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9 Articles in Volume 13, Issue #9
Perioperative Pain Plan: Why is it Needed
A Case for Spinal Cord Stimulation Therapy—Don’t Delay
History of Pain: The Nature of Pain
Safe Usage of Analgesics in Patients with Chronic Liver Disease: A Review of the Literature
PROP Versus PROMPT: FDA Speaks
Editor's Memo: Long-Acting Opioids: More Than a Labeling Issue
Use of Long-term Muscle Relaxants
PAINWeek Highlights: Coping Skills, Insomnia, and Opioid Abuse Deterrence
Letters to The Editor

PAINWeek Highlights: Coping Skills, Insomnia, and Opioid Abuse Deterrence

PAINWeek was held at the beginning of September in Las Vegas, Nevada. Once again, thought leaders in the field of pain management came together to discuss multidisciplinary approached to pain care. To follow is a snapshot of some of the meeting highlights.

Coping Skills Key To Pain Management

Practical coping skills are often an overlooked element of pain management. Ideally, pain management incorporates areas of interventional therapies, medical management, and self-care skills. And “like a three-legged stool, all three are integral components—without one, the stool will tip over,” noted Ted W. Jones, PhD, CPE, Behavioral Medicine Institute, during his lecture at PAINWeek.

However, getting patients to see a pain psychologist—a key step in teaching them coping skills—presents challenges, including the stigma and inconvenience of making additional appointments outside of their monthly visits to their pain specialist. To address some of these barriers, Dr. Jones teamed up with his colleagues at the Pain Consultants of East Tennessee, Knoxville, to teach coping skills within the practice.

Through trial and error, Dr. Jones and his colleagues settled on a program that offers pain patients a single, 2-hour, group session. “These single sessions are billed as a treatment for their medical condition [CPT 96153, 8 units], and a single session is easier to sell and mandate to patients,” noted Dr. Jones. The sessions focus on teaching the five key pain coping skills:

  • Understanding includes providing educational information to the patients about how pain works (types of pain and an explanation of pain gates) as well as understanding specific treatment options. The difference between pain and suffering is also highlighted.
  • Acceptance uses cognitive behavioral concepts to help patients have realistic expectation about therapy and reduce catastrophizing, a key variable in outcomes. Dr. Jones noted that many pain patients blame themselves for being a burden to their families, etc. The “shoulds” are a real problem ... “I should be able to do xyz,” noted Dr. Jones. Helping patients move from a “why me” attitude to “what now” is key to successful outcomes. Gratitude and acceptance are really important elements in recovery.
  • Calming emphasizes the need to relax the body. Stress can amp up pain and by decreasing stress—through Tai Chi, meditation, relaxation techniques, and biofeedback—patients can help to reduce their pain. Proper breathing techniques is the number one skill patients can learn to help decrease stress. Dr. Jones demonstrated a simple 30-second breathing exercise, which helps patients “become belly breathers instead of shoulder breathers.”
  • Balancing focuses on teaching patients how to get into helpful routines. “The goal is to establish a lifestyle that works for the long run,” noted Dr. Jones, including changing from “sprinters to marathoners.” He emphasizes proper sleep hygiene, saying “no,” time management, and activity pacing. The latter strategy can help break the cycle of “crash and burn, where patient over-do it when they are feeling good, and then spend the next two days in bed. We emphasis being the tortoise, not the hare. Slow down, and have enough energy in the evenings to be there for your family.”
  • Coping helps patients ask “what kind of pain am I having?” and then teaching them ways to lessen the pain. This is particularly true for myofascial pain, which, when properly addressed by patients, can be lessened significantly. Dr. Jones also emphasizes distraction techniques to help patients get through a painful episode, including playing video games, doing crossword puzzles, and the like.

A single group session, also demonstrates to patients that “it’s not all about injections and pills,” he said. Plus, group therapy is cost-effective and convenient for patients and physicians. Patients also really benefit from being in a group together and seeing that they are not alone.

Lastly, “offering this class can transform a pain practice into a multidisciplinary pain program,” Dr. Jones concluded.

Insomnia Still Plagues Pain Patients

Insomnia is a common complaint among Americans, affecting 10% to 15% of the general population. But among chronic pain patients, insomnia is a double-edged sword—pain increases a patient’s risk of developing insomnia, and insomnia can worsen pain, according to Michael T. Smith, PhD, CBSM, Professor, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Aside from pain itself, sleep disturbances are one of the most common symptoms associated with chronic pain conditions. Insomnia is defined as sleep disturbances week for at least one month. Experimental and epidemiologic studies have demonstrated that far from being a simple consequence of pain, insomnia and sleep loss also may play a role in the transition from acute to chronic pain, induce hyperalgesia, and contribute to poor psychology and medical outcomes, noted Dr. Smith, who presented a number of cognitive behavior therapies that can be targeted for chronic pain patients.

The first line of treatment is to target the driving forces—stimulation control and sleep restriction. Dr. Smith emphasized that the bedroom only should be used for sleep and sex. “Many people use their bedrooms to eat, read, relax, and watch TV, but for patients with insomnia, one needs to re-establish the bedroom as a place just for sleep and sex.”

To help patient re-establish good sleep patterns, Dr. Smith first establishes a wake-up time for patients—this should be the same time every day, even on the weekends. Once this is established, then the bedtime can be pushed back later or earlier depending on the situation. Restricting sleep actually builds-up the “drive to sleep.” He noted, however, that initially patients may have more fragmented sleep, but gradually (over 2-4 weeks) patients will sleep for longer periods of time and wake up feeling more rested.

