Case Studies in Chronic Pain Case Formulation Pain Types by ...

Case Studies in Chronic Pain‐‐
Objectives
Case Studies in Chronic Pain
Miles Belgrade, MD
Fairview Pain Management Center
• Carry out a physiologic pain assessment that informs
treatment
• Distinguish chronic pain from acute pain and recognize the
dangers in confusing them
• Flare recognition and management
• Opioid management vignettes and the DIRE Score
• Understand the need for a biopsychosocial approach to
chronic pain syndrome
Case Formulation
Pain Types by Physiology
• Name the type of pain
• Identify the acuity:
– Acute
– Chronic
– Recurrent
– Terminal
• Identify contributing factors and barriers
• Assess disease burden
• What treatments are indicated
• Are interventional approaches warranted
• Is this patient a candidate for long‐term opioids
Neuropathic
Inflammation
Mechanical
Bone
Psychogenic
Muscular
Acute, Chronic, Recurrent, Terminal Pain
• Acute Pain is pain that has a beginning, a middle
and a predictable end
• Chronic Pain is pain that persists beyond
expectation and exists independent of the
original cause
• Recurrent Pain is pain that re‐occurs in
stereotyped acute episodes over a long period of
time
• Terminal Pain is pain at the end of life that is
related to the terminal illness
Identify Contributing Factors and Barriers
• Contributing factors amplify or perpetuate pain but are
not the original cause
– Posture
– Stress
– Occupational factors
• Barriers are factors that prevent making a complete
pain assessment or rendering optimal treatment
– Insurance non‐coverage
– Low motivation
– Language barrier
– Transportation/limited resources
– Chemical dependency

Assess Disease Burden
D.I.R.E. Score: Patient Selection for Chronic Opioid Analgesia
For each factor, rate the patient’s score from 1-3 based on the
explanations in the right hand column
core Factor Explanation
1 = Benign chronic condition with minimal objective findings or no definite
Diagnosis
medical diagnosis. Examples: fibromyalgia, migraine headaches, nonspecific
back pain.
2 = Slowly progressive condition concordant with moderate pain, or fixed
condition with moderate objective findings. Examples: failed back surgery
syndrome, back pain with moderate degenerative changes, neuropathic pain.
3 = Advanced condition concordant with severe pain with objective findings.
Examples: severe ischemic vascular disease, advanced neuropathy, severe
spinal stenosis.
1 = Few therapies have been tried and the patient takes a passive role in
Intractability
his/her pain management process.
2 = Most customary treatments have been tried but the patient is not fully
engaged in the pain management process, or barriers prevent (insurance,
transportation, medical illness).
3 = Patient fully engaged in a spectrum of appropriate treatments but with
inadequate response.
Risk
(R= Total of P+C+R+S below)
Psychological: 1 = Serious personality dysfunction or mental illness interfering with care.
Example: personality disorder, severe affective disorder, significant
personality issues.
2 = Personality or mental health interferes moderately. Example: depression
or anxiety disorder.
3 = Good communication with clinic. No significant personality dysfunction or
mental illness.
Chemical Health: 1 = Active or very recent use of illicit drugs, excessive alcohol, or prescription
drug abuse.
2 = Chemical coper (uses medications to cope with stress) or history of CD in
remission.
3 = No CD history. Not drug-focused or chemically reliant.
Reliability:
1 = History of numerous problems: medication misuse, missed appointments,
rarely follows through.
2 = Occasional difficulties with compliance, but generally reliable.
3 = Highly reliable patient with meds, appointments & treatment.
Social Support: 1 = Life in chaos. Little family support and few close relationships. Loss of
most normal life roles.
2 = Reduction in some relationships and life roles.
3 = Supportive family/close relationships. Involved in work or school and no
social isolation.
1 = Poor function or minimal pain relief despite moderate to high doses.
Efficacy score
2 = Moderate benefit with function improved in a number of ways (or
insufficient info- hasn’t tried opioid yet or very low doses or too short of a
trial).
3 = Good improvement in pain and function and quality of life with stable
doses over time.
