Chronic Pain
C U R R E N T 9 C L I N I C A L 9 P R A C T I C E
Chronic Pain: A Primary Care Guide to Practical Management, DAWN A. MARCUS, 2005
Type 2 Diabetes, Pre-Diabetes, and the Metabolic Syndrome:
The Primary Care Guide to Diagnosis and Management, RONALD A. CODARIO, 2005
Bone Densitometry in Clinical Practice: Application and Interpretation, Second Edition, SYDNEY LOU BONNICK, 2004 Cancer Screening: A Practical Guide for Physicians, edited
by KHALID AZIZ AND GEORGE Y. WU, 2001
Hypertension Medicine, edited by MICHAEL A. WEBER, 2001 Allergic Diseases: Diagnosis and Treatment, 2nd Edition, edited
by PHIL LIEBERMAN AND JOHN A. ANDERSON, 2000
Parkinson’s Disease and Movement Disorders: Diagnosis and Treatment Guidelines for the Practicing Physician, edited by CHARLES H. ADLER AND J. ERIC AHLSKOG, 2000 Bone Densitometry in Clinical Practice: Application
and Interpretation, SYDNEY LOU BONNICK, 1998
Sleep Disorders: Diagnosis and Treatment, edited by J. STEVEN
POCETA AND MERRILL M. MITLER, 1998
Diseases of the Liver and Bile Ducts: A Practical Guide to Diagnosis and Treatment, edited by GEORGE Y. WU AND JONATHAN ISRAEL, 1998
The Pain Management Handbook: A Concise Guide to Diagnosis and Treatment, edited by M. ERIC GERSHWIN AND MAURICE E.
HAMILTON, 1998
Osteoporosis: Diagnostic and Therapeutic Principles, edited by CLIFFORD J. ROSEN, 1996
NEIL S. SKOLNIK,MD SERIES EDITOR
Chronic Pain
A Primary Care Guide to Practical Management
Dawn A. Marcus, MD
Pain Institute, University of Pittsburgh Pittsburgh, PA
© 2005 Humana Press Inc.
999 Riverview Drive, Suite 208 Totowa, New Jersey 07512 humanapress.com
All rights reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise without written permission from the Publisher.
All papers, comments, opinions, conclusions, or recommendations are those of the author(s), and do not necessarily reflect the views of the publisher.
Due diligence has been taken by the publishers, editors, and authors of this book to assure the accuracy of the information published and to describe generally accepted practices. The contributors herein have carefully checked to ensure that the drug selections and dosages set forth in this text are accurate and in accord with the standards accepted at the time of publication. Notwithstanding, as new research, changes in government regulations, and knowledge from clinical experience relating to drug therapy and drug reactions constantly occurs, the reader is advised to check the product information provided by the manu- facturer of each drug for any change in dosages or for additional warnings and contraindications. This is of utmost importance when the recommended drug herein is a new or infrequently used drug. It is the responsibility of the treating physician to determine dosages and treatment strategies for individual pa- tients. Further it is the responsibility of the health care provider to ascertain the Food and Drug Administration status of each drug or device used in their clinical practice. The publisher, editors, and authors are not responsible for errors or omissions or for any consequences from the application of the information presented in this book and make no warranty, express or implied, with respect to the contents in this publication.
This publication is printed on acid-free paper. '
ANSI Z39.48-1984 (American Standards Institute) Permanence of Paper for Printed Library Materials.
Production Editor: Robin B. Weisberg Cover design by Patricia F. Cleary
For additional copies, pricing for bulk purchases, and/or information about other Humana titles, contact Humana at the above address or at any of the following numbers: Tel.: 973-256-1699; Fax: 973-256-8314;
E-mail: humana@humanapr.com, or visit our Website: http://humanapress.com Photocopy Authorization Policy:
Photocopy Authorization Policy: Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients is granted by Humana Press, provided that the base fee of US $25.00 per copy is paid directly to the Copyright Clearance Center (CCC), 222 Rosewood Dr., Danvers MA 01923.
For those organizations that have been granted a photocopy license from the CCC, a separate system of payment has been arranged and is acceptable to the Humana Press. The fee code for users of the Transactional Reporting Service is 1-58829-501-X/05 $25.00.
