PAIN UPDATES AND MANDATES Steven M Lobel MD

PAIN : UPDATES AND MANDATES Steven M. Lobel, MD Medical Associates of North Georgia, Northside Hospital

WHY ME? • Regional Representative, AAPM&R Resident Physicians Council 2001 -2004 • President, Residency Association of EVMS 2003 -2004 • Chief Resident, EVMS Department of PM&R 2003 -2004 • Chairperson, Resident Fellow Section, Medical Society of Virginia 2003 -2004 • Consultant to the Composite State Board of Medical Examiners for the subject of Pain Medicine • Consultant to the DEA, FBI, GBI, OIG • Consultant to the Cherokee Multi-Agency Narcotics Squad for the subject of Pain Medicine • Consultant to MCMC, a private peer review company. Reviews performed for disability, treatment authorization, and quality/appropriateness of care

WHAT IS PAIN? An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

MEDICATION • Multiple classes • Medico-legal risks • Drug-Drug interactions

SPECIFIC DRUGS • Main Classes: NSAID’s- mechanical pain Motrin, Aleve, Celebrex, Mobic, Lodine, etc Skeletal Muscle Relaxants- opiate sparing Flexeril, Zanaflex, Baclofen, Robaxin, Parafon, Skelaxin AED’s- neuropathic Lyrica, Neurontin, Keppra, Lamictal, Tegretol, Trileptal Antidepressants- neuropathic and nociceptive Cymbalta, Savella, Elavil, Pamelor, Effexor Opiates- narcotics- nociceptive more than neuropathic

NSAID’S

NSAID SAFETY • Not recommended over age 60 (for daily use) • Increased risk of MI, CVA • ACC June 2010 • Eur Heart J. April 2010 • When they compared this to preceding months without heart problems, they found that filling a prescription for any NSAID raised the risk of cardiac arrest by 31%. • Increased risk of GI bleed- 3500 -8000 deaths per year • Increased risk of elevated LFTs and renal failure

MUSCLE RELAXANTS • • • Zanaflex 2, 4 mg Dose: 2 -8 mg tid prn Sedation Baclofen 10 mg bid upto 20 mg qid. Augments Tegretol Skelaxin Flexeril 5, 10 mg Dose: 5 -10 mg tid prn Sedation Robaxin Parafon Norflex Soma Barbituate like substance, never Rx it. BZD’s High abuse potential, never Rx it. It would appear to reviewer that you are medicating a patient to shut them up, not help them.

OPIATES • Legalized heroin? • Risks and benefits • Abuse, addiction, diversion • Tolerance occurs quickly (2 weeks) • Side effects • WHO Stepladder approach outdated • Pain is the 5 th vital sign (APS 1996, JCAHO 2000)

OPIATES • Morphine • Hydrocodone • Oxycodone • Hydromorphone, Oxymorphone (Opana off market) • Fentanyl, Butrans • Methadone, Demerol, Suboxone, Stadol • Ultram***, Nucynta

WHO IS AT FAULT?

E. R. OR O. R.

NEW LAWS TO THE RESCUE • Georgia (GA PDMP) • Effective January 1, 2018: • Prescriber Requirement: • Each GA prescriber with a DEA shall register to use the PDMP no later than January 1, 2018 and is encouraged to register as soon as possible after July 1, 2017 • Beginning January 1, 2018, every new DEA prescriber registrants must register with the PDMP within 30 days of obtaining a DEA permit

NEW LAWS • Effective July 1, 2018: • On or after July 1, 2018, any person initially prescribing a schedule II opioid or any benzodiazepine shall seek and review a patient’s PDMP information, then at least once every 90 days thereafter, unless the: • Rx is for 3 day supply and no more than 26 ‘pills’ • Patient is an inpatient in a hospital, LTCF, hospice, personal care home. • Patient had out-patient surgery, and the Rx is for up to 10 day supply or 40 ‘pills’ • Patient is terminally ill and in an outpatient hospice • Patient is being treated for cancer

NEW LAWS • Prescribers who violate the requirement to check the PDMP will be held administratively liable to their licensing board • Prescribers making sure inquires shall notate same in the patient’s medical record • A prescriber issuing opioid prescriptions shall provide information to patients on the risks of using opioid and information on proper disposal of opioid • Informed Consent and Agreement for Treatment

