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Transcript

 

Lee Tetreault:

Hello and welcome to Frequently Ask Questions from the session. Chronic pain, 20/20 vision in 60 minutes. We are joined today by Dr. Esther Benedetti, MD FIPP. Doctor, before we get started, would you be able to provide our audience some key pointers from today's session? 

Esther M. Benedetti: 

Absolutely. Chronic pain is a complex entity that encompasses multiple path of physiological mechanisms. Hence, it can be very, very challenging to treat. Treatment success should be measured objectively and not solely using a simple numeric scale, which is basically a subjective report by the patient. Goal oriented therapy is indeed the best way to assess efficacy. Opioids, although they are very potential analgesics, should never be used as a first line treatment for the management of chronic non-cancer related pain. There are serious consequences individual and societal, therefore maximizing a non-opioid pharmacological and non-pharmacological strategies should be sought prior to initiating them. Once an opioid has been decided as a long-term medication. Patient's risk stratification and close monitoring using available risk mitigation tools must be used at the start of therapy and during its use. If the patient receives an opioid and continues to experience pain, if there has not been a change in the baseline medical condition, consider tapering and discontinuation as an option.

Lee Tetreault:

Great, so let's get into some of the frequently asked questions here. First, what is the difference between acute and chronic pain? 

Esther M. Benedetti: 

Acute pain is a normal physiologic response. It basically serves as an alarm system to the individual to have self-protective behaviors to prevent further injury, so therefore it is the normal pain that we all can experience. Chronic pain has really no biological purpose, instead it does become a disease in and of itself.

Lee Tetreault:

So are there different types of pain? 

Esther M. Benedetti: 

Indeed, there are. There's nociceptive pain which basically encompasses nociceptors that are found on skin and subcutaneous tissues and on viscera, so it does encompass both somatic pain as well as visceral pain. There's also neuropathic pain, which is basically a pain that arises out of a lesion of the central or peripheral nervous system and then there's a new classification or nociplastic pain in which there is an alteration of the nociceptive properties, even though there is no evidence of tissue harm or disease of the nervous system.

Lee Tetreault:

So we just went over the different types of pain, does that mean that they are treated differently or is there a better way to treat chronic pain? 

Esther M. Benedetti: 

So indeed because the mechanisms are different, the treatment should be mechanism-oriented hence the treatment can be quite challenging. Some pharmacological agents can work in different types of pains so simultaneously may be able to relieve different types of pain, however, others will not. Non-pharmacological strategies can also be shared in different types of pain, like psychological therapies and physical modalities. However, the best way to treat chronic pain is using a multi-modal, multi-disciplinary and multi-dimensional approach to the patient.

Lee Tetreault:

Do opioids work for chronic pain? 

Esther M. Benedetti: 

They can and first subset of conditions, they indeed can provide some significant relief. However, they should never be considered first-line agents in this particular pathology. And the reason why not is because everybody will develop tolerance to their effects, which means basically that they will lose their efficacy over the course of time, requiring higher and higher doses. They do have associated very complex side effects for which again, they should not be considered as first line in treatment. For some types of pain, they can work moderately well, for others, there's really no scientific evidence to support their use. 

Lee Tetreault:

What are the consequences of long-term opioid therapy? 

Esther M. Benedetti: 

Osteoporosis, hypogonadism, also sexual dysfunction, immunosuppression, constipation, opioid-induced hyperalgesia, would be the most concerning long-term effects.

Lee Tetreault:

Is there any way to mitigate risks for patients starting or continuing opioid therapy? 

Esther M. Benedetti: 

Absolutely, and they should always be used prior to starting opioid therapy and while continuing their use. There are validated scales that can identify patients at risk for opioid use disorder, such as the opioid risk tool or the current opioid misuse scale, which again can help you identify which patients are at higher risk for opioid use disorder. There are the queries to the State Prescription Monitoring Program. Your in toxicology or saliva, or serum. The use of naloxone as the antidote to overdose and also psychological or other psychological assessments. 

Lee Tetreault:

And lastly doctor, how is opioid use disorder diagnosed? 

Esther M. Benedetti: 

So there are specific DSM-5 criteria to identify patients with the diagnosis of opioid use disorder and there are tables available. A simple way to identify a patient in the office is evaluating the 3C's. One is compulsion. So looking for behaviors that are obsessive regarding the habit of consuming the opioid to control. So once you started the medication, you lose control over the habit and three, consequences that the habit can actually continue to cause negative effects on the individual yet they continue to use. And this is probably the most important.

Lee Tetreault:

This is great information, doctor. Thank you so much for your time today.

Esther M. Benedetti:

Thank you, Lee.