Printed in the United States of America. 10 9 8 7 6 5 4 3 2 1 eISBN 1-59259-882-X
Library of Congress Cataloging-in-Publication Data Marcus, Dawn A.
Chronic pain : a primary care guide to practical management / Dawn A. Marcus.
p. ; cm. -- (Current clinical practice) Includes bibliographical references and index.
ISBN 1-58829-501-X (alk. paper)
1. Chronic pain. 2. Headache. 3. Analgesia. I. Title. II.
Series.
[DNLM: 1. Chronic Disease. 2. Pain--therapy. 3. Headache --therapy. 4. Pain--psychology. 5. Primary Health Care--methods.
WL 704 M322c 2005]
RB127.M3855 2005 616'.0472--dc22
2004010140
v
Series Editor’s Introduction
“They are and suffer, that is all they do”
—W. H. Auden1 “Although the world is full of suffering,
it is also full of overcoming it.”
—Helen Keller2
When patients come to us with their pain they present us with a marvelous opportunity—the chance to understand them, to understand how their pain is affecting their lives, the challenge of discovering what is causing their pain, and finally the opportunity to prescribe medications and lifestyle changes to help them gain relief from their pain. Chronic Pain: A Primary Care Guide to Practical Management is an important book, offering concrete evidence-based approaches to diagnose and treat myriad causes of chronic pain that we as primary care physicians see in our office every day. It is an ambitious book, covering this large topic in only slightly more than 300 pages. In doing so, the author understands that for this book to be useful to primary care physicians, who are busy and have little time to concern themselves with unnecessary information, it must be practical, clear, evidence-based, and succinct.
Chronic Pain: A Primary Care Guide to Practical Management approaches the discussion of pain management as primary care clinicians approach their patients, first trying to determine—with as much clarity as possible—the etiology of a patient’s pain; then discussing the specific treatments and general treatments of the condition that has been diagnosed as well as the pain it causes. All this occurs against a backdrop of general issues relevant to all pain management. Most of the common conditions that lead patients to come into our offices with a pain as their chief complaint are covered. The book presents clear recommendations for treatment and supports those recommendations with useful references. Chronic Pain: A Primary Care
1From Auden, W. H. "Surgical Ward." The Selected Poetry of W. H. Auden. Vintage, New York, NY, 1971.
2From http://www.quotationspage.com/quotes.php3?author=Helen+Keller>http://quota- tions page.com/quotes.php3?author=Helen+Keller. Accessed 9/7/04. Quoted also on <http://
www.brainyquote. com/quotes/authors/h/helen_keller.html>http://www.brainyquote.com/
quotes/authors/h/helen_keller.html accessed 9/7/04 .
vi Series Editor’s Introduction
Guide to Practical Management is also filled with excellent easy-to-understand figures, tables, and algorithms.
The Current Clinical Practice Series, conceived by a number of editors at Humana Press, has as its mission to create high-quality, evidence-based books for primary care clinicians, with an emphasis on relevance, and providing practical approaches to common problems. The books in the Current Clinical Practice Series can be used to gain an updated understand- ing of common problems and/or can be placed on office shelves and in PDAs to serve as important references when questions come up during the course of patient care. Chronic Pain: A Primary Care Guide to Practical Management fulfills the mission of this series—it is practical, useful, and relevant. There is no higher compliment for any book of medicine.
Neil Skolnik, MD Professor of Family and Community Medicine Temple University School of Medicine Associate Director Family Practice Residency Program Abington Memorial Hospital
Preface
vii
Thoughts of the busy clinician who picks up the chart for a new visit for a patient with a chief complaint of chronic pain:
I’m already running behind today. Hope the next patient has a straightforward problem. ...Chronic low back pain, failed surgery, out of work for the last 6 months, requesting signature on a disability form, refill of pain medications, and a sleeping pill, refuses to see a psychologist because “it’s real pain.”
How will I ever handle this assessment during a short office visit?
These thoughts have been repeated in some form by most clinicians, easily overwhelmed with the typically complex stories of patients with chronic pain. When confronted with pain patients, it is important to remember that there are three common but false myths about chronic pain:
1. Patients with chronic pain are easy to manage.
2. Chronic pain is easily relieved with just a pill.
3. As pain improves, associated problems (e.g., depression, disability, relation- ship issues) will spontaneously resolve.
