Chronic Pain Management for the Primary Care Provider

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Chronic Pain Management for the Primary Care
Provider

• CDR Steve Moll, DO
• Senior Medical Officer
• USS Saipan (LHA-2)

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What will you do when the patient returns to
your office, after seeing every specialist you
can think of, and says
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What will you do when the patient returns to
your office, after seeing every specialist you
can think of, and saysDoc YOU gotta do
sumpthin about this pain. ??
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Pt seen at After Hours Clinic Female, late 20s,
with acute LBP 77 visits in the last 12 months
! Know what I think?
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Eliminating Frustrations

• Knowledge is Power
• Ownership of the problem
• The Provider ?
• The Patient ?
• Recognize that your frustrations fuel the fire

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Why Am I Here?

• Why is a Family Practice physician giving a talk
  on chronic pain management?
• 1) Default. No one else seemed to be helping.
• 2) My decision to go into FP.
• 3) Rewards.

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Where Am I Going ?

• Have a Game Plan !
• Chronic pain is a multifactorial problem.
• Ochams Razor has no place in pain medicine!
• Treatment requires a multifactorial approach.
• Successful treatment involves treating the
  PATIENT, not the pain.

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Where Am I Going ?

• Primary Care Providers are uniquely qualified to
  manage the chronic pain patient.

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Where Am I NOT Going ?

• Lecture is meant to address the chronic pain of
  musculoskeletal disorders.
• Not oncological pain
• Not abdomino-pelvic pain
• Not LBP necessarily associated w/ nerve
  impingement
• Unable to address specific problems in depth in
  this lecture

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Other Potential Applications

• Fatigue
• Depression
• Chronic Headaches
• Chronic Interstitial Cystitis

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Have a Game Plan
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The Game Plan

• The chronic pain didnt start overnight it
  wont go away in a 15 minute appointment!

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The Game Plan

• History
• Assess
• Reassess the 1st problem assess the 2nd
• Reassess the 1st 2nd, assess the 3rd
• Homework assignments

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The 1st Visit

• Let the patient vent.
• Get the History
• Redirect to ascertain
• Difficulties with sleep
• Psychiatric issues
• Willingness to do whatever it takes
• Concluding the encounterI will need some time
  to thoroughly review your record. In the mean
  time I would like you to keep a journal of your
  pain (sleep, diet, exercise).

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Know the Red Flags of LBP
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The 1st Visit (contd)

• PE (do the essentials). Explain that you
  will do this at the next visit, prn
• Interim treatment measures -Avoid narcotics.

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Between the 1st 2nd visits

• Chart review
• Previous encounters for the same problem
• Treatments offered / duration / effectiveness
• Psych issues
• CHCS
• Previous pertinent labs, radiology studies
• Medication history
• Number of visits in the last year previous years
• Develop further plans of action

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Subsequent Visits

• Reassess previous interventions adjust prn
• Address one new issue
• Focused Hx PE Treatment
• EDUCATE
• Review the game plan
• Schedule f/u

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I know what youre thinking. Yeah, right.
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Roadblocks to Success

• Poor continuity of care
• Little control over your appointment schedule
• Tunnel vision
• Its got to be the HNP on the MRI.
• Provider biases
• Its old age. Get over it.
• Youre fat and need to lose weight.
• Its fibromyalgia. We dont know what causes it
  we dont know how to treat it.
• Inadequate knowledge base

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History

• Fatigue
• Sleep (Quality Quantity)
• Depression
• Anxiety

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History (contd)

• Have you ever been abused?
• Learn about Somatization Disordersand how to
  deal with somatization patients.
• Servan-Schreiber, et al, . Somatizing patients.
• Am Fam Physician (2000611073-8. and
  2000611423-8,1431-2.)

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History (contd)

• How often do you use a heating pad?
• Whats going on in your life? - Is your
  spouse deployed? - Do you have help with the
  kids?
• Exercise- Not enough, or- Too much of a good
  thing
• Smoking. Caffeine.
• Diet obesity.

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The Physical Exam

• Observe
• Ambulation
• Posture
• Ability to move onto/around exam table (document)
• Many problems start where the rubber meets the
  road.
• Touch the patient
• If youre depending on plain films or MRI,
  youre off to a bad start.

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Diagnoses You Should Know

• Forward Head Syndrome
• Brachial Plexopathy
• Rotator Cuff Syndrome
• Thoracic facet syndrome (somatic dysfunction)
• Piriformis Syndrome
• Episacroiliac Lipomas
• Sacroiliac Joint Dysfunctions
• Iliotibial Band Syndrome

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Treatment

• Address each musculoskeletal disorder
• Dont use baby doses to treat big
  problems.(Know your safe therapeutic ranges)
• ?Narcotic analgesics? - rarely (if ever) help
  the patient w/ chronic musculoskeletal pain.

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Treatment (contd)

• Fix the SLEEP problem!
• Raise SEROTONIN levels.
• Treat the depression /or anxiety.

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Treating Insomnia

• No sleep. No relief. No hope.
• R/O Obstructive Sleep Apnea
• Trazadone (Desyrel)
• Allow self-titration
• Explicit verbal written instructions
• Treatment failures? Bipolar until proven
  otherwise.
• TCAs
• nortriptylene
• Avoid zolpidem (Ambien)
• SSRIs

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Boosting Serotonin Levels

• SSRIs
• Start early
• Escalate doses, as tolerated
• Yes this is an anti-depressant. No I
  dont think youre depressed.I am giving this
  to you as an adjunct

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Treatment (contd)

• No HEAT !!
• ICE is nice.
• Fix ergonomic problems
• Exercise

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Treatment (contd)

• Exercise- Flexibility. Flexibility.
  Flexibility.
• - Abdominal core strengthening- Aerobics -
  Water aerobics- Strengthening- Pilates
• NO Bed Rest !!!

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Treatment (contd)

• Physical Therapy
• Electrical stim (TENS)
• Complementary medicine- Acupuncture- Massage-
  Meditation Relaxation Training- Prolotherapy -
  Rolfing- Yoga
• Osteopathic manipulation or Chiropractic
• Whatever it takes !!

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Treatment (contd)

• Empower the patient with knowledge
• TEACH effectively
• Be EXPLICIT
• Check their homework assignments at f/u
• Be convincing! If you dont believe, they wont
  either.
• GETTING RID OF THE PAIN IS THE PATIENTS JOB
  !Giving them the tools to do it is the
  Providers job !

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Conclusion

• The Family Practice Physician
• is eminently qualified to successfully manage
• the multifactorial problems which plague the
  chronic pain patient.

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Questions ?
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