_____Total score = D + I + R + E
Score 7-13: Not a suitable candidate for long-term opioid analgesia
Score 14-21: Good candidate for long-term opioid analgesia
Case Vignettes
• A pt has burning pain down the posterior leg to the calf after
lumbar surgery. How would you classify it
• A 71 yr old man is admitted to hospital with a CVA. He has a
long hx of chronic low back pain and DDD. How do you treat
the low back pain in the hospital
• A pt calls you on the phone because their chronic neck pain
has been worse after he helped his sister move. He has been
on SR morphine for over a year at the same dose, and is
asking for a boost in the dose. What is your response
• A chronic pain patient has lost 2 Rxs. Name two actions you
can take besides stopping the opioids
Case Vignettes
• Neck pain is aching 2 years after a rear‐end collision.
It hurts with flexion of the neck. Pressure over the
trapezius causes referred pain into the occipital area.
What is the physiological type of pain
• The above patient has a newborn. Pain is worse
when she carries the infant. What do you call that
component of the pain
• True or False: It is reasonable to try to get the chronic
pain patient to a pain level that is < 4/10
Case vignette
Verne
• Three years after a car accident, a patient is still not
able to return to work due to pain. She has been
through chiropractic, medication, exercise. She is
getting depressed and feels like her life is taken from
her. What is most likely to help restore her
functioning
– A. Neurontin
– B. A chronic pain management program
– C. A long‐acting opioid
– D. Acupuncture

Verne (cont.)
• 77‐year‐old man with PD and type 2 DM; he has burning and
shooting pain in both feet; his joints ache—especially his hips
and knees; pain is bad at night, but can flare up first thing in
the morning and also when he walks any distance
• He was widowed in the past year and moved to an assisted
living i apartment; he has fll fallen a few times, sustaining i soft
tissue injuries, but no fracture
• Ibuprofen and acetaminophen with codeine
were ineffective; hydrocodone/APAP made
him confused and constipated
• He jokes, “Might as well put me in the pine
box right now”
Verne’s Examination
• Affect discordant with his depressed mood
• Gait is shuffling and wide‐based with postural
instability
• Joint deformities in the hands and knees
consistent it twith OA
• Sensory loss to pin and vibration in the feet and
distal legs; positive Romberg’s sign; absent DTRs
at the Achilles tendons;
feet are sensitive to light touch
• Sacral decubitus ulcer
DM=diabetes mellitus. PD=Parkinson’s disease.
APAP=acetaminophen.
OA=osteoarthritis.
DTRs=deep tendon reflexes.
Pain Types by Physiology
Inflammation
Bone
Neuropathic
Muscular
Mechanical Psychogenic
Clinical Features of
Neuropathic Pain
• Clinical setting
– DM, MS, PD, HZV, spine surgery, CVA, HIV
• Distribution
• Quality and timing
– Burning, freezing, searing
– Jabbing, shock‐like, shooting
– Spasm
– Worse at night
• Physical signs
– Allodynia, hyperalgesia, cooler temperatures, pain
with numbness
MS=multiple sclerosis.
CVA=cardiovascular accident.
HIV=human immunodeficiency virus.
HZV=herpes zoster virus.
Contributing Factors and Barriers
• Contributing factors amplify or perpetuate pain
– Depression or anxiety
– Posture
– Intercurrent illness
• Barriers interfere with pain assessment or with
implementing appropriate treatment
– Insurance noncoverage/resource access
– Low motivation
– Chemical dependency
– Language or communication difficulty
– Conflicting medical therapies
Distribution of Neuropathic vs
Nonneuropathic Pain
A B C
D E F G H
Distribution (shaded areas) of neuropathic (A‐E) vs nonneuropathic (F‐H) pain as depicted by patients in a pain diagram.
A=peripheral polyneuropathy. B=ulnar mononeuropathy. C=thoracic radiculopathy. D=lumbar radiculopathy. E=myelopathy.
F=arthropathy. G=muscular pain. H=mechanical low back pain.
Belgrade MJ. Postgrad Med. 1999;106(6):127-140.

