Download SkelePain - Bolton MLZ

Guideline Development:
Issues for Primary Care
Dr Barry Miller
Consultant in Pain Medicine & Anaesthesia
Royal Bolton Hospital
Pain Facts
from the RCGP commissioning guide (draft)
The easy bit !!
Pain is one of the world’s most common symptoms
Chronic pain appears to be more common now than it was 40 years
ago, and as detailed within the Health survey for England 2011 affects
more than 14 million people
➲ Chronic pain has a major impact on people’s lives, causing
sleeplessness and depression and interfering with normal physical and
social functioning.
➲ It has been estimated that back pain alone costs the economy £12.3
billion per year. The cost of pain from all causes is far higher.
➲ The limited number of specialist pain clinics around the country are
inundated with referrals, and only 14% of people with pain have seen a
pain specialist. Systems and infrastructure are not adequate to meet
need or demand.
➲ Better coordination of services and services designed
around the patient’s needs are essential.
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Implications
Easy implications !!
Pain,
not appropriately managed, results in:
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avoidable visits to GP’s
avoidable steps and delays in a patient pathway
avoidable A&E attendances
avoidable emergency admissions
multiple visits to hospital
high analgesia cost
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Poor quality of life for patients
Duplication and the generation of waste within the system.
How to approach the problem in a
commissioning framework
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Seeing pain as a separate service rather than as an add on to others
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Commissioning pain services using a chronic disease model
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Supporting providers in increasing productivity
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The development of integrated care pathways and service models
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Looking at the best possible outcome for the majority of its population by
following best practice
This model will not work if :
[] Chronic Pain is viewed as a ‘quick fix’ by the Any Qualified Provider (AQP)
agenda, or
[] As an entity that can be managed by managing other diseases
Managing these patients alone is fraught
with pitfalls
Starting place
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There are five 'pain issues' to consider:
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Initial assessment and early management of pain
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Spinal pain
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Chronic widespread pain, including fibromyalgia
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Neuropathic Pain
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Pelvic Pain (male & female)
Diagnosis
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Consider this a 'label' to direct therapy/referral
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Cauda Equina >>>>> Neurosurgery
Joint Pain >>>> Rheumatology
Low Back Pain >>>>> ??????
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It is important to recognise the process of labelling
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Is it a 'diagnosis' ?
(Hint: YES)
For good or bad
Investigate to include/exclude the healthcare options
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Not an end in itself
How to approach
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Remember what healthcare provides
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Surgery
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Injections
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Medicines / Tablets / Creams
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Physiotherapy
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Coping Strategies
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Alternative approaches
Consider 'Low Back Pain'
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Probably the most complicated pathology in modern
medicine
The interaction of muscle, tendon, ligament, joint and
bone is poorly understood
We have no meaningful means of assessing 'function'
or 'dysfunction'
We have simple blood tests to diagnose destructive
disease processes e.g. Rheumatoid
We have crude static imaging to see a 'one time'
snapshot of misalignment / fracture / etc
Managing Low Back Pain
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Where to begin when patient first attends
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How to manage initially – for the many who will
improve spontaneously and rapidly
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How to recognise the risk factors for chronicity
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How to manage the intermediate phase
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Where to go after that
Where to find the answer
Low Back Pain
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NICE guidelines
Low Back pain (excluding Sciatica)
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Less than one year
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Map of Medicines
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Pain of Spinal origin
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(British Pain Society & NHS England’s Clinical Reference
Group for Pain)
Includes NICE approach
Other guidelines
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e.g. Forthcoming SIGN guidelines
Guideline Development
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Diagnosis of 'acute' (simple) low back pain
Red flags and radicular signs not present
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Very early phase
Analgesia
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Simple Paracetamol / NSAIS+PPI / Minor Opioids
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Advice regarding the management of side effects (esp. GI,
constipation)
'Active' advice – verbal & written
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Evidence suggests this has little impact
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StarT tool
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'Physiotherapy' – simplified Pain Management event
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Advice, reassurance, written advice – both on exercise and
local facilities – Low risk discharged
Medium + High risk
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Greater Physiotherapy intervention
Where next ?
All patients should have basic work with specialist
physiotherapists
(in the management and risks of Low Back pain)
Not all physiotherapists can provide this
Guidance, Reassurance, Q&A
Failure to educate and reassure early on is a key
marker of chronicity
Moderate & High ‘risk’ STarT scorers need additional input.
Additional Pharmacology
• Consider what the aim is ?
• Is this part of a rehabilitative, maintenance or holding
strategy
• What drugs?
• TCAs
• sedative at low dose (10-50mg)
• Analgesic (for neuropathic components) at higher
doses (50-100mg)
• Side Effects – don’t underestimate patient concerns
about being labelled as ‘depressive’
• Gabapentinoids
• Strong Opioids
Where Next ?
• Specialist Diagnostic / Physiotherapy services
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Musculoskeletal CATS
Set up to consider non-acute diagnostics
Surgical assessment
Advanced Physiotherapy
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Acute and Sub-acute management
Later management of some chronicity risks
And then……
• Pain Management Service (us!)
• Managing ‘chronicity’
• Pharmacology
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Drug combinations/doses/'outside the BNF'
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Diagnostic, rehabilitative, maintenance
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Individual medium/long term work
Physiotherapy – Active management models,
incl. CBT
Psychology – e.g. CBT, Mindfullness,
Acceptance, etc
Nursing
Pain Management Programme – Gold
Standard Rehabilitative approach
• Interventions
• 'Pain Management'
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