Management of Chronic pain()

DR INAYATH (PG)

DR SADHANA ROY ( MODERATOR)

DR CHANDRASEKHAR
( CHIEF ANAESTHESIOLOGIST )

( CHAIR PERSON)

Definition

The International Association for the Study of Pain defines pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

General Considerations

Methods

Pharmacological therapies
Psychological techniques Physical therapeutic modalities Implanted Electrical stimulators Regional Anaesthesia/Analgesia Ablative Neurosurgical Operations Multi disciplinary Multimodal pain management program

Symptomatic control

Magnifiers

Waddel

Morris Main

1 . Pain at the tip of coccyx 2. Entire leg pain

3. Entire leg sensory loss

4. Give away weakness of the entire lower extremity 5. Absence of pain-free periods 6. Intolerance to procedural or pharmacological treatments 7. Frequent emergency visits and admissions for intractable pain

Non Organic physical signs

Management

Pharmacological treatment
MEDICATIONS ARE NOT THE SOLE FOCUS OF RX IN MANAGING PAIN. U S E O F M E D I C AT I O N S S H O U L D B E D I R E C T E D N O T J U S T T O W A R D S PA I N R E L I E F B U T I N C R E A S I N G F U N C TI O N AN D R E S TO R I N G O V E R AL L Q U AL I TY O F LIFE
THOROUGH MEDICATION HISTORY DEFINE GOALS OF THERAPY BEFORE PRESCRIBING TAILOR MEDICATIONS TO MEET INDIVIDUAL GOALS OF EACH PATIENT IDENTIFY AND TREAT SPECIFIC SOURCE(S) OF PAIN AND BASE THE INITIAL CHOICE OF MEDICATION(S) ON THE SEVERITY AND TYPE OF PAIN PATIENT SHOULD KNOW WHETHER PRESCRIBE OR NOT ABOUT RISKS/BENEFITS WATCH FOR AND MANAGE SIDE EFFECTS FOR OPIODS ( 4 AS) a N A L G E S I A , A D V E R S E E F F E C T S , A C T I V I T Y , A D H E R E N C E )

 Systemic non opiod Analgesics

Pharmacologic al therapies
The German pharmacist, Friedrich A. W. Serturner, extracted an alkaloid from opium in 1803 that was soon known as morphine

Systemic Opiod Analgesics Antidepressants , Anticonvulsants, Local

anaesthetic drugs

Anti arrhythmics, alpha 2 adrenergic

agonists, 5HT3 antagonists,NMDA antagonists

Steroids
Requires understanding of type of pain . Nociceptive or Neuropathic or mixed

Topical Medications Miscellaneous : Vasodilators, Muscle

relaxants

Non opiod analgesics ( PG synthesis inhibitors)

ACETAMINOPHEN MILD MODERATE CHRONIC PAIN NO ANTI INFLAMMATION NO DAMAGE TO GASTRIC MUCOSA RENAL/LIVER SE NO MORE THAN 4 GRAMS/ DAY OFTEN COMBINED WITH OPIODS

Systemic non opiod drugs

NSAIDS
MILD PAIN in LADDER Cox 1 and Cox 2

Cox 2
Cox 3 ( acetaminophen) Rofecoxib / Valdecoxib withdrawn

Celecoxib still doing well

Classification
4 times more used in older groups than younger ones

Goals:
1. 2. 3.

Decrease inflammation
Harness any ongoing tissue destruction Prevent peripheral sensitization of nociceptors by locally released inflammatory factors( Bradykinin, histamine, substance P)

Side effects
Gastritis
Nephropathy Hypertension Hyperkalemia

Hyponatremia
Edema

Consider proton pump inhibitors Ketorolac not more than 5 days continously

Opiods when to start

PERSISTENT MODERATE TO SEVERE PAIN EFFECTIVE IN NEUROPATHIC PAIN NOT RESPONDING TO INITIAL THERAPIES. RARELY BENEFICIAL IN INFLAMMATORY, MECHANICAL OR COMPRESSIVE. NOT RECOMMENDED FOR LONG TERM USE IN HEADACHE INFORMED CONSENT, DOCUMENTATION 4AS COMFORT, OPIOD RELATED SE, FUNCTIONAL STATUS, EXISTENCE OF ABERRANT DRUG RELATED BEHAVIORS

