Download Pain Management

"Hypochondria is
the only illness I
don’t have."
And other comments in relation to pain
If
• Medical decision is making based upon:
• Science
• Logic
• Hence EBM
I Know How We Take Decisions?
• Medical decision is making based upon:
• Science
• Logic
• Hence EBM
• Why opinion and variation?
In Chronic pain guiding objective
evidence is simply lacking
• Socioeconomic and
psychosocial factors
have more bearing
on decision making
I Know How We Take Decisions
• Are you more likely to dismiss pain behaviour
where there is lack of medical evidence for pain?
• How do you judge pain associated with
psychosocial stressors?
• And in combination?
I Know How We Take Decisions
• Are you more likely to dismiss pain behaviour
where there is lack of medical evidence for pain?
• How do you judge pain associated with
psychosocial stressors?
• And in combination?
I Know Secondary Care is not Well
Organised in or Beyond the Trust
• Currently an epidural or
joint injection for pain
might be under the care of:
• Pain clinic
• Rheumatology
• Orthopaedics
• Several other local and
distant providers are also
encouraging referrals
• These services are not:
• Timely
• Close to the patient (when
possible)
• Integrated and
multidisciplinary
• Has “arms” where the
treatments in (and not in)
that arm are clear
• The result: confused
referrers sending
patients around in circles
Chronic Pain Questions
• Who are we, are we needed?
• Pain patients: they’re all mad aren’t they?
• What do X-rays and scans tell us about the cause
of back pain?
• They can’t exercise because it hurts can they?
• Should I see all patients with pain?
• Can we treat any of them, can we treat them all?
My Home
And please help estates
with their spelling
The Team
Epidemiology and
Assessment
How Do Doctors React When
Confronted With a Chronic Pain
Patient?
“I am pleased to see that
you have referred her on to
psychiatry. I hope this will
end all her pain problems”
•
SAS general surgeon MTW from
clinic 29/3/11
Should I see all patients with pain?
• How common is
pain?
• How common are
pain specialists?
• How long have
training programmes
been in place for pain
specialists?
Should I see all patients with pain?
• How common is
pain?
• How common are
pain specialists?
• How long have
training programmes
been in place for pain
specialists?
• 1 in 8 adults in
Europe
• 1 per 32,000 patients
• Not long
• Manchester 13 years
• MTW 8 years
• FFPMRCA 7 years
Can’t we just cure them?
• How good are we at
diagnosing the cause of
back pain?
• Do injections cure pain?
• Do physical therapies
cure pain?
• Does surgery have a
good evidence base in
treating back pain?
• Are the costs of
treatment and range of
treatments increasing?
• Are the outcomes
improving?
Limitations of Assessment
• “It is not possible to interpret clinical
abnormalities on the basis of only anatomical
data”
• “No lesion seen on MRI can be established as the
cause of LBP”
• Lesions do not predict response for the
“evidence based therapies” available
• “Disc abnormalities on MRI occur in up to 1/3 of
asymptomatic patients”
Red Flags
Red Flags
• Up to 25 questions
looking at signs of
• Infection
• Cancer
• Cauda equina/
unstable lesions
• Very sensitive if all
questions asked
>99%
• But……………
• Specificity <1%
When Do Red Flags Matter
• 71 year old female
• 5 month on/off history new back pain
• No radiation
• Came on after viral illness
• Poor response to meds
• Some response to physio (hands on)
• PMH breast Ca “cured 2010”
In This Case
In This Case
Yellow Flags
•
•
•
•
•
•
Attitudes/beliefs about pain
(NB low recovery
expectations)
(Illness) behaviour
Emotions (anxiety, distress &
depression)
Family reinforcement
Work and compensation
issues (blue and black)
A belief in passive treatments
What Has Happened?
On 1st presentation
After 2 years of “treatment”
Learned Dependency Despite a Lot
of Drugs
On 1st presentation
After 2 years of “treatment”
What Do We Accept/Expect?
