Disclosures No financial relationships with commercial interests - PowerPoint PPT Presentation

Disclosures  No financial relationships with commercial interests within the past year Modern Management of Pain:  No discussion of investigational use of Current Strategies for Maximizing Results medications While Minimizing Opioids  There will be discussion of ‘off label’ use of medications or products Henry Crevensten, MD June 2019 *All images from UCSF brand photography, licensed for use, or in the public 2 domain Outline and Scope Learning Objectives:  We will discuss:  At the end of this presentation you will be able to: - Management of chronic pain conditions in the - Describe a framework for evaluating and Primary Care setting: knee, hip, back managing chronic pain - Assess your patient’s pain (using PEG score)  We will review: - Utilize non-opioid pain management strategies - Treatment updates over the past few years - Issues for selected populations (women, geriatrics, underserved, underrepresented)  Methodology: - Case based learning 3 4 1

About Me Outline Alternative /  Associate Professor of Complementary Clinical Medicine at the San Francisco VA, UCSF  Deputy Chief: Primary Care SFVA Medications  Primary Care Clinician, Eureka, CA VA Clinic  About 25% of my patients use prescription opioids to Cannabis treat their chronic non- cancer pain 5 6 Philosophy Slide Take Home Points  No single modality will successfully treat more than a minority of patients with a painful condition 1. Use a stepped and additive approach  Pain relief ↔ improved: sleep, depression, fatigue, quality of life, 2. No single modality works for all patients function, and ability to work  Failure with one modality does not necessarily mean failure with 3. Evidence is mixed others, even within a class  Success or failure can be determined within 2-4 weeks, and 4. Measure and evaluate success, when achieved, tends to be long lasting 5. This is hard  Because success rates are low, a wide range of medications / modalities is needed to do the best for 6. A long-term approach helps most patients, especially in complex chronic conditions 7. Patients may still utilize opioids Perhaps we are not always treating pain, but instead, suffering – Louis Kuritzky, MD Moore, A, et al, Expect analgesic failure; pursue analgesic success, BMJ 2013;346:f2690 7 8 2

A Framework for Managing Chronic Pain Establish the Diagnosis (beyond our scope here, but realize 1. that management may differ) Current State: functionality 2. Current and Past treatment 3. Case: Mrs. Healy Evaluate Risks of treatment 4. Establish Goals 5. Set Expectations 6. Add a Therapy 7. Evaluate Efficacy 8. Repeat 2-8 9. 9 10 Mrs. Healy: Case: Mrs. Healy, 59F, transferring her care to you as she recently chronic knee, hip and back pain moved to the area. PMHx: Hypertension, Depression Establish the Diagnosis Social: drinks 1 glass wine per night. Never smoker a. Exam: left knee bony medial compartment tenderness, small effusion. Straight leg raise positive, left. Pt CC: left knee (OA), left hip (OA), low back pain reports mild radiculopathy in the lower extremities. (degenerative) Pain with extreme of ROM left hip. b. Prior knee, hip x-rays: moderate OA left >> right Rx: ibuprofen; APAP/Hydrocodone 1-2 tabs daily c. Prior MRI, lumbar spine: degenerative disease. No spinal stenosis. Mild foraminal narrowing. Pain recently worse, wondering about an increase in Rx. She has also heard about CBD and is wondering if she should try this. 11 12 3

Case: Mrs. Healy, Case: Mrs. Healy, chronic knee, hip and back pain chronic knee, hip and back pain Goals: Current State  Hike a. Use a brief pain score: i.e. PEG  Improve tolerance of standing Over the past week…  Avoid surgery P = average P ain intensity, 0 = no pain, 10 = worst pain i. E = interference with E njoyment of life, 0 = none, 10 = completely ii. G = interference with G eneral activity, 0 = none, 10 = completely Function: iii.  Can walk, but painful after 500 ft., worse in afternoon. b. Mrs. Healy reports: P = 5, E = 6, G = 5, total 16.  Can’t stand for long to cook, do dishes.  Ibuprofen improves pain to about a ‘4’. 30% improvement is considered meaningful  APAP/Hydrocodone improves pain to about a ‘3’. Krebs EE, Lorenz KA, Bair MJ, et al. Development and initial validation of the PEG, a three-item scale 13 14 assessing pain intensity and interference. J Gen Intern Med . 2009;24(6):733–738. Case: Mrs. Healy, Standard Therapies chronic knee, hip and back pain We won’t cover these, but consider for all patients: Current and Past Treatment • Weight loss – • Acetaminophen: “didn’t work” 5-10% loss can lead to improved pain scores • NSAIDs: ibuprofen 200mg 1-2 tabs BID PRN • Exercise • Acetaminophen/Hydrocodone 5mg/325mg 1 tab PO BID PRN • Physical Therapy: modest improvement in pain scores • Acupuncture: hasn’t tried • Smoking, alcohol cessation/minimization • Physical Therapy: hasn’t tried • Topical creams: hasn’t tried • Mental Health screening • SNRI: no, currently on Zoloft for depression • Substance use disorder screening • Gabapentin: hasn’t tried • TCA: hasn’t tried 15 16 4

