# Presentation: 075699

## INNOVATIVE WAYS TO EVALUATE PAIN CONTROL INTERVENTION EFFECTIVENESS AND COMPLIANCE  byForest Tennant M.D., Dr. P.H.

## Circle of CHAOS & CONFUSION

**ACUTE****	****CHRONIC ****	****MALIGNANT****	****	****NON-MALIGNANT**
**TERRIBLE****	****	****INTRACTABLE****	****	****PALLIATIVE****	**
**MODERATE ****	****	****INTERVENTIONAL****	****MILD****	****	****	**
**SEVERE****	****	****INCIDENT****	****	****RESCUE**
**BREAKTHROUGH****	****PSUEDO-ADDICT****	**** MYOFACIAL**
**CRPS****	****	****	****ADDICT ****	****	****ABUSE**
**RSD ****	****	****	****AROUND-THE-CLOCK****	****	****	****	****	****	**

## USUAL EVALUATION PARADIGM

**Uniform Criteria For Diagnosis**
**Identifiable Standard Treatment**
**Quantifiable Outcome Measures**

## FDA–APPROVED INDICATION

- Morphine (Kadian®, Avinza®, MS Contin®)
- Oxycodone (Oxycontin®)
- Oxymorphone (Opana ER®)
- Fentanyl (Duragesic®)
- 	For the management of _moderate_ to _severe_ pain when a continuous, _around-the-clock_ opioid analgesic is needed for an _extended period of time_.
- NOTE: There are no conversion tables or 1 to 10 pain scales in PDR.

## Fentanyl (Actiq®, Fentora®)

	“Management of breakthrough cancer pain in patients who are already receiving and who are tolerant to opioid therapy for their underlying persistent cancer pain”.

Oxymorphone, Hydromorphone (Dilaudid®, Opana®)

	“Management of pain in patients where an opioid analgesic is appropriate”.

- 	*“**Management of *_***breakthrough ***_*cancer pain in patients who are already receiving and who are *_***tolerant***_* to opioid therapy for their underlying *_***persistent***_* cancer pain”.*
_**Oxymorphone, Hydromorphone**_ (Dilaudid®, Opana®)
- 	*“**Management of pain in patients where an opioid analgesic is *_*appropriate*_*”.*

## Oxycodone, Hydrocodone (Vicodin®, Lortab®, Zydone®, Percocet® Codeine)

	“For the relief of moderate to moderately severe pain”.

Tramadol (Ultram ER®)

	“Management of moderate to moderately severe chronic pain in adults who require around-the-clock treatment of their pain for an extended period of time”.

- 	*“**For the relief of *_***moderate***_* to *_***moderately severe***_* pain”.*
_**Tramadol **_(Ultram ER®)
- 	*“**Management of *_***moderate***_* to *_***moderately severe chronic***_* pain in adults who require *_***around-the-clock***_* treatment of their pain for an *_***extended period***_* of time”.*

## Complications and Risk Management For Interventional Spinal TherapiesPain Medicine: SupplementMay/June 2008

- Indication for Spinal Injection in the Chronic Pain Patient
- Indication for Minimally Invasive Disk and Vertebral Procedures
- Selection of Spinal Cord Stimulation Candidates for the Treatment of Chronic Pain

## SOME COMPLICATIONS OF SEVERE, CHRONIC PAIN 

- Hypertension
- Tachycardia
- Hypercortisolemia
- Hyperlipidemia
- Diabetes
- Osteoporosis
- Arteriosclerosis

- Adrenal Exhaustion
- Fatigue
- Impotence/Loss Libido
- Depression/Suicide
- Anorexia
- Insomnia
- Immobility

## SOME COMPLICATIONS OF SEVERE, CHRONIC PAIN (Cont.)

- Coronary or Cerebral Vascular Accident
- Loss of Mental Capacity
- Contractures
- Body Asymmetry
- Activities of Daily Living
- Loss of Social, Vocational Abilities
- Decline in Activities of Daily Living

## SUMMARYDIAGNOSIS OF SEVERE, CHRONIC PAIN 

**Patient Describes Pain as **_**Constant**_** and Debilitating**
**Failure of Short-Acting Opioids**
**Objective Physical Signs of:****	****Sympathetic (Adrenergic) Discharge**
**	****	****	****	****Sensory Avoidance**
**	****	****	****	****Positional Relief**
**	****	****	****	****Pain Distraction**
**Impairment of:****	****	****	****Activities of Daily Living**
**	****	****	****	****Diet, Sleep, Ambulation**
**	****	****	****	****Concentration/Memory**
**	****	****	****	****Social, Marital, Vocational Relationships**
** ****Laboratory Evidence of Adrenal Hormone Abnormalities, (pregnenolone and cortisol)**

