www.hnehealth.nsw.gov.au/pain

Hunter Integrated Pain

Service (HIPS)

Welcome to

RNC

Understanding Pain

1

2

3

4

Whole person management

The new science

Introducing HIPS & what next?

What is pain?

Outline

What is pain?

Indication of threat Actual or potential

damage Emotional

experience

Short term Often linked to body structures

• under threat• damaged

What is acute pain?

threat ... damage ...Egloff N, Hirschi A, von Känel R. J Pain Research 2013;6:765–70

Lasts 3 months or more Often persisting after body structures heal Wind up of nervous system

What is chronic pain?

hyper-alert ... flea bite feels like the eagles claws

Egloff N, Hirschi A, von Känel R. J Pain Research 2013;6:765–70

The new science2

Role of nervous system Wind up or sensitisation

increases pain Winding down reduces

pain

Structural changes and ongoing pain

Painful, swollen, stiff left ankle

Imagined exercise of the phantom limb relieved symptoms

Haigh et al 2003 Rheumatology

Symptoms without the structure

Davidson, McEwen. Social influences on neuroplasticity. Nat Neurosci. 2012;15(5):689-95

Chronic stress changes neurons

• Ongoing pain linked to emotional response to initial injury

• “Traumatic” memory imprints the brain in a different way

Baliki, Apkarian et al. Corticostriatal functional connectivity predicts transition to CBP. Nature Neurosci. 2012

Back pain recovering

Back pain persisting

Brain changes predict persisting pain

Brain habits

Sheep tracks

Winding up or down

Nervous system

Active treatments

Body structures

Medical treatments

For many people the balance is not right

A need to restore balance

Whole person management3

Biomedical

Mindbody

Connection

Activity

Nutrition

Adapted from Hayes & Hodson. A whole person approach to persistent pain. Pain Medicine 2011;12(12):1738-49

Brainman’s choices Think well Move well Eat well

What is the evidence for medical treatments?

“I think the dose needs adjusting. I’m not nearly as happy as the people in the ads.”

0 2 4 6 8 Moulin et al. Lancet 1996 time (weeks)

Morphine in chronic pain

Well known• Constipation• Drowsy, clouded thinking• Tolerance• Addiction

Did you know about ?• Worsening pain (opioid induced

hyperalgesia)• Sexual dysfunction• Driving impairment, risk of death (especially with sleeping tablets)

Opioid side effects

STEP 1: Rule out danger Harmful structural problems? Red flags – cancer, fracture,

infection, nerve pressure

STEP 2: Medical treatment as part of broad approach

Medications / procedures Time limited Pain recovery plan

Biomedical

Opioid strategy

HIPS support you & GP for as long as needed to wean off opioids

Time limited

This is normal

Mind & body interweave

Awareness of thoughts

Peace of mind

Mindbody

Eccleston C. A normal psychology of chronic pain. 2011;24(6):422-425

Timeline

People, purpose, place

Isolation & disconnection are common

Reconnecting - part of recovery & wellbeing

Connection

Finding the right balance

Body awareness

Awareness of thoughts behind the movement

Ease of movement, ease of mind

Activity

Nutrition

Fruit & vegetables (2 & 5)

Less sugary drinks

Time limited supplements

Address smoking, alcohol, other drugs

NutritionInflammatory diet worsening pain

6 months of low back pain after an injury at work

Scan - disc bulge & tear

Brian’s story

No red flags - spinal structure less relevant

More about changes in brain & spinal cord

Oxycontin not working ‘Men should get on with it’ Pushing through, ‘boom &

bust’ cycle

Brian’s assessment

Opioid wean over 4 months

Goal setting – travel & grandchildren

Awareness of thoughts Pacing activity Improve flare up

management

Brian’s pain recovery plan

Background pain from 8/10 to 6/10

Positive changes in thinking, mood & activity

Less interference with life Flare ups

• fewer• managing differently

Brian’s recovery

30 yrs married Not working due to poor

health Chronic widespread pain

& fatigue

Anna’s story

Nutrition• less processed food• more vegetables• omega 3 fish oil • weight loss 5 kg

Psychological aspects • local counsellor

Anna after Understanding Pain

Onset pain & fatigue age 15 years; ‘fibromyalgia’

Widespread pain in muscles & joints 6-8/10

Long term Norspan – no ongoing benefit

Low mood Avoidance of activity

Anna’s assessment

Large family, Anna eldest child

Father’s business failed when Anna was 15 yrs; he moved away

“my childhood ended” “weight of responsibility

settled on my shoulders”

Anna’s timeline

Biomedical - wean Norspan over 3 months Mindbody workbook / local counsellor Return to work & future education options Walking program - “pacing” Continue “anti-inflammatory” eating

Anna’s pain recovery plan

Phone call at 1 month• Continuing with pain

recovery plan Phone call at 8 months

• 80% less pain & fatigue• Further 5 kg weight loss• Work as part-time cleaner• TAFE course• Mindbody Workbook –

forgiveness

Anna’s recovery

Hunter Integrated Pain Service

Public system Types of pain

• Chronic non-cancer • Acute• Cancer

General practice links

4

1. Use active treatments2. Get support3. Wean pain medication

Key messages

HIPS websitewww.hnehealth.nsw.gov.au/pain

Google: Hunter Integrated Pain Service

Small group

Supported self-assessment

Pain assessment & recovery plan• biomedical• mindbody• connection• activity• nutrition

Assessment and Planning

Your choice

GP Early community link

HIPSAssessment &

Planning

Community options

HIPSoptions

Where next?