Chronic Pain Management

Dr D TonucciMB ChB DCH FRCA FFPMRCAClinical Lead of Pain Service

Consultant in Anaesthesia and Chronic Pain MedicineRoyal Surrey County Hospital NHS Foundation Trust

Mount Alvernia HospitalGuildford Nuffield Hospital

Typical outdated view of pain

• 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 PAIN WASWAS LOW ON LOW ON THE AGENDA OF THE NHSTHE AGENDA OF THE NHS

But things have changed....

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.

Chronic Pain Policy Coalition

All Party Parliamentary Chronic Pain Working GroupLaunched May 2009CMO, 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

• Married and working• Poor career progression• Fertility problems• Many yellow flags• No red flags• Patient very angry and looking for a cure

Initial consultation

• Where to start?• History and examination• Reassure?• MRI scan?• Address opiod dependency?• Address psychosocial issues – marital, work?

MRI scan

• A picture says a thousand words• Reassurance needed• Scan shows Shuermans scoliosis mild• Some inflammation in thoracic facets

Follow up at 6 weeks

• 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

• 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

• Serves a protective function

• Usually has an apparent noxious insult

• Serves no protective function

• Degrades health and function

Acutepain

Insult

Chronicpain

≥3–6 months

McMahon SB and Koltzenburg M. Wall and Melzack’s Textbook of Pain. 5th ed. London: Elsevier; 2006, pgs 205, 235–6McMahon SB and Koltzenburg M. Wall and Melzack’s Textbook of Pain. 5th ed. London: Elsevier; 2006, pgs 205, 235–6

Chronic or Persistent Pain

• 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 lifeLoss of independence

Loss of salaryMissing special

occassions Losing touch with loved ones and friends

Feeling like a burden

Loneliness

Inability to maintain relationships

Inability to achieve goals

Loss of me-time

Loss of personal achievements

Loss of social element

Loss of health benefits

Loss of self esteem

Loss of personal relationships

Loss of contact

Feeling left out

Feelings of isolation

Loss of motivation

The Biopsychosocial Model

IN CHRONIC PAIN:

PAIN ≠ HARMPAIN ≠ DAMAGE

When should we be worried?

• Constant progressive (thoracic, lying down)

• Deformity• History of Cancer• Drug abuse (including

steroids)

• Neurology– bladder– saddle anaesthesia– sensory loss– Bowel / bladder

• Acute trauma• Fever• Weight loss etc

Serious spinal pathology Serious spinal pathology (red flags)(red flags)

Acute / Chronic LBPWhere 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?

• 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?• 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 :

– 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

Neuropathic painPain initiated or causedby a primary lesion or

dysfunction in theperipheral or central

nervous system2

Nociceptive painPain caused by

an inflammatory ornon-inflammatory

response to an overt orpotentially tissue-damaging

stimulus1

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

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

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 Osteoarthritis

Synovial membrane

Cartilage

Synovialfluid

Jointcapsule

Inflammationas bones rub

together

Thinned cartilage

Felson DT. Arthritis Res Ther 2009;11:203Felson DT. Arthritis Res Ther 2009;11:203

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

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

Common descriptorsShootingElectric shock-likeBurningTinglingNumbness

Post-herpetic neuralgia

Chronic post-surgical pain

Post-stroke pain

Diabetic peripheral neuropathy

The co-existence of nociceptive andneuropathic pain

Both types ofpain co- exist in

many conditions(mixed pain)

Neuropathic painNociceptive pain

Webster LR. Am J Manag Care 2008;14 (5 Suppl 1):S116–22Ross E. Expert Opin Pharmacother 2001;2:1529–30Webster LR. Am J Manag Care 2008;14 (5 Suppl 1):S116–22Ross E. Expert Opin Pharmacother 2001;2:1529–30

Lumbarvertebra

Disc herniation

Activation of peripheral nociceptors –cause of nociceptive pain component1

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;13:185–901. 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

Example of co-existing pain: herniated disc causing low back pain and lumbar

radicular pain

To understand drugs in pain medicine we need to understand

how and where they work!