• Culture and pain reporting
• Religion and pain
• Autonomic nervous system
and pain
• Heart rate (variability)
• Skin conductance
(fluctuations)
• fMRI
What is fear avoidance behaviour?
What Not to Say (Medical FAB)
• Hurt = Harm
• All acute back pain is a
“blown disc”
• You should always rest
when in pain
• The nervous system is
hard wired
• You are mad
• Something must be
done
Is Pain impacted by the co-occurrence of
Anxiety and/or Depression ?
Pain only
7
6
Pain + Anxiety
5
Pain + Depression
4
range : 0-10
Pain Score (mean)
Brief Pain Inventory
8
3
Pain + Anxiety +
Depression
2
1
P < .001
Pain Severity
Pain Interference
Bair MJ, et.al Psychosomatic Medicine 2008;70:890-897
Odds ratio
Odds ratio
Does Anxiety, Depression, or Sleep Problems
Predict the Development of Pain?
Depression
(HAD Anxiety sub-score)
(HAD Depression sub-score)
Odds ratio
Anxiety
Sleep
(Sleep Problem Scale)
Gupta A, et.al. Rheumatology 2007. 46:666-671
15 month
Prospective study,
3171 followed, 324
developed CWP
Are My Patients Mad or Representative?
• Many of our
patients have a
significant issue
with:
• anxiety (64%)
• depression (66%)
Dividing Patients
Pathology
Psychology
• Red flags
• Worsening/Improving
• Radicular
• Anxiety/depression/
beliefs
• Non specific
• Risks for chronicity
80% recover vs 40% not settling
10% (near) constant significant limitation
Culture and Pain
• We don’t know
much
• Seems important
though!
Coggon 2013
Investigation(s)/ MRI
• New or changing symptoms
• Previous carcinoma
• Other red flags
• Reassurance (of who?)
• Scans do not often change
much year on year
• Bloods if possibly
inflammatory
• X-ray only if suspected fracture
Smoke, Mirrors, Psychology and the
Brain
And Just in Case You Missed That
Placebo Mechanisms
•
•
•
A positive
consultation with a
health professional is
associated with
better outcome.
The success rate of a
procedure increase
by 10% if you give it
the hard sell
The failures will
suffer increased
distress and
depression
• Naloxone impairs
placebo analgesia
•
Lancet 1978
• Analgesia is
enhanced by a nurse
over a machine
•
Bennetti Lancet 1995
• Remifentanil
effectives versus
placebo nurse and
active nurse
•
Tracey et al
Imagery and Pain
What happens to pain
when you view?
Flowers, Food,
Violence (extreme),
Sex
Placebo Surgery Trials
• Mammary arterial Occlusion
for refractory angina
• Arthroscopy and washout for
arthritic knee pain
• Has this evidence changed
practice?
Treatments
NICE Guidelines for Medium Term
Non Specific Back Pain
• No routine scan, no X-rays
• No diagnostic blocks
• No therapeutic blocks
• No intra discal procedures
• No RF
• Limited hands on therapy (several types)
• Scan if considering spinal fusion for treatment
failures
• (they are allowed psychology pre-surgery if they
are distressed by this)
Why Is the Evidence for Treatments So
Poor?
• Eclectic groups
• Poor/inaccurate diagnosis
• Bad trials lacking objectivity
and rigor, often with real
(and undeclared) conflict of
interest issues
• Many therapies may be
effective for small numbers
of patients, but we simply
aren’t sure which
Looking at Outcomes
(Going Back To Front)
• Most effect sizes are low
• Change in belief,
attitudes and coping
may dictate whether
change occurs regardless
of treatment option
• Guidelines vs patient
preference
• Addressing negative
beliefs
•
•
•
•
•
•
Weight
Smoking
Work
Relationships
Attitude
Pain management
Outcomes 2
• Patient centred
outcomes vs
objective measures
•
•
•
•
•
•
Symptoms
Function
Well being
Social disability
Work disability
Satisfaction
• Minimal clinically
important change vs cost
and inconvenience
• Remember expectation
change
• Learn to mange
expectation
• Best evidence is
more population
based campaigns
Work Is Good For You(r Mental Health)
• We now have evidence
that work is a positive
outcome factor in
mental health
• We have known for
years that being out of
work was a negative!
www.tsoshop.co.uk/flags
Occupational health and Pain
The Big Black Flag?
