Transcript Slide 1

Current pain management
in Lithuania:
system and practice
Alfredas Vaitkus, MD, FIPP
The In-patient Day Department of Pain Treatment
Centre of Anaesthesiology, Intensive Therapy and Pain Management
Vilnius University Hospital Santariskiu Clinics
Vilnius, Lithuania
A piece of history
1953 - 1st pain clinic in USA
 1961 - 1st pain clinic in Europe
 1994 - 1st pain clinic in Lithuania
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A piece of history
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1990-1993 - sporadic enthusiasm in the meaning of
interests and practice
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1993-1994 – several anesthesiologist visit to Norwegian
hospitals (Oslo and Bergen) with support from
Norwegian Cancer Society and Rotary Organization
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1994 - establishment of the 1st pain clinic in Lithuania
(Vilnius University Hospital Santariskiu Clinics)
Dr. Lorens Gran
Dr. Jane Baubliene
Short review of presentation
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Juridical base
System in work
Specialized pain centers
Medicines
Interventional pain management
Postoperative pain management
Palliative care
Organizations
Education
Juridical base
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1997 m.
“Patients should receive scientifically based
analgesic measures in order not to suffer due to
their health disorders“
Law of patients’ rights and compensation for harm (LR)
Recognition of patients’rights to receive pain help
Juridical base
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2001
“Pain is a major healthcare problem. Although acute
pain may reasonably be considered a symptom of
disease or injury, chronic and recurrent pain is a specific
healthcare problem, a disease in its own right.”
European Federations of IASP Chapters (EFIC) Declaration
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Approved by Minister of Health of
Lithuania in 2002.
Recognition of pain problem
Juridical base
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2003
“Concerning invasive pain management
procedures for adults and children in health care
institutions and base price approval.”
Order of Minister of Health (LR)
Legitimation:
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of invasive procedures
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of reimbursement
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of in-patient day department
Juridical base
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Neurolytic procedures
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Instantaneous curative procedures
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radiofrequency destruction
neurolytic procedures
facet blocks
single epidural injection - cervical, thoracic, sacral
single epidural injection – lumbar
trigger point injections
somatic nerve block
Long-lasting curative procedures
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catheterisation of epidural space
intravenous farmacological test or infusion pump installation
Juridical base
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2004
“Concerning obligatory medicinal help and the
order of obligatory medicinal help services and
extent.”
Order of Minister of Health (LR)
Necessity:
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to evaluate intensity
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to use pain scales
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to document pain
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to treat
Juridical base
 2007
„Inventory for requirements of palliative care
services for adults and children.“
Order of Minister of Health (LR)
Legitimation of palliative care services
System in work
Nonmedical help – patient education
 General help
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general practitioners
ambulatory specialists
hospital specialist
Specialized help
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pain centres and consultations
postoperative pain services
palliative care institutions
rehabilitations centres
surgical centers
Pain centres and consultations in Lithuania
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7 hospital based pain clinics
(in-patient day departments)
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2 of them - C-arm fluoroscopy
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several ambulatory pain
consultations
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~15 physicians of different
specialties
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2/3 of them – anesthesiologists
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0 to 2 nurses available for 1
physician
Specialized pain help in Lithuania
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~ 12.000/year visits to pain centres and
consultations
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~ 2/3 visits are due to back pain and joint pain
~ 20% visits due to oncological pain
~ 6.000/year interventional procedures
2008 year data
Medicines availability
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Opioids
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Injections
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Oral
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tramadol, morphine, methadon
Rectal
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tramadol, morphine, pentazocine, pethidine, buprenorphine
tramadol
Transdermal
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fentanyl
Reimbursement
Oncological: morphine (inj., oral), tramadol (inj., oral), fentanyl (transdermal)
Non-oncological for disabled: tramadol (inj., oral)
Medicines availability
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Non-steroidal antiinflammatory medicines
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15 chemical substances
Antiepileptics
 Antidepressants
 Other (Flupirtine)
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Reimbursement
Oncological: several NSAIDs
Trigeminal neuralgia: carbamazepine
Reumatological: several NSAIDs
Diabetic polineuropathy: pregabaline, duloxetine
For disabled: several NSAIDs, amitriptiline
Interventional pain management
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Trigger point inj.
Intraarticular inj.
Facet joint block & radiofrequency denervation
Peripheral nerves
Sacroiliac joint block & radiofrequency denervation
Epidural steroid inj.
Selective transforaminal epidural steroid inj.
Stellate ganglion, thoracic sympathetic, splanchnic nerves, coeliac
plexus, hypogastric plexus, ganglion impar
Long-term epidural catheters
Long-term subcutaneous & intravenous infusions
Intravenous farmacological tests: opioids, lidocaine, ketamine etc.
Intradiscal procedures (coblation nucleoplasty)
Vertebroplasty
Postoperative pain services
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No uniform model of postoperative pain service
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Available models of services:
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Intermitent analgesics according to patient request
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Intermitent analgesics according to schedule
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Continuous analgesic methods with separate postoperative pain service
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Decision is upon the hospital
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Larger hospitals tend to provide more consistent services
Pain service
availability
University hospitals
Regional cetres hospitals
Local hospitals
Yes
82%
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19%
dr.G.Laurinenas data, 2004
Palliative care situation
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Services are at the very begining of systemic
development
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Many long-term nursing and supportive
treatment hospitals are licenced to provide
palliative care
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Not many of them provide palliative care in its
full extend
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Lack of education is considerable
Organizations related to pain
management
Lithuanian Society of
Anaesthesiology and
Intensive Care
Lithuanian
Pain Society
Lithuanian Society of
Palliative Medicine
(chapter of IASP)
Association of
Pain Clinics
Information sources
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“Pain medicine” (Lithuanian Pain Society, journal in Lithuanian)
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“Pain News” (Lithuanian Pain Society, bulletin in Lithuanian)
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“Pain conception and management” (J.Baubliene, book in
Lithuanian)
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“Chronic non-oncological pain and its treatment with opioid
analgesics” (A. Sciupokas, book in Lithuanian)
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“Pain treatment with opioid analgesics” (A.Vaitkus, book in
Lithuanian)
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“Postoperative pain management – good clinical practice”
(Lithuanian translation of ESRA recommendations)
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“Principals of diagnostics and treatment of malignant tumors of main
localizations” (group of authors, book in Lithuanian)
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“Diseases of nervous system” (group of authors, book in Lithuanian)
Education
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Patient education
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Medical students:
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Incorporated in Anesthesiology programme (during 5th year)
Incorporated in Neurology programme (during 5th year)
Residency:
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several programs (e.g. arthritic, diabetic patients)
individual education in the course of treatment
Anesthesiology-reanimatology: 2 months obligatory round in pain
clinic
Neurology: obligatory round in pain clinic
Nursing studies
Continuous medical education
(CME)
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Anesthesiology:
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children postoperative pain, postoperative pain management
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specialized pain management
General therapeutics:
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Neurological
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pain in neurology practice, headaches
Rehabilitation
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acute, chronic pain, oncological
back pain
Palliative care
Vilnius University
and
Kaunas University of Medicine
Conclusions
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During 15 years of development many systemic changes
achieved
Continuous development & growing
5000
4500
Data from Vilnius University Hospital Santariskiu Clinics
4000
3500
3000
2500
2000
1500
1000
500
0
2000
2001
2002
2003
Consultations
2004
2005
2006
2007
Interventional procedures
2008
Conclusions
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Still, improvement needed in:
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pain education,
specialist preparation,
reimbursements for pain medicines and services,
palliative care,
introduction of modern technologies.
Thank you !