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10/20/17 Disclosures of Financial Relationships Managing Pain in the Hospital Post-Operative Pain Acute Pain, Chronic Pain, Cancer Ramana K. Naidu, MD Pain has disclosed relationships with an entity producing, marketing, reselling, or

  1. 10/20/17 Disclosures of Financial Relationships Managing Pain in the Hospital Post-Operative Pain… Acute Pain, Chronic Pain, Cancer Ramana K. Naidu, MD Pain has disclosed relationships with an entity producing, marketing, reselling, or distributing health care goods or services consumed by, or used on, patients. Speaker’s Honoraria Halyard Health Abbott Ramana K. Naidu, MD Director of Pain Management at Marin General Hospital Mt Tam Orthopedics & Spine Center ramonaidu@me.com 1 2 October 20, 2017 The philosophical dichotomy of acute pain… BLISSFUL INSENSATION? CONGENITAL INSENSITIVTY TO PAIN Warning Signal Suffering Avoidance Reminder Depression Healing Helplessness DENTAL ABSCESSES CORNEAL ABRASIONS BONE FRACTURES INFECTIONS 3 3 4 Heckert J. The Hazards of Growing Up Painlessly . NYTimes Magazine. Nov 15, 2012. 1

  2. 10/20/17 Pain: Definitions Pain Assessment and Risk Screening an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Intensity/Severity: Psychological: •Verbal Rating Scale (VRS) •Hospital Anxiety and Depression Scale Acute Pain: •Numerical Rating Scale (NRS) •Pain Catastrophization Scale •Pain that is limited to the expected period of healing. •Visual Analog Scale (VAS) •Beck Depression Inventory •Temporal definitions vary. <1 month. <3 months. <6 months. •Wong-Baker (Faces) •FLACC Substance Use/Misuse/Abuse: •Pain Assessment in Advanced •Opioid Risk Tool Subacute Pain: Dementia Scale (PAINAD) •SOAPP-R •A transitional period between acute and chronic pain where one is concerned the acute pain is •COMM becoming persistent. Quality: •CAGE-AID •Temporal definitions vary. 1-6 months. •Descriptors •Pasero Opioid Sedation Scale •Brief Pain Inventory •McGill Pain Questionnaire Function: Chronic Pain: •Oswestry Disability Index •Pain that persists beyond the expected period of healing. “Objective” •World Health Organization Disability Assessment Scale •Temporal definitiions vary. >3 months. >6 months. •fMRI •Timed Up and Go •Biological Pattern Algorithms •PROMIS, KOOS, WOMAC (location-specific) Cancer Pain End-Of-Life Pain 5 6 Merskey, H. (1964), An Investigation of Pain in Psychological Illness , DM Thesis, Oxford Types of Acute Non-Cancer Pain Types of Chronic Non-Cancer Pain Surgery •Lumbago Headaches Global burden of disease: Pain Trauma 4.3% of the the world’s population is free of Neck Pain/Cervicalgia disease, injury, or sequelae. Bone Fractures Abdominal Pain Burns Joint Pain Global prevalence of Dental Caries: Weapons Neuropathy 2.4 billion individuals Post-Surgical Pain Acute Medical Illness Global prevalence of Tension-Type Syndromes Headaches: Dental Caries Pelvic Pain 1.6 billion individuals Infectious Sequelae Psychological Syndromes Lumbago Greatest cause of years lived with disability Other Syndromes is: Headache Low back pain Abdominal Pain 7 8 Rice, A. S. C., Smith, B. H. & Blyth, F. M. Pain and the global burden of disease. Pain 157, 791–6 (2016). 2

