Transcript

Lee Tetreault:

Hello and welcome to frequently asked questions from the session: Non-opioid pain management. We are joined today by Dr. Kate Galluzzi. Doctor, before we begin, are there any key pointers from today's session that you'd like to share with our audience? 

Dr. Galluzzi:  

You know Lee, I think this session is very important because on several levels, effective pain management really requires a fundamental understanding of not only the pain mechanisms, but also the different types of pain that can occur. And we know with the aging of the population that chronic pain is on the rise in the United States. And unfortunately, paralleling that rise of chronic pain, we've also seen problems with the use of opioid medications and we've actually developed an opioid overuse abuse and overdose death crisis in the United States. It's estimated currently there are about 2 million patients who suffer from opioid use disorder. So I think this session is targeting some of the non-opioid and also some of the non-pharmacological alternatives for treatment of pain.

Lee Tetreault:

Thank you. Let's get into some of these frequently asked questions: How does chronic pain differ from acute pain? 

Dr. Galluzzi:  

Well, everyone knows what acute pain is. Acute pain is when you slam your finger in the car door and you grab it or you put it in your mouth and suck on it, and hopefully it goes away pretty quickly. Chronic pain is defined by IASP, which is the International Association for the Study of Pain, as pain that persists for six weeks or more after the injury that caused the pain has healed. And one of the things that we're seeing now in the literature is a lot of attention towards chronic post-surgical pain. Chronic post-surgical pain is described as pain that persists for a month or more after the resolution of the healing of the surgical site. And it's estimated right now that about 10% of all post-surgical patients, if not treated adequately for their pain, will end up with chronic post-surgical pain. When we talk about opioids, as everyone knows, the CDC, the Centers for Disease Control, have given basically a waiver for patients who have cancer or at the end of life with respect to the use of opioid medications; and there is this big group of cancer survivors who may also have post-surgical pain that is chronic in nature, so we need to be aware of them as well. But really, what we're focusing on in our talk this afternoon, our patients with chronic, non-cancer pain, these are people who have the usual aches and pains associated with aging, with disease states, and so forth.

Lee Tetreault:

What is the first step in treatment of CNCP? 

Dr. Galluzzi:  

So when we say CNCP we mean chronic non-cancer pain. And in essence the most important thing is to establish the diagnosis. You may not believe this, but a recent review showed that fewer than one-third of patients who received a prescription for an opioid medication had a documented pain diagnosis. What that means is that physicians are using the term pain as a diagnosis rather than trying to determine what the true pain generator is. Is the pain generator a disease state? Is the pain generator some altered sensory problem? Is it post-surgical? Etcetera. It's also important for a patient -when you're evaluating them-to be told that their pain is real. Many patients who have pain are looked upon as maybe drug seeking, and it's important for all providers to validate the pain, assure the patient that the pain is real and then to really go after figuring out what's causing the pain because there may be some conditions for which the pain can be relieved without having to use pain medications. An example of that would be a B-12 neuropathy or a poorly controlled case of diabetes mellitus, which may in fact have improvement in the neuropathic pain findings with good control of the disease.

Lee Tetreault:

So, what are the types of pain? 

Dr. Galluzzi:  

That's a really good question because, again, if we are going to treat pain, we have to know what it is that we're treating. Most people think of pain as acute pain or no susceptive pain, that is pain that's mediated through our nerve endings, our sensory fibers, the that go to the brain that react to a noxious injury, or an insult, or a disease. No susceptive pain is the pain of a heart attack, it's the pain that someone has if they're in a post-surgical situation. Then, on the other hand we have neuropathic pain, which is pain that actually results from destruction of neurons in either the peripheral or the central nervous system or both. Examples of neuropathic pain would be painful diabetic peripheral neuropathy or postherpetic neuralgia pain, the type of pain that people will have after an episode of shingles. Inflammatory pain is one of the areas that's really on the rise and that is due to the increasing rate of osteoarthritis as our population ages. And unfortunately as our population gets heavier, we can anticipate that we're going to be seeing more and more patients who have very serious inflammatory pain from osteoarthritis.

And then, of course, we have the disease of rheumatoid arthritis as well, which is a different animal. There's a new kid on the block that the IASP came up with and that is the pain that we used to not really be able to define, it was sort of called like 'other'. It's called nociplastic pain and that is pain that you may think of as either a fibromyalgia type of pain, or irritable bowel syndrome type of pain, that occurs in an individual in whom you really cannot identify the source of the pain. There wasn't a disease, there wasn't a surgery, there wasn't an injury. And there's evidence now that that may be related to small fiber neuropathy. You know I'm a Palliative Care Doc, so I can't go without saying that some patients may in fact have existential pain or spiritual pain; and then, of course, there is psychogenic pain. And guess what? These types of pain can all exist together, which can give us what we call mixed pain. So, lots of types of pain, very challenging.

