Diagnosing & Treating Musculoskeletal Pain In Working-Aged Adults
The Importance of Identifying The Central Pain Phenotype
9/22/17
Presented By:Paul C. Coelho, MD
Salem Health
Objectives
• 1. Become familiar with the 'central pain' phenotype and recognize that it is opioid unresponsive.
• 2. Become familiar with the Pain Catastrophizing Scale as a screening tool for the 'central pain' phenotype.
• 3. Become familiar with the 2016 Fibromyalgia Screening Questionnaire for the central pain phenotype.
Disclosures:The presenters have no financial relationships with a commercial entity producing health care related products and/or services.
Table of Contents
Early Pain Models
Modern Pain Models
FMS, HA, and LBP
The Central Pain Phenotype
Sample Case
Evidence-Based Treatments
1980 Model of MSK Pain
Nociceptive NeuropathicPrimarily due to inflammation or tissue damage in the periphery
Damage or entrapment of peripheral nerves.
NSAID/Opioid Responsive Responds to both peripheral and central pharmacotherapy.
Responds to procedures. Does not respond to procedures.
Behavioral factors minor. Behavioral factors minor.
Examples: Osteoarthritis, Rheumatoid arthritis, cancer pain.
Examples: Diabetic peripheral neuropathy, post-herpetic neuralgia.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1829161/
1990 FMS
https://www.rheumatology.org/Portals/0/Files/1990_Criteria_for_Classification_Fibro.pdf
US Overdose Deaths1980-2014
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1829161/
0
12500
25000
37500
50000
1980 1983 1986 1989 1992 1995 1998 2001 2004 2007 2010 2013
Wolfe ACR FMS1990
FDA Approves OxyContin1995
APS Pain as a 5th Vital Sign1996
Wolfe Recants FMS2008
IOM 100M In Pain2011
Peak Incidence of Prescription OD 45-54
Portenoy Portenoy/Foley1986
Portenoy Recants2012
Variation in Opioid Rx’ing forFMS 2007-2009
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4346177/
Peak Incidence of Prescription OD 45-54
35% of FMS Pt’s Receive SSDI
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4151179/
Disabled Medicare Beneficiaries Rx’d Opioids
FMS Patients Report High PainLevels In Spite of High Dosages
https://www.ncbi.nlm.nih.gov/pubmed/24310048
N = 582
Opioids In FMS: Once StartedSeldom Stopped
https://www.ncbi.nlm.nih.gov/pubmed/26443495
N = 100K, 60% Received Opioids.
30 Day Supply & Risk of COT
https://www.cdc.gov/mmwr/volumes/66/wr/mm6610a1.htm
20% will remain on opioids at 3yrs.
FMS Is Not Opioid Responsive
https://www.ncbi.nlm.nih.gov/pubmed/26975749
Organization
American Pain Society
American Academy of Pain Medicine
American Academy of Neurology
European League Against Rheumatism
Canadian Pain Society
Canadian Rheumatology Association
British Pain Society
2017 Model of MSK PainNociceptive Neuropathic Central
Primarily due to inflammation or tissue damage in the periphery
Damage or entrapment of peripheral nerves.
Primarily due to a central disturbance in pain processing.
NSAID/Opioid Responsive Responds to both peripheral and central pharmacotherapy.
Tricyclic neuro-active compounds. Opioid unresponsive.
Responds to procedures. Does not respond to procedures.
Does not respond to procedures.
Behavioral factors minor. Behavioral factors minor. Behavioral Factors Prominent.
Examples: Osteoarthritis, Rheumatoid arthritis, cancer pain.
Examples: Diabetic peripheral neuropathy, post-herpetic neuralgia.
Examples: FMS, cLBP, cHA, IBS.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1829161/
Comorbid Pain in FMS is the Norm
https://www.ncbi.nlm.nih.gov/pubmed/22364327
Low Back Pain
“Overwhelming evidence reveals that what isoften labeled as a single chronic regional painsyndrome is, upon closer evaluation, a chronicillness beginning much earlier in life, where thepain merely occurs at different points of the bodyat different points in time and is given different labels by subspecialists focusing on “their region” of the body.”
Daniel Clauw, MD
Prevalence of LBP & HA in FMS
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1829161/
2007 Internet Survey of 2596 FMS Pts
Ave Age = 47If due to chance aloneLBP .3 x .05 =1.5% HA: .2 x .05 =1%
Prevalence of FMS in cLBP 42%
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1829161/
Chance Alone: .3 x .05 = 1.5%
Prevalence of FMS in Migraineurs 56%
Chance Alone:.2 x .05 += 1%
https://www.ncbi.nlm.nih.gov/pubmed/25994041
N = 1,730
Head Ache & LBP Predict FMS
https://www.ncbi.nlm.nih.gov/pubmed/26772544
Comorbid Pain in FMS is the Norm
https://www.ncbi.nlm.nih.gov/pubmed/22364327
Fibromyalgia
Low Back Pain
Fibromyalgia Fibromyalgia
Head AcheLow Back Pain
Central Sensitivity Spectrum Disorders
https://www.ncbi.nlm.nih.gov/pubmed/17350675
Overlapping Chronic Pain Conditions
https://www.ncbi.nlm.nih.gov/pubmed/27586833
Prescribers are Poor at DiagnosingCentral Pain Syndromes
https://www.ncbi.nlm.nih.gov/pubmed/23071343
23% Sensitivity
N = 312, 240 FMS+
Prescribers are Poor at DiagnosingCentral Pain Syndromes
https://www.ncbi.nlm.nih.gov/pubmed/23071343
27% Specificity
N = 4M
Prescribers are Poor at DiagnosingCentral Pain Syndromes
https://www.ncbi.nlm.nih.gov/pubmed/20461781
“You cannot guess at the extent of fatigue, unrefreshed sleep, cognitive problems, multiplicity of symptoms, and extent of pain without a detailed interview. The new criteria obligate you to pay careful attention to the patient if you want to diagnose fibromyalgia.”
