ACPA Resource Guide 2018 Edition - The American Chronic ...

ACPA Resource Guide

To

Chronic Pain Management

An Integrated Guide to Medical, Interventional, Behavioral, Pharmacologic and Rehabilitation Therapies

2018 Edition

American Chronic Pain Association

P.O. Box 850 Rocklin, CA 95677 Tel 800-533-3231 Fax 916-652-8190 E-mail ACPA@ Web Site

Copyright 2018 American Chronic Pain Association, Inc. All rights reserved. No portion of this book may be reproduced without permission of the American Chronic Pain

Association, Inc.

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Table of Contents

INTRODUCTION .............................................................................................................................................................6 OVERVIEW OF CHRONIC PAIN TREATMENT................................................................................................................8

PAIN TYPES, SOURCES & CLASSIFICATION.................................................................................................................9 PAIN IN SPECIAL POPULATIONS ...................................................................................................................................10 MAJOR TYPES OF INTERVENTIONS FOR PAIN............................................................................................................13 FUNCTIONAL RESTORATION APPROACHES & PROGRAMS ........................................................................................13 SELF-DIRECTED INTERVENTIONS .............................................................................................................................15

Self-Care, Self-Management, Self-Development ................................................................................................15 ACPA Groups......................................................................................................................................................15 Classes in Chronic Pain & Chronic Disease Self-Management...........................................................................16 ACTIVE INTERVENTIONS ? DELIVERED BY PROFESSIONALS .....................................................................................17 Information Therapy: Reconditioning the Brain.................................................................................................17 Reconditioning the Body: Exercise and Body Awareness.................................................................................18 Pilates ..................................................................................................................................................................19 Yoga ....................................................................................................................................................................19 Tai Chi .................................................................................................................................................................21 Qigong .................................................................................................................................................................21 Feldenkrais........................................................................................................................................................... 22 Postural Re-Training............................................................................................................................................22 Alexander Technique...........................................................................................................................................22 Graded Motor Imagery ........................................................................................................................................23 Virtual Reality .....................................................................................................................................................23 Functional Activity Training ...............................................................................................................................24 Personal Goal Attainment Program .....................................................................................................................24 PSYCHOLOGICAL & BEHAVIORAL APPROACHES ......................................................................................................25 COMPLEMENTARY, ALTERNATIVE & INTEGRATIVEMEDICINE (CAM)..................................................................34 PHYSICAL MODALITIES ? NONINVASIVE INTERVENTIONS .......................................................................................37 Heat & Cold.........................................................................................................................................................37 Therapeutic Massage ...........................................................................................................................................37 Ultrasound ...........................................................................................................................................................38 Iontophoresis .......................................................................................................................................................38 Paraffin (wax) ......................................................................................................................................................39 Infrared Light Therapy ........................................................................................................................................39 Spinal Traction & Spinal Decompression............................................................................................................39 Taping .................................................................................................................................................................. 39 Manipulation & Mobilization ..............................................................................................................................40 Electrical Stimulation Devices (external) ............................................................................................................41 Dry Needling .......................................................................................................................................................42 Trigger Point Injections .......................................................................................................................................42 Intra-Articular Steroid Injections .........................................................................................................................42 Viscosupplementation .......................................................................................................................................... 43 Implantable Devices: Spinal Cord Stimulation & Implantable Drug Delivery System .......................................44 Epidurals, Nerve & Facet Blocks & Radiofrequency Ablation (Rhizotomy) ......................................................49 MEDICATIONS IN GENERAL .......................................................................................................................................51 HOW MEDICATIONS FOR PAIN CAN HELP & HARM..................................................................................................51 IF MEDICATIONS ARE NOT RELIEVING PAIN.............................................................................................................54 BIOSIMILAR AND INTERCHANGEABLE MEDICATIONS ...............................................................................................56 MEDICATION IDENTIFICATION..................................................................................................................................57

American Chronic Pain Association Copyright 2018

3 MEDICATION SIDE EFFECTS, DRUG ALLERGIES & DRUG INTERACTIONS .................................................................58 OFF-LABEL MEDICATION USE..................................................................................................................................60 CLINICAL TRIALS .....................................................................................................................................................61 MEDICATION ASSISTANCE PROGRAMS .....................................................................................................................61 MEDICATION TYPES FOR THE TREATMENT OF PAIN.................................................................................................62 NON-OPIOID PAIN RELIEVERS ...................................................................................................................................63 GASTROINTESTINAL (GI) PROTECTIVE MEDICATIONS..............................................................................................71 OPIOID PAIN RELIEVERS AND THEIR SAFE USE ........................................................................................................73 THE OPIOID DILEMMA..............................................................................................................................................73 GENERAL OPIOID ADVERSE RISKS & SIDE EFFECTS.................................................................................................75 DEFINITION OF TERMS REGARDING OPIOIDS ............................................................................................................79 WHAT ARE OPIOIDS? ................................................................................................................................................84 OPIOID DELIVERY ....................................................................................................................................................86 OPIOID DOSING ........................................................................................................................................................86 OPIOID WEANING/TAPERING....................................................................................................................................86 CLINICAL GUIDELINES FOR THE USE OF OPIOIDS IN NON-CANCER CHRONIC PAIN ..................................................95 KEY STEPS TO USE OPIOIDS SAFELY........................................................................................................................95 OPIOIDS & THE GOALS OF PAIN MANAGEMENT .......................................................................................................96 MONITORING OPIOID MEDICATION USE...................................................................................................................97 URINE DRUG TESTING (UDT) / URINE DRUGSCREENING (UDS).............................................................................99 HERBAL MEDICINES, SUPPLEMENTS, & VITAMINS.................................................................................................101 MEDICAL FOODS.....................................................................................................................................................104 NOT RECOMMENDED FOR CHRONIC PAIN...............................................................................................................106 OTHER MEDICATIONS THAT CAN RELIEVE PAIN ....................................................................................................108 ANTIDEPRESSANTS .................................................................................................................................................108 ANTIEPILEPTIC (ANTICONVULSANT) DRUGS ..........................................................................................................116 SODIUM CHANNEL BLOCKING & ORAL ANTI-ARRHYTHMIC AGENTS ....................................................................118 TOPICAL PAIN RELIEVERS ......................................................................................................................................119 COMPOUNDED MEDICATIONS.................................................................................................................................123 MEDICATIONS & SLEEP HYGIENE...........................................................................................................................124

