Transcript Slide Kit - Guildford GP Education

Chronic Pain Management
Dr D Tonucci
MB ChB DCH FRCA FFPMRCA
Clinical Lead of Pain Service
Consultant in Anaesthesia and Chronic Pain Medicine
Royal Surrey County Hospital NHS Foundation Trust
Mount Alvernia Hospital
Guildford Nuffield Hospital
Typical outdated view of pain
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Pain is easy to sort with a few pills
An easy consultation
Nobody dies of Pain
Making a diagnosis is the priority
Pain does not need a priority
Pain Clinics are where you send your patients
when all else fails
PAIN WAS
LOW ON
THE AGENDA OF THE NHS
But things have changed....
Chronic Pain Policy Coalition
The mission statement:
To improve the lives of people
who live with chronic pain by
developing and sharing ideas
for improved prevention,
treatment and management
of chronic pain in the UK.
All Party Parliamentary Chronic Pain Working Group
Launched May 2009
CMO, Baroness Fitchie, Joan Hester (BPS), Beverly Collett (CPPC), Richard
Branson, Clare Rayner
5th Vital Sign
Publications
• CMO 2009 Report
• CP 18 Wk Commissioning Pathway 2008
• NICE Guidelines
– Low back pain 2009
– Spinal cord stim 2009
– Neuropathic pain 2010
• CCG
• Multidisciplinary teams MSK– less Consultant led
service
• Care closer to home
Case study
• 39 year old male
• Referred to pain clinic with 23 years low back
and thoracic spine pain
• No red flags
• Seen by many specialists
• Previous scans all NAD
• On fentanyl 75 patch
Psychosocial history
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Married and working
Poor career progression
Fertility problems
Many yellow flags
No red flags
Patient very angry and looking for a cure
Initial consultation
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Where to start?
History and examination
Reassure?
MRI scan?
Address opiod dependency?
Address psychosocial issues – marital, work?
MRI scan
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A picture says a thousand words
Reassurance needed
Scan shows Shuermans scoliosis mild
Some inflammation in thoracic facets
Follow up at 6 weeks
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MRI results
Explanation of diagnosis
Explanation of prognosis
Meds regime and opiod withdrawal?
– All this takes TIME which GP’s do not have!
• ADDRESS PATIENT EXPECTATIONS!
• Pain level (% improvement) vs. Quality of Life
Next step
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Wean opiods, switch to bd oral dose
Slow reduction
6 week follow up
Discuss ACCEPTANCE
Pain management : psychology assessment
Mindfullness based stress reduction 6 week
course
What is Pain ?
• “ an unpleasant sensory and /or
emotional experience associated with
actual or potential tissue damage or
described in terms of such damage”
(IASP)
• “pain is what the patient says it is”
What is Chronic Pain?
• Pain that persists a month beyond the usual
course of a disease process
• Pain for more than 3 months
The continuum of pain
Insult
Acute
pain
Chronic
pain
≥3–6 months
• Serves a protective function
• Serves no protective function
• Usually has an apparent noxious insult • Degrades health and function
McMahon SB and Koltzenburg M. Wall and Melzack’s Textbook of Pain. 5th ed. London: Elsevier; 2006, pgs 205, 235–6
Chronic or Persistent Pain
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8 Million people in UK (CMO 2008)
1:4 households affected
1 in 6 GP appointments for pain
4.6 M GP appointments for pain per year
• YET – Doctors train only 13 hrs on pain
• Nurses (10.2) Midwives (6)
• less than Vets (27.4) and Physios (37.5) !!!
Affects all aspects of life
Loss of independence
Loss of self esteem
Loss of salary
Missing special
occassions
Losing touch with
loved ones and
friends
Loss of health
benefits
Feeling like a
burden
Loss of contact
Inability to maintain
relationships
Feelings of
isolation
Loss of social element
Loss of personal
achievements
Inability to achieve
goals
Loss of me-time
Loneliness
Feeling left out
Loss of
motivation
Loss of
personal
relationships
The Biopsychosocial Model
IN CHRONIC PAIN:
PAIN ≠ HARM
PAIN ≠ DAMAGE
When should we be worried?