Fredrick Wolfe
Diagnosing Central Sensitivity Spectrum Disorders
https://www.ncbi.nlm.nih.gov/pubmed/26266995
1. Pain in many body regions. 2. Higher current and lifetime history of chronic pain in several
body regions.3. Multiple somatic symptoms (e.g., fatigue, memory difficulties,
sleep problems, mood disturbance)4. Negative Affect, dispositional pessimism, pain catastrophizing.5. More sensitive to other sensory stimuli (e.g., bright light, loud noises,
odors, other sensations in internal organs)6. 1.5 to 2x more common in women.7. Strong family history of chronic pain.8. High self-reported pain & distress (VAS/NPS/PSD/PCS)9. Pain triggered or exacerbated by stressors.10. Peak prevalence of FMS age 30-59 (working-age).*11. Essentially normal physical examination +/- diffuse tenderness.
2016 FMS Survey Questionnaire96% Sensitivity, 92% Specificity
Pain Catastrophizing ScaleModerate Risk 20-29
High Risk > 30
Elevated PCS Predicts Abuse
https://www.ncbi.nlm.nih.gov/pubmed/23618767
Elevated PCS Predicts Abuse
https://www.ncbi.nlm.nih.gov/pubmed/24612286
Elevated PCS Predicts Abuse
https://www.ncbi.nlm.nih.gov/pubmed/23809983
Why Is Dx’ing FMS/CSS Important?
https://www.ncbi.nlm.nih.gov/pubmed/26266995
1. It is opioid unresponsive.2. Prognosis: It does not improve with time.3. When present amid other CNP conditions – HA, LBP,
etc. – it is likely to be the primary source of morbidity.
FMS Is Opioid Unresponsive
https://www.ncbi.nlm.nih.gov/pubmed/26975749
Natural Hx of FMS
https://www.ncbi.nlm.nih.gov/pubmed/21765102
N = 1,55511yr f/u
Natural Hx of FMS
https://www.ncbi.nlm.nih.gov/pubmed/28077978
N = 762yr f/u
FMS is the Primary Source of Morbidity in Mixed Pain States
https://www.ncbi.nlm.nih.gov/pubmed/27049402
N = 383, 76 FMS+
FMS is the Primary Source of Morbidity in Mixed-Pain States
https://www.ncbi.nlm.nih.gov/pubmed/28182837
N = 156, 25 FMS+
Sample Case
Joyce
Joyce is a 45y/o woman who recently moved from CA to Douglas, County to retire. Her past medical history is significant for a work related back injury for which she was medically retired. She now receives SSD and seeks to establish care with you for primary care needs as well as pain management. Her medication regimen consists of Lisinopril for HTN. She is requesting “Percocet” for pain.
>13 = FMS
7
10
17
Joyce
>13 = FMS
Joyce
>30 Abnl
443
44
3
43
344
44
48/52
Evidence-Based Treatments of FMS
https://www.ncbi.nlm.nih.gov/pubmed/28077978
Treatment Evidence Level
Patient Education 1A
Graded Exercise 1A
CBT 1A
Tricyclics 1A
SNRI’s 1A
Gabapentenoids 1A
NSAIDS 5D
Opioids 5D
Centralized Pain Pt Handout
https://www.painscience.com/articles/central-sensitization.php
Evidence-Based Treatments for FMS
https://www.youtube.com/watch?v=pgCfkA9RLrM
Evidence-Based Treatments for FMS
https://fibroguide.med.umich.edu/
Evidence-Based Treatments for Pain Catastrophizing
Resources
Fibromyalgia Screening Questionnairehttp://www.slideshare.net/101N/pcp-pain-screening-tool
Evidence-Based Treatments for FMS, Dr. Clauw JAMAhttp://www.slideshare.net/101N/fibromyalgia-clinical-review
Daniel Clauw, MD Youtube Video for patientshttps://www.youtube.com/watch?v=pgCfkA9RLrM&t=6s
Sample Centralized Pain Patient Handouthttp://www.slideshare.net/101N/central-sensitization-70569194
List of non-opioid alternatives for chronic non-cancer painhttp://www.slideshare.net/101N/nonopioid-alternatives-for-chronic-noncancer-pain