## FAMILY MEMBER VALIDATIONS

**Do you believe your family member has incurable, severe, pain?**
**	****	****	****	**** Yes****	****	****  No**
**If no, why not? ________________________________________**
**What is the cause of pain? _______________________________**
**Do you have any concerns about this patient’s current pain treatment?****	****	****	**** Yes****	****	****  No**
**If no, why not? ________________________________________**
**Do you think this patient should have more potent or aggressive pain care at this time?****	****	**** Yes****	****	****  No**
**If no, why not? ________________________________________**

## SYMPATHETIC DISCHARGE SIGNS

**TACHYCARDIA**
**HIGH BLOOD PRESSURE**
**DILATED PUPIL**
**VASOCONSTRICTION (Cold Hands or Feet)**
**DIAPHOROSIS / GOOSEFLESH**
**HYPERREFLEXIA**
**INSOMNIA**
**NAUSEA, DIARRHEA**
**ANOREXIA**

_**SYMPATHETIC DISCHARGE SIGNS**_

## RECOMMENDED OBJECTIVE MEASURES TO HELP DETERMINE UNCONTROLLED PAIN  

## COMMON POSITIONAL RELIEF SIGNS 

## COMMON SENSORY AVOIDANCE SIGNS 

- Speaks Slowly, Softly, Hesitantly
- Wears Sunglasses/ Stays in Dark
- Delays Answering Questions
- Wears Hat
- Walks Slowly, Deliberately, and With Wide Gait, Limp, or Foot Drag
- Stares or Looks Straight Ahead
- Avoids Noise
- Shallow Breathing
- Doesn’t Eat or Drink
- Wears Loose or No Clothes Over Painful Areas
- Won’t Brush Teeth, Shave, or Comb Hair

## COMMON PAIN DISTRACTION SIGNS 

## PHYSICAL EXAMINATION FOR SEVERE, CHRONIC PAIN 

_**SYMPATHETIC DISCHARGE SIGNS**_
- 	BP______     Pulse______     RR______     Pupil Size______
- _Reactivity_:  	 Brisk		  Slow	 	 NR
- _Disphoresis/Sweating_:  	 Marked	 Mild	 	 Normal
- _Vasoconstriction_:   Cold Hand	 Cold Feet	  Blue/ Gray Hands
- _Reflexes_:  Upper Extremity	 Brisk		  Slow	 	 None
- 		    Lower Extremity	 Brisk		  Slow	 	 None

## PHYSICAL EXAMINATION FOR SEVERE, CHRONIC PAIN (Cont)

_**SENSORY AVOIDANCE**_
- Talks Softly 			 Yes	     No
- Breath Shallow	 	 Yes	     No
- Sits Edge Chair	 	 Yes	     No
- Shifts Movement		 Yes	     No
- Wears Sunglasses		 Yes	     No
- Wants Darkness		 Yes	     No
- Looks Straight Ahead	 Yes	     No
- Pain on Palpation		 Yes	     No

## PHYSICAL EXAMINATION FOR SEVERE, CHRONIC PAIN (Cont)

_**POSITIONAL **__**RELIEF**_ (Check all that apply)
- Wheelchair/Walker	    	Walk With Wide Gait	
- Drag a Foot		    	Soles Wearing Unevenly	
- Lies on Floor		    	Leans While Sitting		
- Preferentially Stands   	Muscle Atrophy-Back	
- Muscle
- Hypertrophy-Back	    	Other:__________________

## PHYSICAL EXAMINATION FOR SEVERE, CHRONIC PAIN (Cont)

_**PAIN DISTRACTION SIGNS**_**	****	****	****	**
**Ground Down****	****	**** ****Cigarette**** **
**Broken Teeth     ********	**** Burns****	****	******
**Trauma to Head, ****	****Heat Burns/**
**Knuckles, Feet****	****     ****	****Discoloration****	******

## 60-90 DAY TREATMENT ASSESSMENT

**In the past 90 days, how many visits have you made to an **
**emergency room for pain relief?**
**In the past 90 days, how many times have you been **
**hospitalized for pain relief?**
**In the past 30 days, how many days have you been bed-bound **
**due to your pain?**
**If employed, how many days in the past month have **
**you missed due to pain?**
**On a scale of 0 (no pain) and 10 (worst pain ever) how do **
**you rate your pain?**

## 60-90 DAY TREATMENT ASSESSMENT (Cont)

**How many days in the past month have you left your house to shop, visit, work, or volunteer?**
**How many pain flare-ups, have you had in the past week?**
**How many days in the past month has your pain kept you from shopping, visiting, working, volunteering, caring for children, or other daily activities?**
**In the past week, how many meals did you skip because your pain was too severe?**
**How many days in the past month have you been chair or couch-bound?**