DIRE score ( 7-13 ns, 14-21 s)

DIAGNOSIS INTRACTIBILITY RISK
PSYCHOLOGICAL CHEMICAL HEALTH RELIABIITY SOCIAL SUPPORT

EFFICACY SCORE

Opiods

classification

Effects

Opiods
Morphine

Codeine

Hydromorphone Oxymorphone Heroin

Hydrocodone
Oxycodone

Opiods
Alfentanil
Sufentanil Remifentanil Agonists-Antagonists Buprenorphine Butarphanol Pentazocine

Nalbuphine

Anti depressants
Amitryptiline Imipramine Nortryptiline Desipramine Paroxitene Citalopram Venlafaxine

Serotonergic effect Nor adrenergic effect Opioidergic effect NMDA receptor effect Adenosine receptor effect Sodium channel effect Calcium channel effect

Guidelines for TCA use

NEUROPATHIC PAIN FORE WARN ANTICHOLINERGIC , ANTIADRENERGIC, SEDATIVE SIDE EFFECTS. KNOWN TO CAUSE CONDUCTION DEFECTS, AFTER 50 YEARS BASELINE ECG. START 10MG NIGHT DOSE INCREASE BY EVERY 3 DAYS MAX 200-300MG

Anti convulsants
SUPPRESS OR LIMIT THE SPREAD OF ABERRANT NEURONAL DISCHARGE NEURAL MEMBRANE EFFECTS SYNAPTIC EFFECTS CARBAMAZEPINE-NA CHANNEL GABAPENTIN-ALPHA 2 DELTA 2 SUBUNITS OF CALCIUM CHANNEL LAMOTRIGINE-VOLTAGE GATED CATION CHANNELS AND ON GLUTAMATE RELEASE. IF ONE FAILS, OTHER CAN BE USED AS DIFFERENT MODES OF ACTION. GOOD PAIN RELIEF OF NP SYNDROMES (PHN, TN, DN). ANALGESIA IS MUCH LESS DOSE THAN ANTIEPILEPTIC

Drugs
1. 2. 3. 4. 5. 6. 7. 8.

Carbamazapine
Clonazepam Gabapentin Lamotrigine Mexilitene Phenytoin Topiramate

Valproic acid

Anti arrhythmics
CONSIDER WHEN ANTIDERESSANTS AND ANTICONVULSANTS FAIL. BLOCK SPONTANEOUS ACTIVITY OF PRIMARY AFFERENT NOCICEPTORS NA CHANNELS MEXILITENE-DN, NERVES INJURIES AFTER TRAUMA. DN-VERY WELL 150-200MG/DAY TO MAX OF 10MG/KG/DAY TID LEVEL MONITORED 3 MONTHS CI: 2/3 AV BLOCKS.SAFE IN 1 BLOCK

Alpha 2 adrenergic agonists

CLONIDINE INHIBITS BULBO SPINAL PAIN PATHWAY THAT ARE NE DEPENDENT DEPRESS C FIBRE TRANSMISSION REDUCE EXCITABILITY OF DORSAL HORN NEURONS THROUGH A GI-COUPLED POTASSIUM CHANNEL. REDUCE SUBSTANCE P- DECREASE MUSCLE SPASM CONSIDER WHEN ANTICONVULSANTS/ANTIEPILEPTICS FAIL DN, PHN

5HT3 antagonists
ACTS ON DORSAL HORN NEURONS THAT EXPRESS RECEPTORS FOR SUBSTANCE P ( NK1) PARABRACHIAL AREA OF BRAIN CONNECT TO OTHER AREAS OF BRAIN SUCH AS AMYGDALA, HYPOTHALAMUS THAT MODULATE DESCENDING SEROTONERGIC/NOR ADRENERGIC INPUTS FROM THE BRAIN STEM. IV 5HT3 ANTAGONISTS (ONDONSETRON) .REDUCE NEUROPATHIC PAIN COSTLY

