When Chronic Pain
Comes Knocking
Kenneth R. Goldschneider, MD, FAAP
Director, Division of Pain Management
Cincinnati Children’s Hospital
Medical Center
The Chronic Pain Patient Arrives…
Disclosure
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2006 Pfizer Pain Visiting professorship
No promotional activity
Case #1
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12y.o. female presents with 3 months of
severe, constant abdominal pain, epigastric,
sometimes wakes her, interferes with school.
Looks a little uncomfortable. VSS, abd
diffusely tender, o/w (-)
PMHx: headaches 1-2/week, o/w (-)
Meds: PPI, MVits; NKA
FHx: Aunt with “spastic colon”
Functional Gastrointestinal
Disorders (FGIDs)
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Pain anywhere in abdomen
Usually constant or frequent, may waken from
sleep. Many descriptors.
Exam non-focal
Often start with infectious or stressful event
Stress exacerbates
Alarm Symptoms
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Weight loss, vomiting, focal exam or
complaint, decelerating growth curve, GI
blood loss, dysphagia, fever, arthritis, delayed
puberty, perirectal disease; FHx of IBD, Celiac
Dz; Eosinophilic Dz
Pediatric FGIDs
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Functional Dyspepsia
Irritable Bowel Syndrome
Abdominal Migraine
Childhood Functional Abdominal Pain+/Syndrome
Functional Constipation
Nonretentive Fecal Incontinence
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Gastroenterology 2006; Vol 130:1537
They’ll fool ya’
Myofascial pain
 Intercostal neuralgia
 Slipping rib syndrome
 Umbilical hernia
 Xyphoidalgia
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Treatment of FGIDs
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Behavioral Medicine
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Avoid obvious triggers
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Biofeedback, coping, lifestyle adaptations,
parental coaching
Fatty foods, NSAIDs, prolonged NPO
Medication
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TCAs, antispasmodics, PPIs,
anticonvulsants, peppermint oil
Case #2
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14 y.o. WF presents with a two week history of
burning foot pain that started after twisting her
ankle playing soccer. The foot is cyanotic, a bit
puffy, and she won’t let you near it. Straight-A
student, good family.
PMHx (-); Meds (-); NKA; FHx (-)
CRPS Type I
Formerly:
Reflex Sympathetic Dystrophy
Algodystrophy
Algoneurodystrophy
Sudek’s Atrophy
Reflex Neurovascular Dystrophy
Osteodystrophy
CRPS Type I: Diagnosis
1. Develops after initiating noxious event
2. Spontaneous pain or allodynia occurs
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not necessarily dermatomal
disproportionate to inciting event
3. Evidence or history of:
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edema
sudomotor abnormality
skin blood flow abnormality
4. Excluded by existence of conditions otherwise
accounting for degree of pain and dysfunction
RSD: Stages (?)
1. Acute: weeks to months
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warm, dry, most
responsive to treatment
2. Dystrophic: months
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cool, cyanosis/mottling,
sudomotor changes
Traditional sequential stages
may not exist
May be subtypes:
−
−
3. Atrophic: years
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cool, white, atrophy of
muscle/skin
−
Limited vasomotor
predominant
Limited neuropathic
pain/sensorimotor
abnormalities predominant
Florid presentation “Classic
RSD”
Bruehle, et al 2002
Presentation
Age range: 3 years and up
Female:Males = 5:1
Lower:Upper extremity ~5:1
Sports-related injury: ~50%
~85% involved in sports or dance
Spontaneous pain
Mechanical allodynia, edema, cold extremity,
cyanosis
CRPS
Ancillary Findings CRPS
Bone scan: mixed results, not useful
Radiography: non-specific demineralization
Psychological profile: stress seems to exacerbate
Wilder, et al, 1992
Recommendations
Central theme: functional restoration
Objective and Reachable rehab goals essential
PT is key
Psychological treatment essential
Neuropathic meds and occasional block
All components subserve the central theme
Self-management is emphasized
Outcome
Younger patients have
milder course
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less pain, higher
function, fewer
remaining autonomic
signs on follow-up,
shorter duration, more
likely to return to sports
School days missed
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No effect:
Duration of symptoms
Gender
Relation to sports
Immobilization
Number of SNS
in first year after injury
Wilder, et al, 1992
Figure from Reg Anes 23(3)
Case #2 again
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Your CRPS patient returns a couple weeks
later complaining of sleepiness, dizziness, dry
mouth, and (per her mom) significant mood
swings. Her pain is a little better. HR: 115;
mucous membranes dry, cerebellar signs OK;
no SI.
Rx: PT; Bmed; gabapentin; amitriptyline;
TENS unit
Pain Meds?