## 60-90 DAY TREATMENT ASSESSMENT (Cont)

**Which things (below) does your pain keep you from doing: (Check all that apply)**
** ****Bathe****	****	**** Leave House ****	****   Walk ****	**** ****	****  Hobby**
** ****Tie Shoe****	****  Write****	**** ****	****   Attend Church ****	****  Garden**
** ****Drive****	**** ****	****  Stand****	****   Telephone****	**** ****	****  Travel   **
** ****Dress****	****	****  Read****	**** ****	****   House Chores****	****  Sit **
** ****Brush Teeth****	****  Sleep****	**** ****	****  Stand in Line ****	**** ****	****  Sleep**
**  ****Climb Stairs****	****   Care for Pet****	****   Comb/wash Hair****	**

## ARE YOU GETTING BETTER?

- Please draw a circle on the number below to describe the overall
- amount of pain you are experiencing today.
- No pain    0   1   2   3   4   5   6   7   8   9   10    Worst Pain Imaginable
- How many days were you house bound last month? __________
- How many days were you couch bound last month? __________
- Have you been to an emergency room or other medical provider for
- a pain flare since your last visit?  If yes, where?      ** **Yes      ** **No
- How many days in the past month have you considered pain free? ________
- Where on your body is your main pain today? __________________________
- Did you have any pain free hours while awake in the past month? __________

## ARE YOU GETTING BETTER? (Cont)

_**Since starting treatment in the intractable pain clinic what are the improvements you have experienced? (Check all that apply)**_
- Less Intractable Pain			  Yes		   No
- More Movement		 	  Yes		   No
- Fewer Suicide Thoughts		 	  Yes		   No
- Less Depression		 	  Yes		   No
- Able to Work				  Yes		   No
- Fewer Emergency Room Visits		  Yes		   No
- Better Family Life			  Yes		   No
- Leave House More			  Yes		   No

## ARE YOU GETTING BETTER? (Cont)

_**Status and Results of Your Treatment**_
- Do you still consider your pain to be
- permanent and incurable?				  Yes		   No
- Do you believe you still require opioids
- to control your pain?		 		  Yes		   No
- Do you believe that your quality of life
- has improved since you began high
- dose opioid treatment?	 			  Yes		   No
- Do you wish to remain in our intractable
- pain program?					  Yes		   No
- Do you believe your pain is under
- enough control to withdraw from opioids?		  Yes		   No
- Do you believe your pain has permanently
- reduced since beginning the program?		  Yes		   No

## BUILDING A QUALITY LIFEMajor Activities

_**In the past month, did you...**_
- work for money?				  Yes		   No
- participate in volunteer activities?		   Yes		   No
- participate in a hobby?	 		  Yes		   No
- spend time caring for a pet?		  Yes		   No
- perform childcare activities?		  Yes		   No
- talk with family and friends?		  Yes		   No
- spend time reading?			  Yes		   No
- spend time on-line/computer?		  Yes		   No
- write a letter?				  Yes		   No

## BUILDING A QUALITY LIFE (Cont)Major Activities

_**How many times in the last month did you leave your house to...**_
- visit a relative?	___________________________
- attend church?     ___________________________
- shop?  		___________________________
_**In the past month, you have discussed your pain with whom?**_
** Minister****	**** Pharmacist****	****   Attorney****	**** **
**Dentist****	**** Neighbor****	****  Family****	**** **
**  Employer****	****  Primary Physician**
** Other:________________________________________________****	**

## BUILDING A QUALITY LIFE (Cont)Major Activities

_**To keep your mind from deteriorating, which of the following did you do last month...**_
- read a newspaper?			  Yes		   No
- read the bible?		 		  Yes		   No
- read a magazine?	 		  Yes		   No
- read a book?				  Yes		   No
- played cards?				  Yes		   No
- worked crossword puzzles?		  Yes		   No
- worked jigsaw puzzles?			  Yes		   No

## BUILDING A QUALITY LIFE (Cont)Major Activities

_**To keep your mind from deteriorating, which of the following did you do last month(cont)...**_
- played Sudoku?				  Yes		   No
- made something ?		 	  Yes		   No
- worked in outdoor garden?	 		  Yes		   No
- planted and cared for plants?		  Yes		   No
- prepared meals?				  Yes		   No
- cleaned house?				  Yes		   No
- completed household repairs?		  Yes		   No

## SUMMARY

**Severe, Chronic Pain is Diagnosed by a History of **
**Pain and Objective Physical Signs and Laboratory Tests**
**Treatment Effectiveness of Severe Pain Should be           Evaluated by the Suppression of Sympathetic Discharge and Improvement in Physical and Mental Function and Quality of Life**
**Some Severe, Chronic Pain Patients Who Have Taken High Dose Opioids for Over 10 Years Show Steady Improvement**