Multidisciplinary Pain Management (Revelis 12/6/2023)

 A recording of this presentation is available HERE. 

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Thank you to Dr. Yulia Revelis, SMGR Pain Management physician, for an excellent Grand Rounds presentation this week on Multidisciplinary Pain Management. Dr. Revelis, who is fellowship trained in pain management, is a relatively new addition to SMGR. Dr. Revelis took us systematically through how she assesses and treats pain complaints in her clinic. I was most impressed with her pragmatic approach to pain and her simple advice to believe patients when they complain of pain.

Here are the rest of my notes:

• Acute pain: days to weeks (after acute injury, surgery, etc.)
• Subacute pain: <3 months
• Chronic pain: >3 months

Most common pain, no surprise, is low back pain, followed by neck pain, joint pain (knee, shoulder, hip), and TBD or "total body dolor", which is all-body pain.

Dr. Revelis encouraged us to always go back to the history and physical when assessing pain. Also consider imaging, medications/interventions/treatments, social components, and psychiatric components ("depression and anxiety go hand in hand with chronic pain, and it is a vicious cycle")

She covered a few key tools to help in your assessment of pain. These include the following (links are live when possible)

• Oswestry Low Back Pain Disability Questionnaire
• SF-36
• McGill Pain Assessment
• Fibromyalgia Questionnaire
• Pain in Advanced Dementia (PAINAD)

These are all tools to quantify pain, its impact on activities of daily living and quality of life, and can often be used to track benefit of interventions offered.

To evaluate pain, Dr. Revelis encouraged us to go back to the history: get detailed description of the pain, its location, associated factors, chronicity, family history and social history. Then do a focused exam including inspection, palpation and any indicated special testing. "You don't always have to get imaging," she cautioned, "only when it is clinically appropriate to do so." 

Pain management is multifactorial

• Physical therapy
• Medications 
• Interventional options
• Counseling/CBT

Physical therapy offers long-term solutions gives people autonomy and self-determination with regards to their pain. She is a big big fan.

Medication options are many:

• topical meds (including lidocaine patches, Voltaren gel, and compounded creams including ones that have TCA or topical gabapentin)
• NSAID (care with elders, contraindications)
• Acetaminophen is an excellent pain med and is often under-dosed!
• Anti-spasmodic (including cyclobenzaprine, baclofen, tizanidine) her first line is cyclobenzaprine (Flexeril) 5mg at bedtime x 2 weeks max, "start low, go slow". Only rx'd as needed and should almost always be rx'd in conjunction with PT
• Gabapentinoids (gabapentin and pregabalin), particularly for neuropathic or radicular pain
• TCA/SSRI/SNRI: duloxetine particularly helpful in fibromyalgia
• Opioids should be A LAST RESORT, really only indicated for cancer-pain and acute pain, not adequately treated with all of the above

Dr. Revelis is able to over her patients injections, when appropriate, using either ultrasound or x-ray guidance. These include injections of neck, epidural injections, knees, hips, etc. 

It is important to screen for addiction/addictive behaviors in patients with chronic pain and remember that chronic pain specialists are not the same as addiction specialists. Pts with chronic pain exhibiting addictive behaviors should be evaluated by addiction specialists.

When to refer to pain specialist?

• chronic non-cancer pain
• cancer pain
• acute on chronic pain
• most importantly, patients who WANT to be helped