Serious spinal pathology (red flags)
• Constant progressive
(thoracic, lying down)
• Deformity
• History of Cancer
• Drug abuse (including
steroids)
• Neurology
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bladder
saddle anaesthesia
sensory loss
Bowel / bladder
• Acute trauma
• Fever
• Weight loss etc
Acute / Chronic LBP
Where to refer?
• MPTT / GP’sWSI / Sp. physios / CCG Pain
Services
• Ortho Surgeon? - What percentage of new
onset back pain requires surgery?
• Rheumatologist?
• Pain Specialist?
What does pain clinic offer?
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A multi-disciplinary approach
Time
Ownership
Holistic approach
Why do we get better outcomes for QOL and
pain scores
What do we offer in Pain Clinic?
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HOSPITAL : outpatient clinics
COMMUNITY: Farnham, Cranleigh, Haslemere, Cobham
INJECTIONS: treatments
HELP GP’S to reduce multiple referrals
MEDICATION Drug prescribing and advice
SPECIALIST PHYSIO
SPECIALIST NURSING
ACUPUNTURE/ TENS
PSYCHOLOGY :
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Education and Acceptance / Commitment
Pacing
Patient self-management
Psychotherapy / Mindfulness / CBT / ACT
PMP – impact/move groups
Patient compliance?
• Explanation of diagnosis
• Explanation of prognosis
• Starting dose and meds regime?
– All this takes TIME which GP’s do not have!
• ADDRESS PATIENT EXPECTATIONS!
• Pain level (% improvement) vs. Quality of Life
Understanding key types of pain
Nociceptive pain
Neuropathic pain
Pain caused by
an inflammatory or
non-inflammatory
response to an overt or
potentially tissue-damaging
stimulus1
Pain initiated or caused
by a primary lesion or
dysfunction in the
peripheral or central
nervous system2
1. Adapted from Julius D et al. In: McMahon SB and Koltzenburg M. Wall and Melzack’s Textbook of Pain. 5th ed.
London:Elsevier; 2006, pg 35; 2. Adapted from Merskey H, Bogduk N, eds. Classification of chronic pain: descriptions of
chronic pain syndromes and definitions of pain terms, 2nd ed. Seattle, WA: IASP Press; 1994,
pg 212
What is nociceptive pain?
• Inflammatory pain
• Painful region is typically localised at the site
of injury Usually time-limited
• Can also be chronic (e.g. osteoarthritis)2
• Responds to conventional analgesics1
1. McMahon SB and Koltzenburg M. Wall and Melzack’s Textbook of Pain. 5th ed. London: Elsevier; 2006, pgs 235, 471,
906, 1020, 1099
2. Felson DT. Arthritis Res Ther 2009;11:203
Example of chronic nociceptive pain:
osteoarthritis of the knee
Normal joint
Synovial
fluid
Osteoarthritis
Synovial
membrane
Inflammation
as bones rub
together
Joint
capsule
Cartilage
Felson DT. Arthritis Res Ther 2009;11:203
Thinned
cartilage
What is neuropathic pain?
• Pain initiated or caused by a primary lesion or dysfunction in the
peripheral or central nervous system1
• Pain often described as
– shooting, electric shock-like, burning
– commonly associated with tingling or numbness2
• The painful region may not necessarily be the same as the site of
injury.
• Almost always a chronic condition (e.g. post-herpetic neuralgia,
post-stroke pain)2
• Responds poorly to conventional analgesics3
1. Merskey H, Bogduk N, eds. Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain
terms, 2nd ed. Seattle, WA: IASP Press; 1994, pg 212
2. McMahon SB and Koltzenburg M. Wall and Melzack’s Textbook of Pain. 5th ed. London: Elsevier; 2006, pgs 905–6,
992, 1020, 1057, 1076
3. Dray A. Br J Anaesth 2008;101:48–58
Recognition of neuropathic pain
Post-stroke pain
Common descriptors
Shooting
Electric shock-like
Burning
Tingling
Numbness
Diabetic peripheral neuropathy
Post-herpetic neuralgia
Chronic post-surgical
pain
The co-existence of nociceptive and
neuropathic pain
Nociceptive pain
Webster LR. Am J Manag Care 2008;14 (5 Suppl 1):S116–22
Ross E. Expert Opin Pharmacother 2001;2:1529–30
Both types of
pain co-exist in
many conditions
(mixed pain)
Neuropathic pain
Example of co-existing pain: herniated
disc causing low back pain and lumbar
radicular pain
Disc herniation
Activation of peripheral nociceptors –
cause of nociceptive pain component1
Lumbar
vertebra
Compression and inflammation of nerve root –
cause of neuropathic pain component2
1. Brisby H. J Bone Joint Surg Am 2006;88 (Suppl 2):68–71
2. Freynhagen R, Baron R. Curr Pain Headache Rep 2009;13:185–90
To understand drugs in pain
medicine we need to understand
how and where they work!