Assess Disease Burden
Verne’s Case Formulation
Priority
100
90
80
70
60
50
40
30
20
10
0
Goals of Pain Management in
Palliative Care vs Chronic Pain
Return to work
Self‐care
Patient assumes responsibility for symptom management
Increase activity
Functional restoration
Minimize healthcare utilization
Comfort
Support
Ease pain/suffering
• Painful diabetic neuropathy
• Muscular dysfunction/pain due to PD
• OA
• Inflammatory pain due to decubitus ulcer
• Contributing factors:
– Grief and loss
– Depression
• Barriers
– Bradykinesia
– Risk of falls
– Intolerance to analgesics
• Disease burden: fairly high—take mostly
palliative approach
Neuropathic Pain—Treatment
Neuropathic Pain
Disease‐Specific Measures
Glucose control
Infection management
MS treatment
PD treatment
CBT=cognitive behavioral therapy.
Symptom
Management
Local/Regional Treatment
Topical capsaicin
Topical lidocaine
Orthotics
Assistive devices
Epidural/intrathecal drug administration
Nerve root blocks
Sympathetic blocks
Systemic Treatment
Drugs
Behavioral
Treatment
Relaxation
Hypnosis
Meditation
CBT
Systemic Drugs
for Neuropathic Pain
• Anticonvulsants
– Gabapentin
– Pregabalin
– Lamotrigine
– Topiramate
• SNRIs
– Duloxetine
– Venlafaxine
• TCAs
– Amitriptyline, nortriptyline,
desipramine
• Opioids
– Oxycodone
– Tramadol
– Methadone
• NMDA blockers
– Ketamine
– Amantadine
– Memantine
• Dopamine agonists
– Pramipexole
• Alpha‐2‐adrenergic
agonists
– Clonidine
– Dexmedetomidine
• N‐type calcium
channel blocker
– Ziconotide
NMDA=N-methyl-D-aspartate. SNRIs=serotonin-norepinephrine reuptake inhibitors.
TCAs=tricyclic antidepressants.
This information includes a use that has not been approved by the US FDA.
Verne’s Plan of Care
• For DPNP
– Optimize glucose control
– Duloxetine or venlafaxine*
– Recommend a walker
– Check and optimize
shoe wear
– Tramadol for pain flares
• For OA
– Glucosamine supplement
– Scheduled acetaminophen
or NSAID
– Acupuncture
• For muscular pain
– Pool therapy
*Duloxetine and venlafaxine are the choice for this patient,
but other neuropathic pain medications may also substitute for these choices.
DPNP=diabetic peripheral neuropathic pain.
NSAID=non-steroidal anti-inflammatory drugs.
• For decubitus ulcer
– Topical morphine
– Local wound care
– Evaluation of sleep surface
• For contributing factors:
grief/loss/depression
– Duloxetine or venlafaxine* lf – Pool therapy in group setting
– Grief group if Verne
is amenable
• Manage barriers:
– Manage PD (pramipexole)
– (Walker)
– Choose intermediate analgesic
(tramadol)
Summary
• Assess for the 4 cardinal physiologic types of
pain: nociceptive, neuropathic,
muscle, bone
• Determine disease burden to pick goals of
treatment on the spectrum of restorative
to palliative
• Identify and manage contributing factors and
barriers
• Choose neuropathic pain treatments that attend
to the comorbidities

Nikki
• Ms. N is a 27‐year‐old female with systemic lupus erythematosis
and renal osteodystrophy with a history of multiple fractures and
mechanical abnormalities contributing to multiregional joint, bone,
and muscular pain.
• She is on chronic hemodialysis for end‐stage renal disease. She has
chronic pain in her shoulders, back, hips, and both legs in addition to
daily headaches. She has severe hearing impairment and is blind in
one eye from infection.
• She lives with her mother, sister, and niece and spends most of her
time at home watching television. She receives social security
disability income.
• Communication is also difficult because she is hostile toward the
clinicians. She has been unreliable with adhering to physician
recommendations in the past.