NMDA antagonists
KETAMINE, DEXTROMETHORPHAN, MEMANTINE, AMANTADINE. OPIODS WITH NMDA ANT ACTION. METHADONE, DEXTROPROPOXYPHENE, KETOBEMIDONE. KETAMINE..NO SUPPRESSION OF REFLEXES METABOLITENOR KETAMINEANALGESIC. MALIGNANT/NON MALIGNANT NEUROPATHIC PAIN NO ORAL PREPARATION PARENTAL PREP GIVEN ORALLY ORAL 5OMG/ S.L 10MG TID ALTERNATE/ADJUNCT TO OPIODS SEVERE PHANTOM LIMB/ PHN RESPONDS TO KETAMINE. IV . O.125 AND O.3 MG/KG..INFUSION 0.2MG/KG/HR EPIDURALLY-CRPS

Steroids
REDUE INFLAMMATION BY INHIBITING SYNTHESIS AND RELEASE OF PROINFLAMMATORY SUBSTANCES REVERSIBLE LOCAL ANAESTHETIC EFFECT MEMBRANE STABILISATION, BLOCKADE OF PHOSPHOLIPASE A2 ACTIVITY, INHIBITION OF NEURAL PEPTIDE SYNTHESIS. METHYLPREDNISOLONE, TRIAMCINOLONE USED WIDELY FOR EPIDURAL INJECTIONS

Topical applications
CAPSAICIN CHILLI/PEPPER DEPLETE SENSORY NERVE ENDINGS OF THE NEUROTRANSMITTER SUBSTANCE P. NEUROPATHIC PAIN 0.075 PERCENT MUSCULOSKELETAL PAIN- 0.025 PERCENT APPLY 2-4 WEEKS FOR MAX EFFECT NECK PAIN, LOINPAIN-HAEMATURIA SYNDROME, CRPS, CUTANEOUS PAIN, CLUSTER HEADACHE. 1. Sorround application area with petroleum jelly 2. Pretreat with EMLA 3. Co apply GTN

Topical agents

Muscle relaxants
RELIEVE MUSCLE SPASM/SPASTICITY TIZANIDINE: ALPHA2 ADRENERGIC AGONIST REDUCE THE RELEASE OF EXCITATORY AMINOACIDS AND SUBSTANCE P IN POLYSYNAPTIC PATHWAYS DOESNT CAUSE MUSCLE WEAKNESS MIXED WITH IBUPROFEN/PARACETAMOL 2MG/DAY BID-TIDMAX OF 8MG TID CAUSES SEDATION CAREFUL IN RENAL/LIVER DISEASES

BACLOFEN GABA DERIVATIVE SPINAL CORD LESIONS SECONDARY TO TRAUMA OR MULTIPLE SCLEROSIS 10MG /DAY.MAX 80MG TID INCREASE BY 15MG EVERY 3 DAYS NOT RESPONDING TO ORAL.TRY INTRATHECAL

Muscle relaxants
Orphenadrine
Chlorzoxazone Diazepam Methocarbamol

Carisprodol
Tolperisone Cyclobezaprine Tizanidine

Baclofen
Cyclobenzaprine Quinine

IVR sympathetic block

Guanethidine

Like Biers block Relief 2-7 days Vascular access of normal limb

Cont vital monitoring

Affect limb /exanguinated

Reserpine ( 1-2mg)

Bretylium (5 mg)

Phenothiazine ( 515mg)

torniquet, inflation 50-100 above N SBP 20mg of gaunethedine + 50 ml of NS + 500 IU of heparin. Binds sympathetic Nerve endings, depletes norepinephrine

 Alpha1 and alpha 2 adrenergic

Phentolamine

antagonist Prevents excitation of nor adrenaline-sensitive nociceptors 30mg /100ml NS infused over 20 min If pain relieved it SMP If contraindication for sympathetic block

Modified WHO Analgesic Ladder

Quality of Life
Invasive treatments

Proposed 4th Step

Opioid Delivery
Pain persisting or increasing Step 3 Opioid for moderate to severe pain Nonopioid Adjuvant Pain persisting or increasing

The WHO Ladder

Step 2 Opioid for mild to moderate pain Nonopioid Adjuvant Pain persisting or increasing Step 1 Nonopioid Adjuvant

Pain
Deer, et al., 1999

Peripheral /regional + spinal delivery

Techniques because of lack of other , better analgesic

methods. 10-15 percent of cancer related pain helped by this blocks. Best to start with simple then complex regional blocks 1-2 percent patients are suitable for spinal delivery.