Lee Tetreault:

What are the available alternative medical treatments and is there evidence for them? 

Dr. Galluzzi:  

If we're going to try to address pain in an appropriate fashion, we really need to seek alternatives to using opioids and many of these alternatives do not even have to be prescription medications at all. So yes, there is good evidence for some of the forms of complementary and alternative medicine modalities that we recommend as treatment for pain and it may be adjunctive treatment in the sense that the patient may also be getting a medication, but these can be implemented. Probably the one area that has been studied the most and has the best evidence is cognitive behavioral therapy in which an individual is able to approach the problem of pain and be able to learn coping skills and mechanisms whereby they're able to overcome the pain through their behaviors. Things like weight loss and exercise, I'm a big believer in motion is lotion. If people can remain active, that can be used adjunctively for treatment of pain. Acupuncture has good evidence for some patients in pain. And let's not forget massage. And, as you know, I'm an osteopathic physician, so we use our hands to treat pain all the time. That's what we do. We use osteopathic manipulative treatments for all types of pain, both acute and chronic, and I think these are things that everyone should be aware of and everyone should try to implement them in their patients as much as possible.

Lee Tetreault:

So what's new regarding acute pain treatment? 

Dr. Galluzzi:  

I really think this is an important question because there is now ample evidence that shows that if acute pain is not adequately treated it can go on to actually become chronic pain. So let's take chronic post-surgical pain. This would be an ideal model for us to talk about how we might impact the development of pain in a person who's having surgery because... Especially if it's an elective surgery we can plan for it. So one of the big things that's being done now in surgical centers is what we call pre-emptive analgesia, patients actually get medications prior to the surgery, during the surgery, and then targeted therapy after the surgery to try to blunt the pain response, cut down the pain, what a reflex arc if you will, and down-regulate the pain. And I think that treating acute pain is very important. Is there a role for opioids in treatment of acute pain? Yes, there is, but that role for opioid should be, again, in the acute phase at the lowest dose possible and maybe with other medications at the same time, so that it's easier to wean the patient off of the opioid quickly.

Lee Tetreault:

And lastly, Dr. Please give us a quick summary of the available medications for pain.

Dr. Galluzzi:  

Well, everyone knows about opioids and we all know that the CDC has tried to give us some guideline regarding their use. Things like morphine, hydromorphone, oxycodone, there's a number of them. These are to be used very cautiously and only in selected patients. For chronic non-cancer pain, if we can determine the source of the pain, then we should be treating it at its origin if we can. So, inflammatory pain clearly we wanna use anti-inflammatory medications like steroids may be very useful in inflammatory pain, especially in the short term as well as the COX-2 or the LOX-2, the non-steroidal anti-inflammatory medications.

We can also, for neuropathic pain, use different types of medication that mediate different receptors. The NMDA receptors have been shown to respond for neuropathic pain, we can use the alpha-2 Delta ligands, which some people refer to as the gabapentinoids, gabapentin and pregabalin; and other anti-epileptic agents have been shown to be very, very effective in treating forms of neuropathic pain. And in addition to that, you can also use serotonin reuptake inhibitor. So things like duloxetine or venlafaxine, which are serotonergic and also have some norepinergic activity are very, very useful for neuropathic pain. For no susceptive pain, again, non-steroidals, aspirin may be useful, acetaminophen can be useful. And then, in no susceptive pains we're looking at the anti-epileptic medications, the serotonergic medications and possibly other forms of topical medications. There is some new research that's looking at cannabinoids and low-dose cannabinoids that are used sometimes in combination have been shown to be useful, but the evidence for them is still lacking simply because unfortunately medical cannabis remains a schedule one substance in the United States.

So I think in the coming years we're gonna be seeing a lot more focus on using these types of medications and what I wanna say in conclusion is that maybe one thing isn't gonna work for everyone. Pain is complex, there can be more than one generator for the pain. And what is very important to think about is what we call multi-modal therapy, trying to use all of the things that we've talked, the complementary and alternative modalities, the non-opioid modalities, the lifestyle changes, perhaps cognitive behavioral therapy coupled with maybe other types of medications and there may be some novel substances coming down the line as well. So I think this is a fascinating area of medical practice as challenging as it is, I think it's one of the most rewarding things that we can do as doctors to try to help people manage their pain.

Lee Tetreault:

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

 

 

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