• Defensive practice
• Time off
• Denied return
• Difficulties in arranging
phased returns
• Acceptance that an
uncomfortable task is
damaging
• Ergonomics and evidence?
•
•
•
•
•
•
Awkward postures
Standing and walking
Manual handling
Pushing and pulling
Bending and twisting
Lifting and carrying
Managing Pain Outside a Pain Clinic
•
•
•
•
•
•
Standard drugs
Anti inflammatories
Anti neuropathics
Physiotherapy
Osteopathy
Alternatives
• Support, encouragement & reassurance
“Hands on Therapies”
•
•
•
•
Traction-a few poor trials
failed to demonstrate
benefit
Manipulation-short term
benefit? No better than
placebo in long term
Acupuncture has widely
conflicting reviews in the
literature
Massage-little literature
but that there is suggests
a least a short term
benefit
•
•
•
•
Magnets-evidence is
strongly against an effect
Lumbar supports-no
evidence
TENS-weak evidence at
best
Hydrotherapy-short term
(at least) improvement in
function not in pain
Evidence in Physiotherapy
•
•
Lamb et al: Back skills training trial. BMC
Musculoskelet Disord. 2007 Feb 22;8:14.
Bennell et al: Efficacy of standardised manual
therapy and home exercise programme for chronic
rotator cuff disease: randomised placebo
controlled trial. BMJ 2010
Activity risk has a U shaped curve (at least in the
Dutch)
STarT back
•
Cooper et al: Mortality predictors.....BMJ 2010
•
•
Exercise
• General exercise can have a modest positive
benefit for pain and function
• Core stability has some promising evidence of
benefit
•
•
•
•
•
Swimming
Pilates
Tai Chi
Yoga?
Cycling?
“They can’t exercise because it
hurts”
• So they can’t lose
weight
• Is the weight the
problem
• Do any of our patients
lose the weight
• How does weight loss
surgery work
• What does it achieve
in our patients?
Licenced to fail
Pharmacological Treatment Options
(for Neuropathic Pain)
• Lorazepam
• Clonazepam
• alprazolam
•TCAs (many)
•Venlafaxine
•Duloxetine
Benzos
SSRIs
SNRIs
α2δ
ligands
•
•
•
•
•
Fluoxetine
Sertraline
Paroxetine
Citalopram
escitalopram
• Gabapentin
• Pregabalin
Initial Treatment
of Neuropathic
Pain (West Kent
guidelines)
Case: Smokey Management
• 24 year old female
• Chronic fatigue
• Widespread pain
• Multiple opinions
• Poor response to
“treatments”
• Oxycodone 2-250mg
• Tramadol 400
• Amitriptyline 100
• Citalopram 40
• Duloxetine 60
• Diazepam
• Zopliclone
Case: Smoky Management
• Tertiary orthopaedic referral
• Further pain clinic referral gave a “plan”
•
•
•
•
•
•
Increase duloxetine
Add Gabapentinoid
Lignocaine infusions
Long term hydrotherapy
Long term acupuncture
Consider psychology
• Allow local clinic to sort this
Is Morphine the Answer?
Side Effects
•
•
•
•
•
•
•
•
Constipation
Nausea
Xs sweating
Dry mouth
Poor concentration
Drowsiness
Libido/?fertility
?Immune function
(Driving)
Key points to remember before prescribing opioids for long term pain
•Opioids are not first line drugs for chronic pain conditions. Simpler therapies, (drug & non-drug), should
have been tried first and proved ineffective.