Dr. Smith also emphasized the use of good sleep hygiene practices, including aerobic exercise (4 times a week), having quiet time before bed (relaxation, meditation), and increasing internal body temperature. “Taking a hot bath before bed has a two-fold effect, it is a ritual way to wind-down and relax, as well as increase core body temperature, which helps produce slow-wave sleep,” noted Dr. Smith.

For patients whose circadian rhythms have been altered, he recommends the use of a light box, either in the morning or evening, depending on their condition. For example, for someone who is falling asleep too early, expose them to bright light three hours before bed. Night owls, on the other hand, should be exposed to bright light early in the morning. Dr. Smith cautioned about the use of illuminated e-readers, like iPad’s and other tablets, which can delay sleep (and annoy sleeping partners).

Opioid Abuse-Deterrent Technology

A number of posters at this year’s PAINWeek focused on new drug developments. A clear trend emerged—drug-deterrent technology. Lynn Webster, MD, co-founder and chief medical director of Lifetree Clinical Research, Salt Lake City, Utah, sat down with Practical Pain Management to discuss his work with one agent—MNK-785, which is being developed by Mallinckrodt Pharmaceuticals.

PPM: Why the need for yet another opioid medication?

Dr. Webster: The problems of potential misuse and abuse of opioid pain medications are a key focus for the Food and Drug Administration. In fact, in January of 2013, the FDA issued Guidance for Industry: Abuse-Deterrent Opioids—Evaluation and Labeling. Clearly the FDA and the public want to have access to pain medications, but want to insure that these medications are not easy to abuse or misuse.

The Human Abuse Liability [HAL] study that we conducted compares abuse-related characteristics of MNK-795, an extended-release, oral formulation of oxycodone and acetaminophen, with those of Percocet, which is a commonly prescribed immediate-release oxycodone/acetaminophen formulation. In the study, intact and crushed tablets of MNK-795 had statistically significant lower measure of drug liking, drug high, and good drug effects compared to Percocet [P>0.001].

PPM: Why are these results important for pain management?

Dr. Webster: These results are significant because oxycodone and acetaminophen combinations are widely used for managing acute pain, but are commonly abused. There is a real need for improved formulations that provide pain control without producing the euphoric effect that addicts seek. These studies are an important tool for the FDA to assess the relative abuse potential of a new drug. MNK-795 is the first oxycodone-acetaminophen combination to show less drug-liking, drug high, and good drug effects compared to Percocet. The most common adverse events associated with MNK-795 included nausea, vomiting, and pruritus.

New Oral Medication Aimed at OIC

In April, the FDA approved lubiprostone (Amitiza) for the treatment of opioid-induced constipation (OIC) in patients with chronic non-cancer pain. Lupiprostone, an oral medication, joined methylnatrexone bromide (Relistor) as agents specifically approved for OIC. This is the third indication for Amitiza, which is also approved for the treatment of chronic idiopathic constipation and irritable bowel syndrome with constipation (IBS-C) in adult women.

The FDA based their approval on phase 3 clinical trials that found lubiprostone improved spontaneous bowel movements (SBM) and opioid-induced constipation (OIC) in patients with chronic non-cancer pain. M. Mazen Jamal, MD and colleagues from the University of California, Irvine, presented the results of one of the randomized controlled studies at PAINWeek. In the study, 431 patients were randomly assigned to receive lubiprostone or placebo. More than one-quarter of libiprostone-treated patients (27.1%) were SBM responders compared with 19% of controls. The median time to first bowel movement was also significantly shorter in the treatment group compared to controls (23.5 h vs 37.7 h). According to the researchers, lubiprostone was also associated with less straining, better stool consistency, and improved constipation severity scores versus controls. The most common adverse events included diarrhea (11.3%), nausea (9.9%), and abdominal pain (7.1%).1

The phase 3 trail was supported by a research grant from Sucampo Pharmaceuticals.

Support of Alkaline-Rich Diet

Researchers presented further evidence that diet may affect pain. Supplementing the diet with alkaline-rich foods in pain patients may reduce the metabolic acid load and increase magnesium and Vitamin D levels, resulting in an improvement in pain symptoms, hypothesized a team of investigators from Cardinal Pain Center and Clinical Research Institute, Methodist Medical Center, Dallas.

According to Vijay Arvind, MD, lead investigator, chronic latent metabolic acidosis is thought to worsen pain symptoms by lowering the intracellular levels of magnesium. Intracellular magnesium is crucial for proper metabolism of Vitamin D. Deficits in Vitamin D have been shown to worsen pain. Therefore, an alkaline diet would optimize the function of enzyme systems and Vitamin D function by increasing intracellular magnesium levels.

To study their hypothesis, the team enrolled 20 patients with chronic pain lasting >6 months who were being treated with opioid medications. Their average pain score was 5 out of 10 on the visual analog scale (VAS). During the 8-week study, patients were instructed to include at least 5 servings of alkaline-rich food per day, including fruits, vegetables, fruit juices, and potatoes. The patients also kept a detailed log of their food intake, pain score, and number of pain pills used each day.2

Incorporation of an alkaline-rich diet reduced VAS pain scores and opioid pill intake by 10% in the 11 patients who completed the 8-week study. A 5% improvement in mean duration of sleep was also reported. Because this was such a small study, Dr. Arvind emphasized that further studies needed to be done to demonstrate any benefits of an alkaline diet on chronic pain, muscle mass, and Vitamin D metabolism.

Last updated on: October 28, 2013
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