General priciples
Pt should be referred early for consideration of intervention Pain carefully assessed/investigated to determine a nerve

block is feasible and likely to help Careful explanation to ensure full understanding and consent of pt is essential Pt should be given adequate time to think about intervention. Must understand the nature of procedure, what it can and cannot achieve.effects/side effects Must not cause functional defects Neuro destructive must be selective for sensory/autonomic and leave the motor paths and sphincters intact After care services should be available.

General indications
Somatic pain confined to a few dermatomes such as

radicular limb pain

Autonomic nerve involvement such as visceral pain,

intractable angina
Vascular pain

General Contraindications
Patient refusal Local or systemic infection

Non correctable coaggulopathy

Lack of skilled pain management specialist Lack of support services in hospital

Simple nerve blocks

Trigger point injections Intra articular injections

Hospice setting Sterile supplies, short, bevelled nerve blocking needles.

Complex techniques
Risks of adverse events

Requires image intesification

Must be performed in hospital

Eg : brachial plexus, paravertebral blocks Success rate improved by peripheral nerve stimulator and insulated needles

Drugs used
Clear understanding of pharmacology of drugs

involved is vital. Single injections : local anaesthetic, long acting bupivacaine, levobupivacaine, ropivacaine ..most appropriate May be combined with steroid whose local effects depend upon potency , solubility and dose Opiods Botulinum toxin for trigger points , spasticity

Chemical neurolysis
Practised for about 140 years

Phenol, alcohol, glycerol are most commonly used. Phenol- mixture of carbolic acid,phenic acid, phenylic acid, phenyl hydroxide, hydroxy benzene and oxybenzene. LA effect, no pain to inject. Highly soluble in glycerine. Hyperbaric If mixed with water more neurolytic such as chemical sympathectomy. Conc 7-8 percent needed for neurolysis 24-48 hours for effect >8.5 grms .seizures

 Ethyl alcohol absolute alcohol 95 percent

Perineural injection very painful

Hypobaric to spinal fluid Choice in ceoliac plexus block

Less toxic, 90-98 percent completely metabolised

Glycerolneurolysis of the trigeminal ganglion Mild neurolytic

General complications
Vasovagal collapse

Local pain after injection

Allergy Toxicity

Nerve or spinal cord damage from needle trauma

Side effects from unopposed actions of drugs such as

opiods

Simple peripheral blocks and injections

Scar or stump injection:

Pain due to nerve entrapment in scar or amputation stump Use EMLA 2 hours prior to injection Smallest needle possible Inject gently/slowly LA /LA+depot steroid

Myofascial trigger point injections

Pain occurs as result of trauma, back pain, headache, due to

general debility and poor posture Myofascial pain syndrome Pressure over area: pain/taught band, jump sign + associated ANS changes, EMG increased activity 2-3 ml of long acting LA such as bupivacaine or ropivacaine, fine needle, gentle and slow. Repeated not recommendedcan cause fibrosis Botulinum ..3 -4 months Minimum after care Should combine with regular exercises Fibromyalgia is different with sleep disturbance and behaviour changes..trigger injections will make things worse

Peripheral Nerve blocks

Sound knowledge of local anatomy + experience

LA / LA + depot steroid

Eg: Greater Occipital nerve block: U/L or B/L for post head pain that ofter radiates anteriorly to the eye 3-5ml b/w mastoid process and greater occipital protuberance into the muscle layer where the nerve lies

pp

Supra scapular nerve block

Shoulder pain

Adjunct to intra articular shoulder injection

Catheter technique also described 5ml LA+ steroid by using small needle over the mid

point of the upper border of scapula. Nerve lies in groove Deep injection avoided ..pneumothorax