•Complete relief of pain is rarely achieved. Strong opioids should never be viewed as monotherapy but as
part of a broader approach to improve patient function.
•The goal should be to reduce pain sufficiently to facilitate engagement with rehabilitation and the
restoration of useful function.
•A clear diagnosis should be available if possible.
•It is recommended that there is a sole or restricted number of prescribers
•Develop a treatment plan prior to starting opiods; these should involve clear goals with a steady plan to
progress towards them.
•Most types of chronic pain may respond, however there are around 30% of non-responders.
•If in doubt, consider specialist referral at an early stage
Practical prescribing
Morphine is the opioid analgesic of choice. (consider laxative & antiemetic cover at dose initiation)
Long-acting (LA) formulations given at regular intervals are preferred & are associated with a lower risk of problem
behaviour. These should never be taken as required.
Dose should be started low and titrated upwards reviewing regularly for efficacy, side effects & signs of problem
behaviour
Warn the patient it may take some time to determine if the drug will be effective.
Upward titration of the dose should stop when either pain is relieved or side effects become intolerable. Optimal
dose is when patient experiences analgesic efficacy (10-30% pain reduction), minimal benefit from further dose
increases and no major side effects. Increasing the dose above this will merely increase side effects.
Occasionally short-acting preparations taken as required (alone or in combination with LA formulation) may give a
better result. eg pain varies in intensity during the day or pain is intermittent. (Note:The combination of regular LA
and PRN short-acting is often used in palliative care)
Injectable opioids should not be used in the management of patients with persistent noncancer pain BUT are widely
used in palliative care and cancer related pain.
If patients do not achieve useful relief of pain symptoms at doses between 120-180mg morphine equivalent in 24
hours, referral to a specialist in pain medicine is strongly recommended.
Opioid choice if morphine is ineffective or not tolerated.
•No opioid has demonstrated a clear clinical advantage in either efficacy or a reduction in side effects over
others
•Many opioids are available; it is better to become familiar with only a few. Surveys suggest patients prefer
patches but they restrict water based activity, do not stick well in hot weather and are expensive. Compound
preparations are not recommended
•If no response/intolerable side effects, consider switching to another opioid.
•Do not continue with opioid treatment if patient has failed on 3 different preparations.
Opioid equivalent for long-acting formulations on a 24 hour period
Remember: These are approximate. If you switch opioid, start on 50-75% equivalence of the previous drug;
remember re-titration may be necessary.
Please note this conversion chart has been simplified; no conversion is exact and other charts may vary.
Conversion ratios: 24 hour PO morphine to fentanyl: divide by 4
PO morphine to PO oxycodone : divide by 2
PO tramadol to PO morphine: multiply by 0.1
PO codeine/dihydrocodeine to PO morphine: multiply
by 0.1
Take great care at higher dose conversions and seek advice if necessary.
WEST KENT GUIDELINES FOR
PRESCRIBING STRONG OPIOIDS IN ADULT
NON-CANCER CHRONIC PAIN
Monitoring
Patients need regular review (at least monthly during dose titration) until well established on treatment. Review for
both:
•Efficacy. (Improved function, well being & sleep are as important as reduced pain)
•Side effects. These will occur in 80% of patients. Common side effects include constipation, nausea, itching,
somnolence, poor memory & dizziness
Points to note:
•Remember to consider laxative & antiemetic cover at dose initiation.
•Most side effects will settle except constipation & itching
•Tolerance to pain relieving effects may occur and often this seems to happen early in treatment; it may limit opioid
use.
•Patients on stable doses who are not affected by drowsiness are able to drive. Patients should not drive during dose
titration.