Nikki
• Ms. N’s primary physician prescribes hydrocodone/acetaminophen 5
mg/500 mg every 4 h as needed. She says she takes about six to
eight tablets per day but it is not controlling the pain.
• The physician suspects she is abusing opioids because of lost
prescriptions and requests for early prescriptions and for
“something stronger.”
• She uses doses of hydroxyzine hd for uncontrolled itching regularly. l She
had previously tried nonsteroidal antiinflammatory drugs (NSAIDs),
antidepressants, and diazepam without relief.
• She tried biofeedback, chiropractic care, Transcutaneous Electrical
Nerve Stimulation (TENS), and counseling, but she is currently only
utilizing medications.
• She has moderate lip reading ability and limited hearing. Her
mother is present and appears to be an exhausted caregiver and
advocate.
Nikki
• On physical examination, Ms. N presents as a young
woman of short stature, her physician has to repeat
things over and over before she understands.
• She is completely blind in the right eye. Her skin is
excoriated in places where she scratches. There are
deformities of the long bones at sites of healed old
fractures. She has multiple tender points on the neck,
back, and limbs.
• She can walk independently. She has peripheral
neuropathy with a stocking distribution loss of pinprick
and vibratory senses and absent deep tendon reflexes.
Nikki’s Pain Assessment
• What is/are the physiologic types of pain
• What is the temporal type of pain
• Identify contributing factors and barriers
• Determine the disease burden
• Develop a treatment strategy
• Is Nikki a candidate for long‐term opioid
analgesics What is her DIRE Score

D.I.R.E. Score: Patient Selection for Chronic Opioid Analgesia
For each factor, rate the patient’s score from 1-3 based on the
explanations in the right hand column
Score Factor Explanation
Diagnosis
Intractability
Risk
Psychological:
Chemical Health:
Reliability:
Social Support:
1 = Benign chronic condition with minimal objective findings or no definite
medical diagnosis. Examples: fibromyalgia, migraine headaches, nonspecific
back pain.
2 = Slowly progressive condition concordant with moderate pain, or fixed
condition with moderate objective findings. Examples: failed back surgery
syndrome, back pain with moderate degenerative changes, neuropathic pain.
3 = Advanced condition concordant with severe pain with objective findings.
Examples: severe ischemic vascular disease, advanced neuropathy, severe
spinal stenosis.
1 = Few therapies have been tried and the patient takes a passive role in
his/her pain management process.
2 = Most customary treatments have been tried but the patient is not fully
engaged in the pain management process, or barriers prevent (insurance,
transportation, medical illness).
3 = Patient fully engaged in a spectrum of appropriate treatments but with
inadequate response.
(R= Total of P+C+R+S below)
1 = Serious personality dysfunction or mental illness interfering with care.
Example: personality disorder, severe affective disorder, significant
personality issues.
2 = Personality or mental health interferes moderately. Example: depression
or anxiety disorder.
3 = Good communication with clinic. No significant personality dysfunction or
mental illness.
1 = Active or very recent use of illicit drugs, excessive alcohol, or prescription
drug abuse.
2 = Chemical coper (uses medications to cope with stress) or history of CD in
remission.
3 = No CD history. Not drug-focused or chemically reliant.
1 = History of numerous problems: medication misuse, missed appointments,
rarely follows through.
2 = Occasional difficulties with compliance, but generally reliable.
3 = Highly reliable patient with meds, appointments & treatment.
1 = Life in chaos. Little family support and few close relationships. Loss of
most normal life roles.
2 = Reduction in some relationships and life roles.
3 = Supportive family/close relationships. Involved in work or school and no
social isolation.
Efficacy score
1 = Poor function or minimal pain relief despite moderate to high doses.
2 = Moderate benefit with function improved in a number of ways (or
insufficient info- hasn’t tried opioid yet or very low doses or too short of a
trial).
3 = Good improvement in pain and function and quality of life with stable
doses over time.
______Total score = D + I + R + E
Score 7-13: Not a suitable candidate for long-term opioid analgesia
Score 14-21: Good candidate for long-term opioid analgesia