  3. 10/20/17 Types of Cancer Pain Do we need to manage pain? Consequences of untreated/unmanaged acute pain for the patient: Tumor-Related •Autonomic changes Mass Effect, Swelling, Nerve Irritation, Bony Mets •Endocrinological changes: increased cortisol, insulin resistance, etc. •Psychological distress Surgery •Development of chronic pain —> all of the above Post-Surgical Pain Syndromes Radiation Neuritis and Neuropathy Consequences of untreated/unmanaged pain for the provider: •Empathetic distress Chemotherapy •Ethical consequences Headache, Peripheral Neuropathy •IASP Declaration of Montréal •Legal Consequences Acute Pain • James , 1991, North Carolina* Non-Cancer Chronic Pain Conditions • Chin , 1998, California* * end-of-life cancer pain cases 1. Manage pain •What is standard of care in pain management today? 2. Prevent •What is the goal of acute pain management? chronification 9 10 Rich, B. Physicians’ legal duty to relieve suffering. West. J. Med. 175, 151–2 (2001). Persistent Post-Surgical Pain (PPSP) Chronification… yes, it’s a word. PROCEDURE Approx Approx Approx Number Approx Maximal Incidence Incidence of of Cases Number of PPSP Severe PPSP Annually in USA Patients at Risk for PPSP per the process by which acute pain becomes chronic pain year A neologism ubiquitous in the pain literature; commonest use in regards to migraine. Lower Limb 30-80% 5-10% 159,000 127,000 Amputation Sternotomy 30-50% 5-10% 598,000 299,000 Thoracotomy 30-40% 10% 280,000 112,000 Breast Surgery 20-30% 5-10% 479,000 144,000 Inguinal 10-50% 2-4% 609,000 304,000 Herniorraphy Total Hip 12-28% 5% 400,000 112,000 Replacement Total Knee 8-13% 5% 605,000 78,000 Replacement Cesarean Section 10% 4% 220,000 22,000 11 12 Ossipov, M. H., Morimura, K. & Porreca, F. Descending pain modulation and chronification National Inpatient Sample (NIS) 2007 Data http://www.hcup-us.ahrq.gov/nisoverview.jsp Kehlet et al. The Lancet. 2006 of pain. Curr. Opin. Support. Palliat. Care 8, 143–51 (2014). 3

  4. 10/20/17 Persistent Post-Surgical Pain (PPSP) Analgesia vs Hyperalgesia anxiety catastrophization depression psychology age chronic or pre-operative persistent acute post-operative pain pain post- operative pain genetics adjuvant analgesics nerve-sparing technique surgical anesthetic anti-hyperalgesics infection prevention technique technique regional anesthesia 13 14 Modified from Macrae Analgesia vs Anti-Hyperalgesia Pearl: Analgesia vs Anti-Hyperalgesia Analgesia Anti-Hyperalgesia NO anti-hyperalgesia NO analgesia The management of pain must involve both COX- Alpha-2 Low-dose analgesia and anti-hyperalgesia Inhibitors Agonists Ketamine Acetaminophen Magnesium Analgesia will address acute physiological and psychological adverse effects. Lidocaine Analgesia and Anti- Hyperalgesia Anti-hyperalgesia will address the chronification of pain Analgesia BUT Hyperalgesia and the resultant long duration of physiological and Regional psychological adverse effects. Opioids Anesthesia 15 16 4

  5. 10/20/17 Overview of Anatomy: Nociception Overview of Anatomy: Pathological Nociception Central sensitization Memory formation Emotional response Sympathetic response Hypothalumus-Pituitary-Adrenal response Attenuation of Descending Inhibition Descending facilitation 1662 Dorsal Horn: Rexed Laminae II, V RENÉ DESCARTES TREATISE OF MAN Peripheral sensitization Dorsal Root Ganglion (DRG) modulation Tissue Chemokines 17 18 Basbaum, A. I., Bautista, D. M., Scherrer, G. & Julius, D. Cellular and Molecular Mechanisms of Pain. Cell 139, 267–284 (2009). Basbaum, A. I., Bautista, D. M., Scherrer, G. & Julius, D. Cellular and Molecular Mechanisms of Pain. Cell 139, 267–284 (2009). Biological Biological Pharmacologics: Opioids Pharmacologics: Opioids 4,000 BCE -1840 19 20 Brownstein MJ. A Brief History of Opiates, Opioid Peptides, and Opioid Receptors. Proc National Acad Sci (PNAS). June 1993. 5

  6. 10/20/17 Biological Biological Pharmacologics: Opioids Pharmacologics: Opioids 1840-1975 1970-2007 21 22 Brownstein MJ. A Brief History of Opiates, Opioid Peptides, and Opioid Receptors. Proc National Acad Sci (PNAS). June 1993. Brownstein MJ. A Brief History of Opiates, Opioid Peptides, and Opioid Receptors. Proc National Acad Sci (PNAS). June 1993. Biological Biological 2000-2017 Pharmacologics: Opioids Pharmacologics: Opioids. America today. CDC GUIDELINES DEA CHANGES CDC RAISES DECLARATION OF ACETAMINOPHEN- CONCERNS CONTAINING OPIOIDS to MONTREAL SCHEDULE II from 5th VITAL SIGN PURDUE SCHEDULE III LAWSUIT • Americans constitute 4.6% of the world’s population and consume approximately 80% of the world’s opioids. • Americans consume 99% of the world’s hydrocodone 2000 • There are enough prescribed opioids for each American to take a prescription opioid 2007 2010 2014 2016 every 4 hours for a month. • Estimated 2.1 million Americans with prescription opioid substance use disorder in 2012 • Estimated 467,000 addicted to heroin in 2012. 23 24 American Society of Interventional Pain Physicians (ASIPP). Manchikanti L, Pain Physician National Institute on Drug Abuse (NIDA) 6

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