•The likelihood of unwanted effects & interactions increase when opioids, (including tramadol) are used in conjunction
with other centrally acting drugs, such as antidepressants, anticonvulsants & alcohol
•Exercise extreme care in the elderly and those with known renal impairment
•Remember to review the agreed treatment plan as part of the monitoring process. This is important as this focuses
on goals such as increased function and return to normal activities as well as pain control.
Stopping opioids
•Around half of patients trialled on strong opioids will discontinue them within 2 years. This may be due to lack of or
loss of effects, side effects, problem behaviour, resolution of the pain
•If opioids are stopped suddenly about half of patients will suffer withdrawal effects. These can be dangerous.
•Tapering the dose by 25-50% every few days is adequate to avoid this for most patients.
•If pain flares markedly or symptoms of withdrawal still occur temporarily, slow or reverse changes
•If in doubt, seek specialist advice
Special situations
•Low dose long-acting morphine is recommended as first line in most situations
•In renal failure morphine and pethidine (and their metabolites) may accumulate and should not be used.
•Fentanyl, tramadol and buprenorphine are considered safer options in renal failure however use with caution.
•Butrans patch may be a sensible choice when (1) patient is frail/elderly (2) there is a marked & troublesome on/off
effect with codeine or (3) codeine resistance is suspected and an alternative opioid is indicated prior to the use of
strong opioids.
•There is evidence of opioid induced hyperalgesia in some patients and this should be considered especially if
increasing doses seem to be needed to control pain when previously a stable dose was used.
Problem drug use
•Physical dependence is a normal physiological response; however psychological dependence is not.
•Addiction is a drug craving when a patient knows that the effects are harmful. If concerned, shorten prescription &
review times, consider dose reduction and referral for a specialist opinion.
•The rate of problem drug use in this group of patients is unclear
•A past history of problem drug use is only a relative contra-indication for prescribing
Opioid equivalent for long-acting formulations on a 24 hour period
Morphine
(mg/24hrs)
oral
10
20
Oxycontin
(mg/24hrs)
oral
5
10
Fentanyl
(mcg/hr)
patch
Buprenorphine
(mcg/hr)
patch
30
~ 12
5
10
40
60
90
120
180
270
20
30
45
60
100
160
12
12-25
25
50
75
20
35
52.5
70
Remember: These are approximate. If you switch opioid, start on 50-75% equivalence of the previous drug;
remember re-titration may be necessary. Take great care at higher dose conversions and seek advice if unsure
Please note this conversion chart has been simplified; no conversion is exact and other charts may vary.
The “cost” of managing
opioid-induced constipation
Targinact tablets
10/5 mg b.d.
®
OxyContin + Docusol
®
+ Senokot syrup
OxyContin®
+ Docusol
OxyContin®
+ Movicol
®
OxyContin + Dioctyl
+senna tabs
OxyContin®
+ Dioctyl
OxyContin + lactulose (500 ml)
+ senna tabs
OxyContin
+ lactulose (500 ml
Injections What Are They For?
• Cure
• Palliation
• Obtunding an acute
inflammatory response
• Creating a window of
opportunity
• Avoiding drugs and side
effects
• Making money
Injections can have complications
Injections
• Steroids have an evidence base for
radiculopathy
• Epidurals do not for chronic back
pain (NNT 10)
• Epidurolysis has no evidence in its
favour either blind or via endoscope
and can make you blind
• In the long term repeat injections
will run out of steam
But
• There are situations where we
might help
Discography
• Does Discography Cause
Accelerated Progression of
Degeneration Changes in the
Lumbar Disc: A Ten-year
Matched Cohort Study
Carragee et al
Spine. 2009;34(21):2338-2345
Case-Disc Disease
•
•
•
•
26 year old man
Manual job
Low back/left leg pain
Some improvement with
hydrotherapy
• RNS-not for surgery
• “Seeking a cure”
At Pain Clinic
• Straight to discography
• And…..