Ascending Pain Pathway

Remember fMRI

Descending Pain Pathway

Pharmacology of Pain

Analgesics may act:1. At the site of injury to reduce nociceptor firing2. May alter / slow / stop nerve conduction3. May modify transmission in DRG / dorsal horn / CNS4. May affect central component and emotional aspect

of pain5. May act on descending pathways6. 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;175:265–752. Bennett MI et al. Pain 2007;127:199–2033. Haanpää ML et al. Am J Medicine 2009;122:S13–S21

1. Gilron I et al. Can Med Assoc J 2006;175:265–752. Bennett MI et al. Pain 2007;127:199–2033. Haanpää ML et al. Am J Medicine 2009;122:S13–S21

Making a diagnosis

LISTEN

LOCATE LOOKNervous system

lesion/dysfunction2

Sensory abnormalities,pattern recognition1,2

Patient verbal descriptors,Q & A1

1. Baron R, Tölle TR. Curr Opin Support Palliat Care 2008;2:1–82. Haanpää ML et al. Am J Medicine 2009;122:S13–S211. Baron R, Tölle TR. Curr Opin Support Palliat Care 2008;2:1–82. Haanpää ML et al. Am J Medicine 2009;122:S13–S21

‘Numbness’

‘Shooting’

‘Burning’

Patients with neuropathic pain may use these

pain descriptors

Be alert for commonverbal descriptors of NeP

‘Electric shock-like’

‘Tingling’

Locate: correlate the region of pain to the lesion/dysfunction in the nervous system

Carpal tunnel syndrome2 Diabetic peripheral neuropathy3Lumbar radiculopathy1

1. Freynhagen R, Baron R. Curr Pain Headache Rep 2009;13:185–90 2. Michelsen H, Posner A. Hand Clin 2002;18:257–683. Perkins T, Morgenlander JC. Postgrad Med 1997;102:81–2, 90–2

1. Freynhagen R, Baron R. Curr Pain Headache Rep 2009;13:185–90 2. Michelsen H, Posner A. Hand Clin 2002;18:257–683. Perkins T, Morgenlander JC. Postgrad Med 1997;102:81–2, 90–2

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

– 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–S212. Gilron I et al. Can Med Assoc J 2006;175:265–753. Baron R, Tölle TR. Curr Opin Support Palliat Care 2008;2:1–8

1. Haanpää ML et al. Am J Medicine 2009;122:S13–S212. Gilron I et al. Can Med Assoc J 2006;175:265–753. 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 utilisethe 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;127:199–2032. Freynhagen R et al. Curr Med Res Opin 2006;22:1911–201. Bennet M. Pain 2007;127:199–2032. Freynhagen R et al. Curr Med Res Opin 2006;22:1911–20

The inter-relationship between neuropathic pain, sleep and

anxiety/depressionPain

Functionalimpairment

Anxiety anddepression

Sleepdisturbance

Nicholson B et al. Pain Med 2004;5 (Suppl 1):S9–S27 Nicholson B et al. Pain Med 2004;5 (Suppl 1):S9–S27

Patients with neuropathic pain experience significant co-morbid symptoms

Patients with ‘moderate’ to ‘very severe’ discomfort (n=126)

4020 70600 503010

Patients (%)

Difficulty sleeping

Lack of energy

Drowsiness

Difficulty concentrating

Depression

Anxiety

Poor appetite

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al im

pai

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Adapted from Meyer-Rosberg et al. Eur J Pain 2001;5:379–89Adapted from Meyer-Rosberg et al. Eur J Pain 2001;5:379–89

Non-pharmacological treatment ofneuropathic 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;175:265–752. Pardo-Fernández J et al. Rev Neurol 2006;42:451–4

TENS, Transcutaneous electrical nerve stimulation

1. Gilron I et al. Can Med Assoc J 2006;175:265–752. Pardo-Fernández J et al. Rev Neurol 2006;42:451–4

Pain condition Recommendations for first line

Recommendations forsecond/or third line

Painful polyneuropathy

Gabapentin Lamotrigine

Pregabalin Opioids

Tricyclic antidepressant SNRI

Tramadol

Post-herpetic neuralgia

Gabapentin Capsaicin

Pregabalin Opioids

Lidocaine, topical (for small area of pain allodynia)

Tramadol

Tricyclic antidepressant Valproate

Trigeminal neuralgia Oxcarbazepine Surgery

Carbamazepine

Central pain Amitriptyline Cannabinoid

Gabapentin Lamotrigine

Pregabalin Opioids

EFNS guidelines on pharmacological treatment of neuropathic pain

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 inhibitorAdapted from Attal N et al. Eur J Neurol 2006;13:1153–69

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 inhibitorAdapted 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

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