Chronic Pain management strategies

**Reidhead, Charles \[Charles.Reidhead@MAIL.IHS.GOV\]**

**Sat 1/24/2004 9:41 AM**

Dear All,

One of my colleagues at this service unit is beginning a Performance
Improvement Project to improve treatment of Chronic Pain, and to create
consensus among our staff regarding this. Is there anyone out there who
has already tackled this issue? It would be nice if we could learn from
your experience before we get started.

I was able to look at the NC4 website that has an excellent summary of
standard guidelines regarding chronic pain:
[www.ihs.gov/NonMedicalPrograms/nc4/nc4-clinguid.cfm#event](http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-clinguid.cfm#event)

We would appreciate any experience or documents that you may have -
especially if they have a proven track record.

Sincerely,

Ty

**gina schmidt \[gina12wis@HOTMAIL.COM\]**

**Sat 1/24/2004 1:58 PM**

I am a Nurse Practitioner with a pending application to the public
health services corps. I have really enjoyed the information that I have
received on this site. I currently work as an outpt Chronic Pain NP in
Navarre Florida. I work with A Physician who sits on the board of ASAM.
He is a Fellow. He has been doing Addiction Medicine and Chronic Pain
for the past 17 years. The reason I give the credentials is because I
have learned a substantial amount from him and would like to share
information as it is appropriate.

Chronic pain is a subject that definately needs to be tackled, there is
a very large population who suffer. Some from the actual cause of the
pain and others from the rebound effect of the narcotics they have been
prescribed. I am currently working with a 21 year old female who after
several hours of pushing had a cessarian delivery. Her pelvis was
displaced in the process, after the birth she was put on percocet for
six weeks. When she tried to use other medications her pain was not
relieved, she continued to complain and see several providers. She then
found a chiropractor who has been adjusting her, but in the mean time (a
period of 7 months) she has become habituated to the percocets.
Everytime she would think she did not need them she would have
withdrawls, well the number one symptom of withdrawls is increased pain,
therefore she would seek out more percocets.

The only way to get the percocets is to make appointments with
providers, they would give her a few and a away she would go to continue
the cycle. She was referred to me to evaluate her pain and her narcotic
use. After taking a psychosocial hx as well as a physical hx, I
discovered that she has multiple risk factors that "wire" her so to
speak for addiction. I have since detoxed her (outpt) and changed her
medication to a long acting, low sedating, low abuse potential
medication called Buprenex.

Next I will slowly taper her off of the medication, as well as encourage
physical medicine, and other modalities to assist with any residue pain.
I will also be sending her to some outpt pain groups as well as groups
about addiction. So she will have a good understanding of what happened
to her. Incidently by the time she came to see me she was up to 12 - 18
percocets a day without pain relief. This is just one small expample of
what can be done with a chronic pain program. Sorry if this was winded I
hope it was beneficial.

Gina Rose-Schmidt, ARNP

Board Certified

**Hays, Howard \[ghhays@ANMC.ORG\]**

**Sat 1/24/2004 6:27 PM**

The Anchorage Primary Care Center at ANMC has a thoroughly researched,
detailed, and well-established program for management of chronic pain.
It's not perfect but it is worth looking at rather than starting from
scratch. Lilly Sickler is the Project Manager for the Chronic Pain
Program and could presumably give you information, such as copies of
policies, procedures, and contracts, if you contact her directly.

Lilly, I hope I'm not opening up a floodgate in your direction.

**Dasilva-Stephen, Jacqueline (TUC)
\[Jacqueline.Dasilva-Stephen@MAIL.IHS.GOV\]**

**Mon 1/26/2004 7:14 AM**

This is actually a nice scenario of what can be done. The burden of
chronic pain on any practice is huge. Unfortunately, at least at our
facility, we have such little flexability and poor availability with
pain meds, both narcotic and non-narcotic. I would love to hear of what
other medications you have had experience with that have been helpful in
weaning off the narcotics that are more likely to have abuse potential
as well as not covering pain control well. THanks!

**Timothy Domer M.D.**

**Mon 1/26/2004 1:17 PM**

From:

Timothy Domer M.D.

Clinical Director

Fort Defiance Service Unit

We have had a Pain Management Committee for a number of years. The
committee

was the result of a PI project. Through that group a number of
hospital-wide

initiatives have been undertaken - including distribution of basic

information on pain followed by a few test questions. Everyone is
required

to turn in their answers to document that they understand the
information.

The biggest issue in any chronic pain program appears to be education -

education of the medical staff, nurses, mental health, pharmacy,
patients

and families. Unless chronic pain is treated as a chronic illness, like
DM,

with a multidisciplinary approach, there is little chance for treatment

success. Many, if not most, providers treat chronic pain as acute pain

occurring over a long period of time. Chronic exposure to pain results
in

distinct physiologic and psychological changes which must be understood
and

dealt with in the context of a chronic illness. Drug therapy alone is

usually not effective.

I recently completed a Fellowship in Geriatrics and Palliative Medicine
and

have prepared a series of talks on recognition and treatment of Chronic
Pain

Syndrome, which are being presented to the Medical and nursing staffs.
We

are also planning a unit in the hospital designed to better provide

palliative and end-of-life care. Ongoing education in pain and symptom

management will be a major part of the success of that unit.

If anyone is interested I would be happy to share specifics from our

experience and our ongoing approach to chronic pain management and

palliative care.

**Riley, Sheila (OKCMIA) \[Sheila.Riley@MAIL.IHS.GOV\]**

**Wed 1/28/2004 11:10 AM**

I have not been able to work with chronic pain patients much at the
Indian Health Service,however, I have studied it much and worked with
hospice patients. Are you looking for measures to assess and track? The
correct medications?

I am interested in what you are doing and how it could work elsewhere

Thanks

Shiela Riley, ARNP