FOX NEWS CLIP

BUT WHAT IF? • Turf them after 2 nd script. • Finding a good pain doctor is hard. • Most make money off procedures • Many are poorly trained. • Some are pill mills. • Many use NP or PA to see the folks for pills and order the procedures for the doc to do. This is bad for everyone. • Communication is key. Repeat: “That is not how I treat pain. ”

CHRONIC PAIN-(NOT YOU) • UDS, SOAPP-R, Pharmacy call, Database checks, Outside records, ICAT. Serial exams with functional goals documented as well as 4 A’s and 4 C’s. • Aberrant behaviors, analgesia, activity levels, adverse effects • Continued use despite harm, cravings, compulsive use, and loss of control Defer to PCP or Pain Physician if already on meds. Communication and documentation are essential.

CLINICAL PSYCHOLOGY • You have TMD, it can hurt • How you deal with the hurt makes you who you are. • When you cannot cope, there is additional help • It’s homework for your psyche. • Reversing the downward spiral.

PROCEDURES FOR PAIN • Stellate block-Diagnostic/Therapeutic/Neurolytic • Sphenopalatine block • Neurolytic • Gasserian block-Diagnostic/Therapeutic//Neurolytic • Neuromodulation

STELLATE OBJECTIVE: The goal of the present study is to verify the efficacy of stellate ganglion block (SGB) in the treatment of facial pain that can be found in different pathological syndromes, and also to examine whether the efficacy is dependent upon when this therapy is administered. PATIENTS: Fifty patients (divided into two randomized groups) with facial pain caused by traumas, iatrogenic issues, herpes zoster, or neurological pathologies participated in this study. DESIGN AND INTERVENTIONS: The first group (N = 25) was treated with SGB produced by 10 administrations of 10 mg of levobupivacaine given every other day, followed by one administration per month for 6 months thereafter. The second group was treated with meds. RESULTS: Before treatment, the mean visual analog scale (VAS) pain score for the first group was 8. 89; after the 10 th block treatment it was just 0. 2, and it remained at that reduced level for the 6 th and 12 th months. Before treatment, the mean VAS pain score for the second group was 8. 83; after the 20 th day on medication it was reduced to 4. 1, after 6 months it was 5. 7 and after 12 months it was 4. 9. CONCLUSIONS: It does not work unless you do too many to be worthwhile.

SPG • The sphenopalatine ganglion and its involvement in the pathogenesis of pain has been the subject of debate for the last 90 years. • Current indications for blockade of the sphenopalatine ganglion include sphenopalatine and trigeminal neuralgia, migraine and cluster headaches, and atypical facial pain. • The techniques for blockade range from superficial to highly invasive. Efficacy studies, though few and small, show promise in patients who have failed pharmacologic or surgical therapies.

SPG

SPG

SPG

SPG

A NEW LOOK AT SPHENOPALATINE GANGLION BLOCKS FOR CHRONIC MIGRAINE • This simple, inexpensive procedure may provide a relatively low-risk option for the treatment of chronic migraines. By Soma Sahai-Srivastava, MD and Kellie Spector, BS. Practical Pain Management. 2016

GASSERIAN • Done as diagnostic block with minimal dose of local anesthetic while using conscious sedation. • Therapeutic procedure could ensue using pulsed or thermal radiofrequency. • Other options include glycerol, phenol, or alcohol.

GASSERIAN

GASSERIAN

GASSERIAN • Radiofrequency gasserian rhizotomy should be considered with caution in patients with atypical facial pain. • In this subset of patients, long-term prognosis has not been optimistic, and significant psychosocial comorbidity may be present. • This is why you do not refer for the procedure, you refer for evaluation for the procedure.

NEUROMODULATION • High Lateral Cervical Spinal Cord Stimulation (SCS) for Neuropathic Facial Pain: Report of 10 Cases • Leads placed at C 1 -2 were able to reduce pain in 100% of V 3, 88% of V 2, and 0% of V 1. • 5/8 patients studied had 81% relief on average.

NEUROMODULATION

NEUROMODULATION • Peripheral nerve stimulation and/or field stimulation is a useful technique in alleviating facial pain and refractory headache syndromes • Wires placed in the subcutaneous tissues or directly over peripheral nerves modify the afferent signal with a pleasant paresthesia • Readily performed, reversible, and non-destructive.