Hypnotics for Insomnia (sometimes called sedatives).......................................................................................126 Sedating Antidepressants...................................................................................................................................127 Sedating Antipsychotics ....................................................................................................................................128 Non-Medication Treatment of Insomnia............................................................................................................128 MUSCLE RELAXANTS .............................................................................................................................................130 BOTULINUM TOXINS...............................................................................................................................................131 NMDA INHIBITORS (INCLUDING KETAMINE) .........................................................................................................132 LOW-DOSE NALTREXONE (LDN)...........................................................................................................................133 ANTIHYPERTENSIVE & ADRENERGIC DRUGS, BISPHOSPHONATES, THALIDOMIDE, & CALCITONIN ........................133 CENTRAL NERVOUS SYSTEM (CNS) STIMULANTS .................................................................................................135 MIGRAINE HEADACHE TREATMENT .......................................................................................................................136 ALCOHOL & CHRONIC PAIN ...................................................................................................................................141 THE EFFECTS OF CIGARETTE SMOKING ON PAIN ....................................................................................................143 MARIJUANA ............................................................................................................................................................ 144 Illegal Drugs ..........................................................................................................................................................147 INTERNET PAIN-MANAGEMENT RESOURCES ...........................................................................................................147 FINAL COMMENTS ....................................................................................................................................................148

American Chronic Pain Association Copyright 2018

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Contributors & Reviewers

Written, reviewed & updated yearly by Senior Author & Editor Steven Feinberg, MD, MPH with special thanks to the following Contributors and Reviewers. Steven Feinberg, MD, MPH, is a practicing pain medicine physician in Palo Alto, California, and is an Adjunct Clinical Professor at Stanford University School of Medicine. Vladimir Bokarius, MD, PhD, LAc, is Board Certified in Psychiatry and Pain Medicine. He is the Medical and Research Director of Comprehensive Care Consultants and Medical Director of Center for Occupational Health. Jennifer Christian, MD, MPH is Board Certified in Occupational Medicine. In her clinical practice, she cares for working age patients with persistent distressing and disabling symptoms despite prolonged medical or surgical treatment. She is also President of Webility Corporation which serves as a catalyst for positive change in workers' compensation and disability benefits systems. Beth Darnall, PhD, is Clinical Professor in the Division of Pain Medicine at Stanford University and principal investigator for multiple nationally funded scientific pain treatment research studies. Rachel Feinberg, DPT, PT, is Chief Physical Therapist and Director of the Feinberg Medical Group Functional Restoration Program in Palo Alto, California. Cheryl Hayes, PharmD, MBA, MJ, BCPS is a clinical pharmacist with HealtheSystems. Joseph Hayes, MD, MPH, PRIUM Medical Director. Donna Kalauokalani, MD, MPH, is Board Certified in Anesthesiology and Pain Management. She serves as Medical Director for Folsom Pain Management, and Mercy San Juan Hospital Pain Management Services. She is currently President of the American Chronic Pain Association. Regina Mears, BPharm, MS, clinical pharmacist and pharmacy informatics for HealtheSystems. Mark Pew, Senior Vice President, PRIUM. Mel Pohl, MD, FASAM, is a Board-Certified Family Practitioner. He is the Chief Medical Officer of Las Vegas Recovery Center (LVRC).

Special thanks to Yvonne Selden for her editing assistance.

American Chronic Pain Association Copyright 2018

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A STATEMENT FROM THE ACPA BOARD OF DIRECTORS

Since 1980, the American Chronic Pain Association (ACPA), a non-profit, tax exempt organization, has offered a support system for people with chronic pain through education in pain management skills and self-help group activities. To learn more about the ACPA and how to become a member, please visit our web site at or call the National Office at 800-533-3231. The American Chronic Pain Association (ACPA) advocates a multi-modal strategy for addressing chronic pain. The ACPA focuses on pain management skills and self-help strategies that individuals can use in conjunction with modalities discussed with and approved by their health care professionals. The ACPA considers the use of medication and other treatments to be a matter for individuals to determine in conjunction with their health care professionals. The ACPA takes no position on medical treatment choices. Thus, information the ACPA provides in this resource guide about medical care is educational and informative only. The ACPA Resource Guide to Chronic Pain Management combines practical clinical experience and the most recent scientific information presented in an easy to read format for consumers and professionals. Input comes from many sources, including from individuals, from industry sources, some of which support the ACPA with grants. Dr. Feinberg, Senior Author and Editor, receives no funds from industry. As lead author, Dr. Feinberg receives input from many sources but takes full responsibility for the content of this Guide. Dr. Feinberg and the ACPA welcome input regarding any recommended changes, additions or deletions.

American Chronic Pain Association Copyright 2018

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