Ascending
Pain Pathway
Descending
Pain Pathway
Remember fMRI
Pharmacology of Pain
Analgesics may act:
1. At the site of injury to reduce nociceptor firing
2. May alter / slow / stop nerve conduction
3. May modify transmission in DRG / dorsal horn / CNS
4. May affect central component and emotional aspect
of pain
5. May act on descending pathways
6. OR COMBINATION OF THE ABOVE
Neuropathic pain can be successfully
managed by general practitioners
(GPs)
• neuropathic pain usually presents in a
recognisable way1
• Patient verbal descriptors of pain often
provide useful clues to the diagnosis
• Differentiating neuropathic from nociceptive
pain helps GPs initiate appropriate
management steps3
1. Gilron I et al. Can Med Assoc J 2006;175:265–75
2. Bennett MI et al. Pain 2007;127:199–203
3. Haanpää ML et al. Am J Medicine 2009;122:S13–S21
Making a diagnosis
LISTEN
Patient verbal descriptors,
Q & A1
LOCATE
LOOK
Nervous system
lesion/dysfunction2
Sensory abnormalities,
pattern recognition1,2
1. Baron R, Tölle TR. Curr Opin Support Palliat Care 2008;2:1–8
2. Haanpää ML et al. Am J Medicine 2009;122:S13–S21
Patients with neuropathic pain may
use these
pain descriptors
‘Electric shock-like’
‘Burning’
‘Shooting’
‘Numbness’
‘Tingling’
Be alert for common
verbal descriptors of NeP
Locate: correlate the region of pain to the
lesion/dysfunction in the nervous system
Lumbar radiculopathy1
Carpal tunnel syndrome2
1. Freynhagen R, Baron R. Curr Pain Headache Rep 2009;13:185–90
2. Michelsen H, Posner A. Hand Clin 2002;18:257–68
3. Perkins T, Morgenlander JC. Postgrad Med 1997;102:81–2, 90–2
Diabetic peripheral neuropathy3
Look for the presence of sensory
and/or
physical abnormalities
• First, inspect the painful body area and compare
it with the corresponding healthy area:1
– Differences in colour, texture, temperature, sweating2
• Then, conduct simple bedside tests to confirm
sensory abnormalities associated with
neuropathic pain:1–3
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Gauze or a piece of cotton wool
Pinprick
Pinch
Thermal (hot or cold object)
Aetiology-specific tests
1. Haanpää ML et al. Am J Medicine 2009;122:S13–S21
2. Gilron I et al. Can Med Assoc J 2006;175:265–75
3. Baron R, Tölle TR. Curr Opin Support Palliat Care 2008;2:1–8
Several screening tools are available to
help the
identification of neuropathic pain
• Commonly used verbal descriptors of neuropathic pain are recognised as a
valuable guide for clinicians1
• Several screening tools have been developed that utilise
the predictive value of these terms:1
– Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) scale
– Douleur Neuropathique en 4 questions (DN4)
– Neuropathic Pain Questionnaire (NPQ)
– painDETECT
• Some (e.g. DN4 & painDETECT) can be completed in the waiting room,
potentially saving GPs’ valuable consultation time2
1. Bennet M. Pain 2007;127:199–203
2. Freynhagen R et al. Curr Med Res Opin 2006;22:1911–20
The inter-relationship between
neuropathic pain, sleep and
anxiety/depression
Pain
Functional
impairment
Anxiety and
depression
Nicholson B et al. Pain Med 2004;5 (Suppl 1):S9–S27
Sleep
disturbance
Patients with neuropathic pain experience
significant co-morbid symptoms
Patients with ‘moderate’ to ‘very severe’ discomfort (n=126)
Type of functional impairment
Poor appetite
Anxiety
Depression
Difficulty concentrating
Drowsiness
Lack of energy
Difficulty sleeping
0
10
20
30
40
Patients (%)
Adapted from Meyer-Rosberg et al. Eur J Pain 2001;5:379–89
50
60
70
Non-pharmacological treatment of
neuropathic pain
• Given their presumed safety, nonpharmacologic