Patients with chronic pain present a unique set of challenges to the primary care physician, who must first recognize and accept the difficult and complex constellation of problems often encountered by these patients.
The clinical management of chronic pain is frequently requested by patients seeing primary care physicians, although most medical schools provide little background for dealing with these often complex patients.
Patients with chronic pain often report a variety of complaints, including pain, sleep abnormalities, mood disturbance, and interference with personal, social, and work relationships. Lack of easily identified pathology in patients who report disabling symptoms may result in conflicts between patients and their treating clinicians. In addition, managing chronic pain generally requires assessment and treatment of pain, associated symptoms, and disability.
Developing pain management skills requires listening to patients’ stories, becoming invested in their lives, and following the results of prescribed therapy over ensuing months and years. The information and recommendations provided in this book are the result of many instructive hours of listening to patients describe their own pain experiences, both the nociceptive symp-
toms and the profound impact that their pain had upon many aspects of their lives. I will always be profoundly grateful to those many patients who trusted and shared their lives with me and truly educated me to become a pain doctor.
Dawn A. Marcus, MD
viii Preface
Contents
Series Editor’s Introduction ... v
Preface ... vii
Continuing Medical Education ... xi
Value-Added eBook/PDA ... xiii
Part I. Introduction 1 Chronic Pain and Headache ...3
2 Summary of Pain Management Issues: Frequent Concerns in Treating Chronic Pain Patients ... 11
Part II. Pathogenesis 3 Pathogenesis of Chronic Pain ... 17
Part III. Common Chronic Pain Conditions 4 Headache ... 33
5 Cervical and Lumbar Pain ... 55
6 Abdominal Pain ... 75
7 Arthritis ... 91
8 Neuropathic Pain ... 111
9 Myofascial Pain ... 131
10 Fibromyalgia ... 147
Part IV. Special Groups 11 Pediatric Pain ... 167
12 Pregnancy and Pain ... 185
13 Geriatrics and Chronic Pain ... 201
14 Gender and Ethnic Issues in Chronic Pain ... 219
ix
Part V. Comorbid Conditions
15 Psychological Comorbidity ... 237
16 Obesity and Chronic Pain ... 253
Part VI. Opioids 17 Opioids in Chronic Pain ... 269
Appendices Patient Educational Materials ... 289
Appendix A. Rationale Behind Pain Management ... 293
Appendix B. Exercise and Pain Management ... 297
Appendix C. Psychological Pain Management ... 303
Appendix D. Pain Medications ... 305
Appendix E. Chronic Headache ... 307
Index ... 321
x Contents
xi
Continuing Medical Education
RELEASE DATE December 1, 2004
EXPIRATION DATE December 1, 2007
ESTIMATED TIME TO COMPLETE 5 hours
ACCREDITATION
This activity has been planned and implemented in accordance with the essential areas and poli- cies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of The American Society of Contemporary Medicine and Surgery and Humana Press/eXtensia. The American Society of Contemporary Medicine and Surgery is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical edu- cation for physicians.
CREDIT DESIGNATION
The American Society of Contemporary Medicine and Surgery designates this educational activity for a maximum of 5 category 1 credits toward the AMA Physician’s Recognition Award. Each physician should claim only those credits that he/she actually spent in the activity.
METHOD OF PARTICIPATION AND FEE
The American Society of Contemporary Medicine and Surgery is pleased to award category 1 credit(s) toward the AMA Physician’s Recognition Award for this activity. By reading the chap- ters and completing the CME questions, you are eligible for up to 5 category 1 credits toward the AMA/PRA. Following that, please complete the Answer Sheet and claim the credits. A minimum of 75% correct must be obtained for credit to be awarded. Finally, please complete the Activity Evaluation on the other side of the Answer Sheet. Please submit the Answer Sheet/Activity Evaluation according to the information printed on the top of that page. Your test will be scored within 4 weeks. There is no fee for this activity. You will then be notified of your score with a certificate of credit, or you will receive an additional chance to pass the posttest. Credit for the activity is available until December 1, 2007.
xii Continuing Medical Education
FACULTY AND DISCLOSURE
Faculty for CME activities are expected to disclose to the activity audience any real or apparent conflict(s) of interest related to the content of the material they present. The following relationships have been disclosed:
Dawn A. Marcus, MD
Research Support Eisai, Pfizer
PROVIDER DISCLOSURE
The American Society of Contemporary Medicine and Surgery is an independent organization that does not endorse specific products of any pharmaceutical concern and therefore has nothing to disclose. Humana Press/eXtensia are independent organizations that do not endorse specific products of any pharmaceutical concern and therefore have nothing to disclose.