Upper limb blocks

Ulnar, radial, median nerve entrapments

Simple to perform
Pt may get transient motor weakness Protect limb during this time Ilioinguinal iliohypogastric nerves blocked in the

groin to treat nerve entrapments or pain in surgical scars

Femoral nerve block

Pain in hip- reduce muscle spasm in patients with

femoral fractures or metastasis. Lateral to femoral artery in groin 10 ml volume Care to avoid iv Total analgesia- obturator, sciatic, lateral cutaneous nerve of thigh. 3 in 1 block. 20-25 ml Lower limb blocks: common peroneal and tibial nerves - nerve entrapments

Joint injections and spinal injections

Intra articular

Shoulder, hip or knee

Simple to perform Better results with flouroscopy/radio opaque

contrast LA + depot steroid Dose/volume depends upon size of the joint and severity of pain Opiods can be injected into inflammed joint Spinal injections: facet joint / dorsal root blocks

Regional nerve blocks

Individual nerves, plexus or ganglia

Technically demanding
Basic monitoring: venous access, spo2, ECG, NIBP Skilled assistance,sterility, monitoring, equipment,

appropriate imaging, resuscitation, and aftercare Single prognostic block, single therapeutic block, neurolytic block,infusion techniques, Radiofrequency lesioning

Trigeminal ganglion block

Reported 100 years ago in Rx of T.neuralgia

Facial pain due to head/neck cancers

Lesioning near base of the skull Under flouroscopy

Ind: unilateral facial pain, T.neuralgia, facial pain

from MS CI: heart blocks, pt who cannot lie still TN: Largest CN,-face, scalp, cornea, nasal cavity, mouth , teeth.muscles of mastication.

 T. ganglion lies in foramen ovale in middle cranial

fossa, near the apex of petrous temporal bone. Med- cavernous sinus, sup-inf .surf of temp bone , post-brain stem Sensory root leaves ganglion from dorsal to ventral----ophthalmic, maxillary, mandibular.

Procedure
Radio frequency or neurolytic lesions can be

performed in supine, awake, able to cooperate so light sedation. Flouroscopy in 2 planes to locate f.ovale on affected side After Local infiltration needle or radiofrequency probe is inserted 2-3 cm lateral to the angle of mouth and medial to masseter.

Brachial plexus block

Unilateral arm pain

Brachial plexitis
Radiation plexitis Combined with stellate ganglion block

Procedures on arm
CI: phrenic/RLN palsy on contralateral side Pneumothorax on contralateral side

Intercostal block
Unilateral, well localised, chest wall pain within few

dermatomes Ind: rib fractures , chest wall pain, rib mets Sp. cI: b/L pain, obesity, contralateral pneumothorax, poor resp function

Intra pleural block

LA in pleural cavity 20ml , supine, spreads diaphragm to lung apex Multiple intercostak, sympathetic, splanchnic. Ind: u/L chest, multiple fractures C/I: B/L pain, contralateral p thorax,poor resp function. Pleural space: lung apex to about L1 Sitting or by side Infiltrated sup to 8th rib in 7th ICS abt 10 cm lateral to spinous process. Epidural needle . LoR technique. Complications : p.thorax,bleeding from Intercostal vessels, Horners syndrome, patchy analgesia.

Para vertebral block

Nerves can be blocked at any level after emerge from

v. foramen Cervical/thoracic.only unilateral Lumbar bilateral can be done Ind: pain in specific dermatome in cervical, thoracic, lumbar. Nerve invasion from tumour Radicular pain from spinal degeneration Radicular pain from vertebral collapse

Technique
Use flouroscopy

Short , bevelled needle . Insert to contact transverse

process Redirected caudally to depth 1-2 cm that lies near nerve root. Radio opaque contrast then used. 5ml with or without depot steroid.

Stellate ganglion block

Patient Position: Supine, with a roll placed under the shoulders to

extend the neck. Indications: Diagnosis and treatment of sympathetically mediated pain of the face, neck, and upper extremity; treatment of postherpetic neuralgia of the cervical dermatomes. Needle Size: 25-gauge precision Glide needle. Medication/Volume: 5 to 10 mL of 0.25% bupivacaine

Coeliac plexus block

Lumbar sympathetic block

Ganglion impar ( Walther ganglion) block