Neuropathic Pain We won’t cover these, but evidence for neuropathic pain treatment for:  SNRIs (duloxetine, venlafaxine) Alternative and Complementary  Gabapentin Practices  Pregabalin  Tricyclic Antidepressants 17 18 Selected Alternative and Complementary Practices Acupuncture  back: small effect on pain, function - knee: not clinically significant - Yoga  Medications back: mod effect on pain and function - Tai Chi  back: mod effect on pain and function - Mindfulness  back: small effect on pain and function - $$ (not covered by insurance) Minimal side effects AHRQ Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review. 2018 19 20 Chou R, et al, Nonpharmacologic Therapies for Low Back Pain. Ann Intern Med.;2017 166:493–505 5

2018 JAAOS Network Meta-analysis: Knee OA 2018 JAAOS Network Meta-analysis: Knee OA Treatment Rank, Combined Pain and Function RCTs, minimum 30 patients, followed > 4 weeks  Naproxen Ibuprofen Celecoxib Diclofenac Ranked effectiveness probabilities for pain and function  Naproxen had largest effect on function and overall ranked #1  for pain + function effect, followed by IA steroid, PRP, and then ibuprofen IA Steroid had large effect on pain, no sig on function  IA Steroid IA PRP Acetaminophen, IA HA, no different than placebo  IA HA Acetaminophen Placebo Drawbacks: heterogeneous, direct comparisons could be Gastrointestinal and Cardiovascular side effects  lacking, did not include PT, exercise IA = intra-articular; PRP = platelet-rich plasma; HA = hyaluronic acid Jevsevar DS, Shores PB, Mullen K, et al. J Am Acad Orthop Surg. 2018 May 1;26(9):325–336 21 22 2015 Annals of Int Med Network Meta- 2017 Lancet Network Meta-analysis: analysis: Knee OA Knee and Hip OA  Utilized RCTs, 100+patients, knee/hip OA, comparing Utilized RCTs  NSAIDs or acetaminophen with placebo Evaluated pain, function, stiffness   Evaluated pain, function IA HA with greatest effect on pain and function, followed by  diclofenac  All interventions except for acetaminophen were superior to placebo Acetaminophen: no different than placebo   Diclofenac 150mg / day was most effective in improving Drawbacks: lower-quality studies. IA HA compared to oral pain and function  placebo da Costa BR, et al, Lancet. 2017 Jul 8;390 Bannuru RR,et al. Ann Intern Med. ;162:46–54 23 24 6

NSAIDs, oral: selected classes NSAIDs: Caution Salicylates Propionic Acids Acetic Acids  4-fold increase in GI bleed risk, 3-fold in COX-2 • ASA • Naproxen • Diclofenac • Salsalate • Ibuprofen • Etodolac  Risk increases with age • Ketoprofen • Indomethacin  Use PPI in patients with elevated GI risk • Ketorolac  Choose naproxen in patients with CV risk Oxicams COX-2  Avoid in patients with recent CV event • Meloxicam • Celecoxib • Piroxicam  Avoid in patients with HF Some patients may respond better to NSAIDs in a different class, and sometimes even within a class British Journal of General Practice 2016 25 26 Topical Treatments Acetaminophen: Update Cochrane Review, 2017  Topical Diclofenac and ketoprofen had - modest effect on OA, mostly knee Smaller effect, less evidence for - Tylenol topical lidocaine (back pain, neuropathic)  capsaicin (post-herpetic neuralgia)  Increase in liver enzymes Some of the topical NSAID is absorbed systemically 27 28 7