INTENDED AUDIENCE
This activity is intended for internal medicine and family physicians, obstetrician/
gynecologists, psychiatrists, geriatricians, rheumatologists, physician assistants, and nurse practitioners.
OVERALL GOAL
The overall goal of this activity is to update the knowledge of clinicians on strategies and techniques needed to comprehensively manage patients with chronic pain.
LEARNING OBJECTIVES
After completing this CME activity, participants should have improved their overall knowledge and attitudes in regard to managing chronic pain. Specifically, attendees should be able to:
• Understand the pathogenesis of chronic pain.
• Discuss the prevalence and predictive factors for a variety of chronic pain conditions, as well as how those conditions change when occurring in different age categories or unique medical conditions, such as pregnancy.
• Describe assessment strategies for patients with a variety of common chronic pain condi- tions.
• Differentiate state-of-the-art treatment techniques for a variety of chronically painful conditions, including both medication and non-medication therapies.
• Assess controversies surrounding use of opioids in chronic pain patients and develop practical strategies for considering supplemental opioids in individual patients.
UNLABELED/ UNAPPROVED USE DISCLOSURE
In accordance with ACCME standards for Commercial Support, the audience is advised that this CME activity may contain references to unlabeled or unapproved uses of drugs or devices.
Value-Added eBook/PDA
This book is accompanied by a value-added CD-ROM that contains an Adobe eBook version of the volume you have just purchased. This eBook can be viewed on your computer, and you can synchronize it to your PDA for viewing on your handheld device. The eBook enables you to view this volume on only one computer and PDA. Once the eBook is installed on your computer, you cannot download, install, or e-mail it to another computer; it resides solely with the computer to which it is installed. The license provided is for only one computer. The eBook can only be read using Adobe®Reader®6.0 software, which is available free from Adobe Systems Incorporated at www.Adobe.com. You may also view the eBook on your PDA using the Adobe® PDA Reader®software that is also available free from Adobe.com.
You must follow a simple procedure when you install the eBook/PDA that will require you to connect to the Humana Press website in order to receive your li- cense. Please read and follow the instructions below:
1. Download and install Adobe® Reader® 6.0 software
You can obtain a free copy of Adobe® Reader® 6.0 software at www.adobe.com
*Note: If you already have Adobe® Reader® 6.0 software, you do not need to reinstall it.
2. Launch Adobe® Reader® 6.0 software
3. Install eBook: Insert your eBook CD into your CD-ROM drive PC: Click on the “Start” button, then click on “Run”
At the prompt, type “d:\ebookinstall.pdf” and click “OK”
*Note: If your CD-ROM drive letter is something other than d: change the above com- mand accordingly.
MAC: Double click on the “eBook CD” that you will see mounted on your desktop.
Double click “ebookinstall.pdf”
4. Adobe® Reader® 6.0 software will open and you will receive the message
“This document is protected by Adobe DRM” Click “OK”
*Note: If you have not already activated Adobe®Reader®6.0 software, you will be prompted to do so. Simply follow the directions to activate and continue installation.
Your web browser will open and you will be taken to the Humana Press eBook registration page. Follow the instructions on that page to complete installation.
You will need the serial number located on the sticker sealing the envelope con- taining the CD-ROM.
If you require assistance during the installation, or you would like more infor- mation regarding your eBook and PDA installation, please refer to the eBookManual.pdf located on your CD. If you need further assistance, contact Humana Press eBook Support by e-mail at ebooksupport@humanapr.com or by phone at 973-256-1699.
*Adobe and Reader are either registered trademarks or trademarks of Adobe Systems Incor- porated in the United States and/or other countries.
xiii
