Friday, 15 Feb 2019

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Complex Pain Syndromes in the Emergency Room

Emergency physician Chris Hahn, MD, doesn't have any trouble conjuring a simple definition of fibromyalgia. "Just think about the most annoying chief complaints you can imagine. That's the diagnostic criteria."

But, he told colleagues this week, strategies can help doctors get through the frustration of treating fibromyalgia and related conditions. "Amplified pain syndromes are all essentially the same thing," he said in a presentation at the annual scientific meeting of the American College of Emergency Physicians. "It's very important to believe your patients and sit down and talk to them. You don't need to use medications. But if you do use them, opiates are probably never going to be the right answer in these circumstances."

Amplified pain syndromes like fibromyalgia and complex regional pain syndrome (CRPD) can present with a variety of vague symptoms like total body pain, generalized fatigue, dizziness, and "just feeling off," said Hahn, who works at Mount Sinai's St. Luke's and West hospitals in New York City. "These are all the things we don't like to see when we pick up charts."

To make things more complicated, these patients may have any of dozens of other symptoms such as bladder problems, blurred vision, and sun sensitivity. "You get these big workups," he said, "and you don't find anything."

What to do? According to Hahn, it's crucial to understand that these conditions are real. "You might not believe fibromyalgia is a thing," he said, but studies have proven that people with these conditions "all have central augmentation of pain processing. Something is happening with the wiring of the patient's brain."

Sit down with the patient, he advised, even though they may be difficult to talk to. "Explain what's going on and how you understand their situation and their symptoms," he said. "'The wiring in how you process pain is off, and that needs to be fixed. You have to use cognitive behavioral therapy to work on the wiring.'"

Not every patient, of course, will be willing to visit a therapist. "What if you have a patient you cannot talk down, and your voice is not enough?" Hahn asked. The answer: A prescription is a possibility, although "there's no good evidence in the emergency department for which pain mediations are the best," he said.

Ketamine is one possible strategy, he said, pointing to research that supports its use in CRPD. He added that patients tend to be either responders or non-responders.

Earlier this year, the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists released consensus guidelines that said there's "moderate evidence" for the use of ketamine to treat CRPD; 4-10 days of treatment are needed to provide relief up to 12 weeks. There was "weak or no evidence" to support ketamine's use for immediate improvements for fibromyalgia and mixed neuropathic pain.

Another alternative is gabapentin, which has shown some benefit over placebo in CRPD, Hahn said. He recommends a single dose of 600-1,200 milligrams. But will the patients get high? "Yes," he said, "that's exactly what's going to happen," but the risk of abuse is low. Also, overdoses are non-lethal. But, he said, research suggests the drug worsens the risk of death from opioid overdoses.

Intravenous lidocaine is also an option. "This is coming to an emergency department near you," he said. "It's as effective as morphine and safe. If you have lidocaine and you're throwing the kitchen sink at someone, it's not an unreasonable option."

A systematic review published earlier this year said "there is limited current evidence to define the role of intravenous lidocaine as an analgesic for patients with acute renal colic and critical limb ischemia pain in the ED. Its efficacy for other indications has not been adequately tested. The safety of lidocaine for ED pain management has not been adequately examined."

Finally, Hahn pointed to haloperidol, an antipsychotic drug that he considers a "game-changing" treatment for cyclic vomiting. He said it appears to stop the brain from revving the pain response over and over again. "You need to 'cement their brain' so it can go to sleep and break the cycle."

As for things not to do, he suggests avoiding opioids for these pain syndromes because of the risk of poor long-term outcomes.

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