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Anticonvulsants
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Antidepressants
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Neuopathic, headache, abdominal pain
Antihypertensives
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Neuropathic, abdominal pain, headache
Neuropathic pain, headache
Local Anesthetics
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Neuropathic, back pain
AnaesthesiaUK
Adjunct Meds
Anticonvulsant Side Effects
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Minor:
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Sedation, dizziness, trouble with memory or
concentration, extremity swelling
Major:
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Renal stones (Topiramate)
Rash, Stevens-Johnson Syndrome (any)
Liver dysfunction (valproate, carbamazepine)
Pancreatitis (valproate)
Mood swings (gabapentin)
Antidepressant Side effects
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Minor:
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Sedation, mood swings, weight gain/loss,
insomnia, dry mouth
Major:
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Suicidal ideation (any, more prominent in SSRIs)
Prolonged QT, Torsades de Pointe (tricyclics)
SSRI interactions (CYP 2D6)
Topical Treatments
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Lidocaine patch
(Lidoderm)
Approved for PHN
 Used for back pain,
localized
neuropathic pain
 Systemic toxicity
unlikely
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Clonidine patch
Capsaicin
TENS
Transcutaneous
Electrical Nerve
Stimulation
Descending Inhibition
Cognitive Control
Large Fibers
Action
SG
Small Fibers
Herbs
Not your Parents’ Nuts and
Berries
Dietary Supplement and Health
Education Act, 1994
Created the dietary supplement
category
Herbs may claim effect but not
promise cure
No standard for quality
No proof needed of efficacy or safety
DSHEA: Implications
Potency can vary
Contaminants may exist
Additives can be used
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No mention needed on the label
Active ingredient need not be contained
One preparation may be vastly more or less
potent than another
Herbs
May apple
(podophyllum):
recommended for
pediatric
constipation relief
Foxglove
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As a poultice over the
kidneys to induce
urination, over the joints
for inflammation, and as
a tea, for heart failure
Library of Health, 1920
VP-16
(etoposide)
Digitalis
Herbs
Nicotinaea tabacum:
touted for medicinal
purposes
Tobacco
Indian Hemp: “used
with benefit in
neuralgia”
“for medicinal
purposes cannabis is
used to quiet spasms
and produce mental
quietude”
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Library of Health,
1920
So, what’s popular at the
herb shops?
Herbs
Chamomile
(Chamaemelum nobile)
Mild sedative effect, antispasmodic
Works
Cross-allergenic with ragweed
Contains coumarin
Garlic
(Allium sativum)
Treatment of familial
hyperlipidemia in children (8-18
years)
Garlic oil or placebo TID x 8
weeks
No effect
May increase bleeding risk
 (PT/INR/platelet effects)
Herbs
Ginger (Zingiber
officinale)
Echinacea (Echinacea
purpurea)
Anti-nauseant and
antispasmodic
Effective
May inhibit platelet
function
May be mutagenic
Immuno-stimulant
Appears to work
Hepatotoxic in long term use?
Tachyphylaxis may develop
3 different species, effect?
Herbs
St. John’s Wort (Hyperecium
perforatum)
Uses: depression, anxiety,
sleep disorders
Adverse effects:
Photosensitivity, dry mouth,
fatigue, dizziness, nausea,
constipation
Drug interactions: Other photosensitizers, SSRIs,
pseudoephedrine, MAOIs
Feverfew
(Tanecetum parthenium)
Uses: migraine headaches
Adverse effects: apthous
ulcers, rebound headaches,
GI irritability, increased
bleeding risk
Drug interactions: NSAIDs,
heparin, warfarin, inhibits
Fe+++ uptake
Herb: risks and interactions
Bleeding
Sedation
Chamomile
Feverfew
Garlic
Ginkgo
Ginseng
Valerian
Kava kava
GE Reflux
Peppermint
Case #3
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17 y.o. with spondylolysis-based back pain
presents with increased pain, sweating,
tachycardia. He is noted to be unpleasant to the
RNs. He says he ran out of methadone a few
days ago, and ran out of Percocet yesterday.
Opioids in Pediatric Chronic
Pain
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Few patients
Organic diagnoses
Stable regimens, once titrated
Dx: Cancer, Ehlers-Danlos, JRA, EBD, CF,
Sickle Cell,
Withdrawal
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Usually a “red flag”
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Lost/stolen Rx, misuse, not following directions,
Sx: same as for adults
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Increased pain, tremors, sweating, tachycardia,
irritability, yawning, diarrhea
Withdrawal
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Need to contact Pain Clinic
Usually, a bolus dose, then a few days of the
prior dosing until they can get to clinic
If history of abuse is known, referral to detox
is appropriate
3 day grace period
Opioid Contracts
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Between Chronic doc and patient/family
Defines rules of engagement
All opioids to come from Pain Clinic
Usually requires pt to contact Clinic of need to
go to ED/Urgent Care Clinic
PAIN MANAGEMENT SERVICES
CONTROLLED
SUBSTANCES CONTRACT
Controlled substances are sometimes a part of a pain treatment plan for chronic pain. It is
our goal to treat pain in a medically sound and ethical manner. This contract is intended
to outline clearly the terms under which controlled substances will be used to treat
your/your child’s chronic pain condition.
1. I will use the medications only as prescribed by the doctor.
2. I will not receive any pain prescriptions from any other doctor or treating
facility (e.g. emergency room, urgent care facility).
3. All pain prescriptions are for my use only; I will not share them.
4. I will not take more medication than is prescribed. If my pain is not controlled, I
will contact the Pain Management Service.
5. Lost, damaged or destroyed prescriptions will not be replaced.
6. A stolen prescription may be replaced if a police report is filed.
7. Selling pain medication prescribed by the Pain Management Service will result in
immediate discontinuance of the medication, and a police report will be filed.
8. I agree to urine and/or blood drug screening at any time.
9. These medications can affect judgement, coordination, concentration and alertness.
I understand that it is not advisable to operate machinery, automobiles or make
important decisions when starting or adjusting the medications.
10.I will not hold any member of the Pain Management Service responsible for
problems caused by stopping the prescription of controlled substances.
I understand the above information and agree to follow the medical plan and rules
for the use of controlled substances. If I break this contract, the doctor may stop
prescribing the medication in question. Medical care will continue to be provided.
___________________________________
Patient
Date
___________________________________
Parent/Guardian
Date
___________________________________
Physician
Date
___________________________________
Witness
Date
Interacting with Pain Teams
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Referrals
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Feedback
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Pt should return to PMD for referral to Clinic
Note or call to Pain Clinic helpful
Admissions
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Should not be done for a chronic pain condition
without consultation with Clinic (for
established patients)
Thank You
Kenneth.goldschneider@cchmc.org