Download Reducing referrals to the chronic pain clinic

REDUCING REFERRALS TO
THE CHRONIC PAIN CLINIC
Dr Damien Smith FRCA, FFPMRCA
Consultant Anaesthesia & Pain Management
Hillingdon NHS Trust
RECENT NATIONAL PAPERS &
REPORTS



Report by Chief Medical Officer 2009
Nice guidelines for management of lower back
pain
Review of chronic pain services (Wales)
HEALTH SECRETARY AND CMO
CMO REPORT 2009
PAIN : BREAKING THROUGH THE BARRIER
United Kingdom : Pain in numbers
 7.8 million people live with chronic pain
 NHS spent £584 million on 67 million
prescriptions for analgesia
 1 million women suffer with chronic pelvic pain
 1.6 million adults suffer with chronic LBP
 49% adults with CP experience depression
 25% of sufferers lose their jobs
 500 pain specialists in the UK
 Roughly 1 specialist per 250,000 people
 (1 specialist per 32,000 sufferers????)

CMO REPORT
When pain becomes chronic, normal damping
mechanisms stop working
 Biological, psychological and social factors
combine to exacerbate symptoms
 Modern pain management should address all
these elements with an “Integrated Approach”
 Treatments involve activity, rehab, drug therapy,
psychological therapy, TENS, acupuncture and
interventions
 Key is to ensure all aspects are INTEGRATED
and joined up rather than instigated in isolation

IDEAL MODEL
CMO REPORT : IDEAL MODEL?
Level 1 Specialiast Care
Complex Pain Relief
Procedures
Level 2
Community Care
Pain management programmes
Level 3
Primary Care
Out patient physio,
Treatment guidelines
Education programmes
WAYS TO REDUCE REFERRALS
More level 3 services in the community?
 Educational programme for GP’s
 Prescribing guidelines
 Pharmacy teaching of community pharmacists

WAYS TO REDUCE REFERRALS
More level 2 care
 Community screening teams
 Interdisciplinary CBT based programmes
 Patient support groups
 Physio
 ? TENS clinics
 ? Acupuncture clinics
 ? Consultant sessions in the community

NICE GUIDELINES MAY 2009
Early Management of Persistant Lower Back
Pain
 Patients must have back pain for LESS than a
YEAR
 Does NOT cover SUSPECTED :
 Malignancy
 Infection
 Fracture
 Radiculopathy
 Inflammatory disorder

NICE GUIDELINES
Care should be patient centred
 Give patients advice and information to promote
self management
 Exercise
 Manipulation
 Acupuncture
 Psychology

EXERCISE PROGRAMMES
EXERCISE PROGRAMMES
8 sessions over 12 weeks
 Groups of 10
 Aerobic activity
 Muscle Strengthening
 Posture Control
 Stretching

MANUAL THERAPY
MANUAL THERAPY
SPINAL MANIPULATION!!
MANUAL THERAPY
Spinal manipulation
 Spinal mobilisation
 Massage
 MAY be performed by osteopaths and
chiropractors
 9 sessions over 12 weeks

ACUPUNCTURE
ACUPUNCTURE
Advises 10 sessions over 12 weeks
 Does not advise injection of therapeutic
substances into the back

COMBINED WITH PSYCHOLOGY
PROBLEMS WITH THE GUIDELINES
NICE summary: we recommend acupuncture and
manipulation because they work every bit as
good as placebo but we don't recommend
injections as they only work as well as placebo.
 Advise patients to have osteopathy and
chiropractor services?????
 Lack of regulation concerns!!!
 Concerns from medical profession about potential
damage from poorly practiced spinal
manipulation.

PROBLEMS WITH GUIDELINES
No discussion with The British Pain Society
 Multidisciplinary body
 Conflict of interest with BPS chairman
 Chairman had to resign
 NEXT MONTH BPS & NICE will meet to look at
‘reformulating’ the guidelines.

WAYS OF REDUCING REFERRALS
Do not refer patients with NON specific back
pain
 Do not refer patients with less than 1 year
history
 Offer patients exercise, manual therapy,
acupuncture and psychology
 DO REFER patients with known specific back
pain
 DO REFER patients with potential mailignancy,
infection, fracture, radiculopathy or
inflammatory disorder

RECENT SURVEY OF GP’S ABOUT
SERVICES
Questionnaire about local chronic pain services
and questions exploring ways to improve pain
services.
 48% satisfied with service
 15% dissatisfied
 37% neither

WAYS TO IMPROVE THE SERVICE
GP’s wanted: More pain education in GP surgeries
 More advise through the internet
 More hospital based study days

WAYS TO REDUCE NEW REFERRALS
GP’s requested a telephone helpline
 Different triage system
 Email helpline
 More psychological training for community staff
 Stricter criteria to accept patients to pain clinic

PRESCRIBING GUIDELINES FOR
PREGABALIN
Based on a guideline produced by the European
Federation of Neurological Studies
 Algorithm for treatment of neuropathic pain

Neuropathic pain
Localised
Lignocaine patch
Satisfactory
TCA
Gabapentinoid
Pain Clinic
Lignocaine patch
TCA
Gabapentinoid
TRICYCLIC ANTIDEPRESSANTS
Amitriptyline starting dose 10-25 mg nocte
 Dose may be increased to 50 mg nocte
 Not an antidepressant dose and will not interact
with concurrent antidepressants
 Convert to Nortriptyline if problems with
drowsiness (not licensed for pain / /equivalent
dose)
 Contraindications include glaucoma,
hypertension and may lower seizure threshold in
epileptics

GABAPENTIN
Starting dose 300 mg od
 Gradual increase over days up to 900 mg tds
 Requires a lot of patient compliance
 Usually safe to take with other medications
 Effects may be seen in WEEKS
 Dosage needs to be adjusted in patients with
renal dysfunction
 Do not stop abruptly, needs to be done over
weeks

PREGABALIN
Starting dose 75 mg bd
 Increase to 150 mg bd if tolerated
 Can work up to 300 mg bd in some cases
 Effects may be seen in DAYS
 Safe in patients with renal dysfunction

LEICESTERSHIRE MEDICINES
STRATEGY GROUP
Neuropathic pain
Localised
Lignocaine patch
Satisfactory
TCA
Gabapentinoid
Pain Clinic
Lignocaine patch
TCA
Gabapentinoid
OTHER GUIDELINES
RCGP uses CREST guidelines (2006)
 www.rcgp.org.uk

NICE guidelines (March 2010)
 www.nice.org.uk

ANY QUESTIONS?

[email protected]