or
potentially dangerous causes
Determine impact on patients life
Take a detailed pain history to aid in
controlling this pain

PAIN HISTORY
O = Other associated symptoms ( nausea with
stomach cramps, swelling with somatic pain,
depression, anxiety)
P = Palliative/provocative factors (mobility,
touching, eating)
Q = Quality
R = Region/radiation
S = Severity ( 0 to 10 )
T = Timing (when started,
continuous/intermittent, time of day)
U = Untoward effects on activity or quality of life,
including psychosocial, spiritual effects

HOW DO YOU TELL WHICH

PAIN SYNDROME? HISTORY!

Somatic focal, ache/throb/sharp, maybe with

swelling/edema/redness, tender, worse with
movement, better at rest, maybe from trauma
Visceral viscous organ colicky, vague,
diffuse, worse with meals, liver/spleen/pancreas
may be more constant, more focal, worse with
eating, uterine colicky, pelvic, maybe with
discharge
Neuropathic burning, sharp, tingling, either
dermatomal or stocking-glove, worse with
touch, maybe with numbness

DRUGS IN WHO STEP LADDER

Step 1: Acetomenophen, Tramadol

(Ultram) plus adjuvant
Step 2: Tylenol #2/3/4, Vicoden,
Darvocet, Percocet
Step 3: Morphine, Dilaudid, Fentanyl,
Demerol, Methadone, Oxycodone,
Levodromaran

Marschkes Modified Pain Escalator

ADJUVANTS TO SOMATIC PAIN

Non-pharmacologic:
Ice, heat
Physical therapy
Chiropractic/osteopathic
manipulations
Massage
Acupuncture
Yoga
Topical agents (Ben Gay/Icy
Hot with menthol,
salcylates, Capcaicin)
Local injections (steroids,
lidocaine)
Glucosamine shown to help
with osteoarthritis

Pharmacologic:
NSAIDs
Cox 2 inhibitors
Steroids
Muscle relaxants

SPECIAL SOMATIC PAIN

SYNDROMES
Boney mets:
Local RT
Pamidronate and
other
diphosphonates
Strontium 89 and
other radioactive
isotopes, taken up
by osteoclasts

Vertebral compression
fractures:
Calcitonin
Pamidronate
Vertebroplasty

VISCERAL PAIN

Anti-cholinergics for colicky pain

H2 blockers/PPIs for PUD/GERD
Steroids for enlarged organs with
capsular swelling
NSAIDs for uterine pain
Nitrates for angina
Others celiac/pelvic plexus blocks, RT
for enlarged organs, massage, herbs,
aromatherapy, acupuncture, healing
touch

NEUROPATHIC PAIN

Tricyclic antidepressants
Anti-epileptics
Anti-arrhythmics
Topical agents lidocaine, capsiacin
Steroids for spinal radiculopathies
Others RT for spine mets, TENS/PENS units
and also spinal electrical stimulators
CAM - Acupuncture, massage, PT, yoga,
healing touch

OTHER CAM ADJUVANTS

Herbals/supplements glucosamine shown to be useful

in osteoarthritis, certain herbs like chamomile useful for
colicky pain
Homeopathies/flower essences for relaxation, visceral
pain
Healing touch/Reiki using energy techniques, useful
with emotional components
Neuro Emotional Technique A chiropractic technique
also useful with emotional components
Mind focusing therapies:

Meditation, yoga, guided-imagery, hypnosis, biofeedback

Art/music/humor therapy, pet therapy
By distraction, found to lower HR/RR and decrease pain up to
10-20%

ADDING AN OPIOID
To achieve quick pain relief:
(LOAD)
1. Start low dose,
short-acting
2. Dose q peak
3. P.C.A. not prn
(Patient controls it)
4. Re-eval in 4 hrs. to
figure out what dose is
needed

prn dosing

Low-dose, short-acting opioids

Tylenol #3, 1-2 tabs

Vicoden, Norco, Lortab
1-2 tabs
Darvocet N-100, 1-2
tabs
Percocet, 1-2 tabs
Vicuprofen, 1-2 tabs

DOSING LIMITED BY
ATTACHED DRUG (max
Tylenol a day is
4000mg)

MSIR/Roxanol,5-10mg
PO, 1-3MG IV/SQ
Dilaudid, 1-2mg PO,
0.25-0.5 IV/SQ
OxyIR, 5-10mg PO
NEVER USE DEMEROL
IN CHRONIC PAIN!!!

MAINTAINING AN OPIOID
For constant pain:
(MAINTENANCE)
1. Go long (convert 24hr
total of short acting
directly to long acting)
2. REM breakthru = 1020% of total daily dose,
as short-acting,
immediate release
3. Re-eval, if 4+
breakthru/d, increase
maintainance dose

LONG-ACTING OPIOIDS

MS Contin, Oramorph, q12hr, in 15,30,60, 100,

and 200mg tabs
Kadian, Avinza, q24hr, in 20,50, 100mg timerelease capsules (can be opened to ease swallowing
or put thru gastric tubes)
OxyContin, q12hrs, in 10,20,40,80, and 100mg
tabs
Duragesic (Fentanyl) patches in 25,50,75, and 100
ug/hr q48-72hrs.
Palladone (Dilaudid) q24hr, in time released
capsules

CAVEATS IN OPIOID USE

With pure agonists, the sky is the limit

80% of the time dose needs to be increased because the disease is
advancing; 20% because of tolerance.
Mixed or partial agonists (Stadol, Talacen, Talwin) have a ceiling,
neurotoxicity, and can induce withdrawal if on other opioids
Methadone q8-24hr drug, may be better with neuropathies &
addiction because inhibits the NMDA receptor in the brain, though
half-life 6-100hrs so watch for accumulation
Demerol neurotoxic metabolite can build up in 1 wk, in 1 day with
renal failure
Oral, sublingual, rectal short acting meds peak within 1 hr., IV/SQ
peak within 10 minutes. Choose oral if they can do it.
Use conversion tables to switch narcotics, start at 50-100% of
equivalent dose
To taper drug, decrease by 25% a day.

OPIOID SIDE EFFECTS

Constipation is a given, no tolerance develops, use

stimulants (Senokot, Bisocodyl, Pericolace)
Nausea/vomiting tolerance can occur in 2-5 days,
compazine/reglan can help
Sedation tolerance can occur in 2-3 days, changing
drug or Ritalin can help if persists
Clonic jerks usually hi doses, can change drug or
benzodiazepam can help
Respiratory suppression in toxic doses, never see it if
have pain or use the drugs the right way

PHYSICAL vs. PSYCHOLOGIC

DEPENDENCE
PHYSICAL DEPENDENCE:
Tolerance (20-40%) up-regulate opioid receptors to
need higher dose for sustained effect
Withdrawal (20-40%) after 2 wks, withdrawing drug
leads to adrenaline response (sweating, tachycardia,
tachypnea, cramps, diarrhea, hypertension); avoid by
decreasing drug 25% a day.
PSYCHOLOGIC DEPENDENCE:
Addiction (0.1% in CA pain) a need to get high
where drug controls your life, compulsive uncontrolled
behavior to get the drug; lie, cheat, steal.

PSEUDO-ADDICTION:
Physical dependence confused with
psychologic dependence
Pain-relief seeking, not drug-seeking
When right dose used, patient functions
better in life, whereas opposite true with
the true addict
To help diffentiate: one MD controls the
drug under a specific contract with pt., one
pharmacy, frequent visits, pill counts