Chronic+Pain

=Chronic Pain= Chronic pain, like Headache often has little "objective evidence" and can be challenging. Continuity and an established relationship are invaluable - though often take many visits and months to years to estabilish. For the "first time visit" with these patients, some modicum of caution and obtaining old records before starting narcotics is prudent - particularly in younger (under 40) patients with no physical deformity or clear history. The sections/MAPs on Low Back Pain and Depression may be overlapping and useful.

DDx (differential)
Includes many organic causes (DJD, fractures, metastatic tumors, etc) Many More fuzzy causes (Fibromyalgia, etc) and Many less organic causes (Depression, Addiction)

Tx (treatment)
Many pharmacologic options exist, but non pharmacologic Tx (exercise, support groups, insight/CBT Therapy) may be helpful to many. For some pain, SSRI's, TCA's and other traditional drugs may help. The **WHO pain treatment ladder** discusses increasing level of medications (NSAIDs, Combo's, pure Narcotics)concominant with the level of pain (or lack of control), and most would advocate for those on chronic narcotic use, a reasonable "pain contract" with ongoing monitoring for red flags (cresendo use, diversion, concominant ilicit drug use).

Integrated Pain Management is a pain specialty group contracted with CCHP and is able to provide one time consultations regarding appropriate management of chronic pain, as well as interventional studies including nerve blocks and epidural steroid injections. They have offices in Antioch, Walnut Creek, Oakland and Alameda. When sending referrals please specify clearly whether you want a one time consultation (which might actually take them 2-3 visits) or ongoing management or a procedural intervention.

Also keep in mind Dawn Marie Wadle's pain consultation clinic which is an excellent resource for West County and Ken Saffier's buprenorphine treatment clinics at CHC and MHC for the medical treatment of opiate addiction.



Some Links: American Cancer Society's, which includes an opioid equivalent dosing scheme

Urine Toxicology Screen

 * [[file:ccrmc/Pain Guideline Table (CCRMC) 10.28.11.doc|Pain Guideline Table (CCRMC) 10.28.11.doc]]
 * [[file:ccrmc/CAGE-AID questionnaire 2008.pdf|CAGE-AID questionnaire 2008.pdf]]
 * [[file:ccrmc/DIRE Score - Patient Selection for Chronic Opioid Analgesia.pdf|DIRE Score - Patient Selection for Chronic Opioid Analgesia.pdf]]
 * [[file:ccrmc/Opioid Risk Tool 2005.pdf|Opioid Risk Tool 2005.pdf]]

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