treatments should be considered whenever
appropriate1
• In general non-pharmacological treatment is
complementary to drug therapy2
• Non-pharmacological treatment options include2
– Physiotherapy
– Pain Management Programmes
– Acupuncture
– TENS
TENS, Transcutaneous electrical nerve stimulation
1. Gilron I et al. Can Med Assoc J 2006;175:265–75
2. Pardo-Fernández J et al. Rev Neurol 2006;42:451–4
EFNS guidelines on pharmacological
treatment of neuropathic pain
Pain condition
Painful
polyneuropathy
Post-herpetic
neuralgia
Trigeminal neuralgia
Central pain
Recommendations
for first line
Recommendations for
second/or third line
Gabapentin
Pregabalin
Lamotrigine
Opioids
Tricyclic antidepressant
SNRI
Gabapentin
Pregabalin
Lidocaine, topical
(for small area of pain allodynia)
Tricyclic antidepressant
Oxcarbazepine
Carbamazepine
Amitriptyline
Gabapentin
Pregabalin
Tramadol
Capsaicin
Opioids
Tramadol
Valproate
Surgery
Cannabinoid
Lamotrigine
Opioids
Guidelines based on evaluation of controlled clinical trials evidence. Not all treatments recommended are licensed for the indication. Prescribers should also be aware of contraindications
and cautions when using certain agents in certain patients
(e.g. elderly).
EFNS, European Federation of Neurological Societies;
SNRI, serotonin-norepinephrine reuptake inhibitor
Adapted from Attal N et al. Eur J Neurol 2006;13:1153–69
Neuropathic Pain Summary:
• Neuropathic pain is prevalent and under-reported1,2
• In most cases it can be:2
– Recognised
– Diagnosed
– Managed by general practitioners
• A simple, stepwise approach to diagnosis may help differentiate between
neuropathic and nociceptive pain2–5
• Several evidence-based treatment guidelines are available from learned
societies and experts, which propose similar approaches to
pharmacological management6–8
• Early detection and successful management of neuropathic pain includes
not only pain relief but also improvement of overall quality of life2
1.Wallace MS. Curr Opin Anaesthesiol. 2005;18:548–54; 2. Haanpää ML et al. Am J Medicine 2009;122:S13–S21; 3. Baron
R, Tölle TR. Curr Opin Support Palliat Care 2008;2:1–8; 4. Jensen TS et al. Eur J Pharmacol 2001;429:1–11; 5. Gilron I et
al. Can Med Assoc J 2006;175:265–75; 6. Attal N et al. Eur J Neurol.2006;13:1153–69; 7. Dworkin RH et al. Pain
2007;132:237–51; 8. Jost L et al. Ann Oncol 2009;20 (Suppl 4):170–3
Guidelines for the Management of Chronic
Non-Malignant Pain (CNMP) in Primary
Care (not including neuropathic pain (NeP)
• Step 1:
Step 2
Step 3
What else?
Physical and Alternative
Treatments
Physical and Alternative Treatments
• Physical- heat/ cold/ TENS/ hydro/ supports/ US/ IR
• Manipulation- PxTx/ chiropracter/ osteopathy/ deep
tissue massage
• Alternative- acupuncture
Headache!
Psychologicaly based therapy
Pain Management Programmes (MDT)
● Medication
• Coping
• Contingency
• Pacing
• Education
• Goals (SMART- specific/ measured/ agreed/ realistic/ timed)
• Pain Behaviours
• Reinforcement
Pain interventions?
• Injections – lack of RCT’s
– Epidurals and Facet Joint Injections - no firm evidence
but patients like them!
– Radio frequency for facet – more evidence
– SI Joint injection / RF – minimal evidence
– Nerve root injection good for trigger pain and acute
disc – good evidence
– Piriformis block
– ? trigger points
– Pulsed RF treatment / peripheral neuromodulation
– ? Botulism toxin
• Discography
• Intra-discal electrotherapy / nucleoplasty /
vertebroplasty
Facet Joint Injections:
Radiofrequency Ablation
SI Joint Pain
Spinal Cord Stimulation:
Thank you