Understanding Pain : A Framework for care

Maureen Allen MD CCFP(EM)

Learning objectives• What is pain?

• What role does pain play?

• What are the different types of pain?

• Understanding Flare-ups

• How to get clients active who live with persistent pain

Case 1

• 59 year old female with stroke 6 months ago

• Pain right side of body, legs greater than arms

• Pain is burning, occasionally sharp

• Hurts to touch the skin on right side

• Investigations show stroke only

• Pain 8/10 but can increases to 15/10 at times

Case 2

• 22 year old male with a spiral fracture of his right tibia from hockey injury 1 week ago

• Pain 5/10

Case 3

• 94 year old male with end stage lung disease

• Severe chest pain related to the work of breathing

• He has refused all treatment

• He just want to be made comfortable

What is pain?

• Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.

Classification of Chronic Pain Task Force on Taxonomy. IASP Press 1994

What is Pain?

• Alarm system

• Protective

• Essential for survival

• But…..Not all pain is the same

• Nor…..is all pain protective despite it’s severe nature

Often described by its…..

• Transmission -Nociceptive

-Neuropathic

• Etiology -illness

-Injury

-Surgery

-Unknown

• Duration

-Acute (0-6months)

-Chronic (> 6 months)

Subjective experience

Influenced by many factors

Types of Pain:Acute

• Caused by an injury, illness, surgery or unknown cause

• Results in new pathology or progression of pre-existing disease (Fracture, Crohn’s disease etc.)

• Predictable

• Protective

• Gone by 6 months

TissueMuscleBone

Nociceptive

Types of Pain:Chronic “Persistent”

• Caused by an injury, illness, surgery or unknown cause

• Do not come back to a pain free baseline (>6 months)

• Pain severe but inaccurate and no longer protective

• Sensitization

• Lose the ability to filter and process input (Pain nerves never shut off)

• Chronic illness

• “Pain baseline” and “Flare-ups” important to know

NEUROPATHIC

Baseline pain 5/10

What do we mean by sensitization?

What do we mean by filter and process?

What do we mean by “Pain baseline” and “Flare-up” Pain

• Pain “baseline” is the daily average pain that the patient experiences : 2-9/10

• Pain “Flare-up” is an increase in the patients pain baseline that can last hours to days

• Caused by activity (too much or too little), poor sleep and thoughts and feelings

• Come back to their pain baseline never 0/10

• Repeat flare-ups can lead to a Pain spiral

Pain spiral

Activity

• Pushing through not good for persistent pain

• Brain still wants to protect the patient

• “Pacing”

• Goal is to find an activity they like so they’re motivated to do it

• Realistic target (distance or time) that they can do on a good day and bad day

• Plan progression (every 4 days by 10%)

Sleep

• Bedroom is for sleep an intimacy only

• No screens: They can make the bedroom a wakeful space

• Our body and immune system needs to recharge

Thoughts and feelings

• The brain can’t tell the difference between emotional pain and physical pain

• The chemistry is the same

• “Depression hurts”Brown Brene. Ph.D., LMSW. Daring Greatly. Gotham Books. 2012.

Pain scales : Good or bad?

IT DEPENDS: What are we measuring?

PAIN INTENSITY

Describing pain in terms of intensity only is like describing music in terms of it’s loudness

Complexity of Pain and Suffering

PAIN

PHYSICAL

PSYCHOLOGICAL

SOCIALSPIRITU

AL15/10 pain=15/10 suffering

Pacing

CannabinoidsTopicals

Noble M, Treadwell JR, Tregear SJ et al. Long term opioid management for Chronic Non-Cancer Pain. Cochrane Database of Systemic Reviews 2010, Issue 1. Art N.: CD006605. DOI: 10. 1002/14651 858. CD006605. Pub 2.

PHARMACOLOGY TREATMENT GOALS

ACUTE PAIN

CHRONIC PAIN ANDCHRONIC

PAIN FLARE-UP

30-40% Pain reduction

Avoid SedationImprove Function

CANCER PAIN OR PAIN AT THE END OF

LIFE

80-100% Pain

reductionMay Cause Sedation

May Compromise

Function

Treatment goals

We alter pain chemistry through pharmacology, and by how we think and feel.

Pharmacological choices?

• Acetaminophen (Tylenol)

• NSAID’s (Advil, Aleve etc)

• TCA (Elavil)

• Anticonvulsants (Lyrica, Gabepentin)

• Broad spectrum antidepressants

(Duloxetine, Effexor)

• Topicals

• Opioids (SA vrs LA)

• Cannabinoids (Smoke, drink or ingest) Maximum is <2 grams a day

• Lidocaine, Ketamine etc...

•Sense of entitlement when opioids and Cannabis are requested that can wear you down. •“Hyperemesis cannabinoid syndrome”

Lynch, Mary MD. Drugs and Therapeutics for Maritime Practitioners. Pharmacology of Chronic Pain. Vol 20, No 5/6 October/November, 1997.

If it only gets you through the day is it holding you back?

15 joints a day?!wtf?

Permission granted Chronicle Herald Dec 2013

Addiction

• Life threatening illness

• A chronic, life long, relapsing illness

• A patient with a past history will ALWAYS be at higher risk

• Neurobiological

• Can takes a life of it’s own

• 4 C’s

• Compulsive use

• Impaired control over drug use

• Continued use despite harm

• Craving

Diversion

• Diversion of prescription drugs involves the unlawful channeling of regulated pharmaceuticals from legal sources to the illicit marketplace.

Where to begin

• What type of pain are you dealing with

• If pain co-exists with addiction, addiction needs to be the priority in addressing care

• Treatment goals and functional goals different

• Validate that their suffering is real

• Multiple strategies needed

• Medication only one tool

• Pain self management group

PACING

• How to get active when you live with persistent pain

• Needs to be an activity that the client wants to do

• Based on time or distance

• Understanding the client’s daily pain baseline

• Avoiding Flare-ups

• It’s NOT about getting fit or losing weight

• It’s about.....

• Neuroplasticity

Re-booting or Retraining the pain system

• Neuroplasticity

• Plasticity of our CNS

• f MRI data

• Key to recovery is understanding pain flare-ups and what causes them

Finding Joy and Happiness again

The journey is the client’s

• You’re there to provide your expertise and to support them

• But….Not everyone is ready to embrace change

• Do not measure your success by pain reduction alone

• Look at your functional and ADL goals

• Understand what’s realistic with respect to time frame for recovery

• Nervous system need consistency and to feel safe with the activities

Summary

• Pain is subjective

• Validate that the pain and suffering are real

• Recovery time and approach vary for every client

• Know what we bring to the table (Attitudes, judgement, stigma)

• Know what type of pain you’re treating

• Knowledge is power for you and the client