Disc Treatments
•
•
•
At this stage the
available evidence for
all intra-discal
therapies is poor and
they should be
viewed as
experimental not
proven
Dubious trials exist
that got some
therapies a license
The American
guidelines conclude
this (ASA 2010)
Surgery in LBP
• Place for surgery in
non specific LBP?
(fusion vs rehab)
• Supposed superiority
of surgery vs EBM
superiority of PMP?
• Newer treatments
and better outcomes
• MRC collaborative
BMJ 2005
• Louisiana vs New
York
• FDA license for disc
replacements
Is Surgery Becoming More
Common for LBP
• 1990-2000 220% increase in spinal operations in
US
• 1997-2002 procedures per year 320,0001,000,000
• 5x lower in UK
• All this despite fusion being an unproven
operation and ethics of disc replacement surgery
trials questionable
Costs of Failed Surgery
• Direct medical appointments, scans, treatments,
drugs (1998 est 1.6billion/year)
• Indirect transport, adaptions, social care, lost
productivity, DLA (1998 est 6.6-12 billion/year)
• Rate of FBSS is unknown (but est 10-40% AAPM
2001)
Failed Surgery versus Other
Chronic Diseases
FBSS
Rheumatoid
Pain score
higher
QoL (EQ-5D)
0.16
0.4-0.75
Disability
(Oswestry)
Employment
56
27
Brit Med J 2010; 340: c221
lower
Similar Qol with NIDDM and CCF (Pain 2010; 149: 338–344)
Brit Med J 2010; 340: c221
• Similar Qol with NIDDM and CCF (Pain 2010; 149: 338–344)
Factors Predicting Poor
Outcome From Surgery
• Chronicity (the “deconditioning syndrome”)
• Not first operation
• Scale of operation
• Psychological factors/disorders
• Non specific “signs”
• Smoking
Disc Prolapse
Disc “Surgery”
Possibly the Best Fusion in the
World
Case-Expectation Management
• 17 year old female
• Heavy landing show
jumping
• Immediate hip pain
• Admitted via A+E and
single split disc on
scan
• Improved 5-60% with
analgesia and an
epidural
• Improvement cessed
• Referred to Kings
despite already
having had 2
opinions locally
• No change
• Re-referred with no
mention of long term
drug problem
Managing Difficult Patients
• Do not doctor shop
or cure seek or use
scatter guns
• Order the right tests
at the right time
(agree guidance)
• Know who to refer to
and when
• Manage expectation
• Manage fear
But if you do…..
Pain Management
Programmes
Open Access Psychology?
Open Access Psychology?
Recommendations From the British
Pain Society
Excerpts from the BPS Consensus
Guidelines in Pain Management in
Adults 2007
“Pain management
programmes bases on
cognitive behavioural
principles, are the
treatment of choice…”
“Evaluation of outcomes
should be standard
practice, assessing
distress/emotional
impact of pain…”
Better than placebo up to at least 2 years
Not everyone is suitable
Back school is not a pmp
Cognitive Behavioural Management of
Chronic Pain
41.2
*
38.2
*
*
34.9
31.9
• Six weekly 90
n=41
minute group
sessions
• Based on CBT
Attention
management
manual
Pre-treatment
Post-treatment
7.1
*
*
6.1
5.6
Average Pain
n=18
*
3 month Follow-up
5.7
(0-10 scale) Pain-related Anxiety
20) n=20
6 month Follow-up
(Pass-
(data for individuals completing 6 month follow-up)
Elomaa MM et al. European Journal of Pain. 2009
Barriers to Improving Care
•
•
•
•
•
Self interest
Self importance
Inaccurate selling
Lazy or friendly referring
Poor management
• Failing to spot the obvious/lack of insight
Those Who Try Tend To Do
Better
I know Unhappy Back Pain Patients Get
Brain Rot
Patients with chronic back pain (CBP) had 511 % less whole brain gray matter, equivalent
to 10-20 years of normal aging
Apkarian AV,et.al. J Neurosci.2004;24(46)P10410-10415