Presented by: Dr Brendan Moore – Pain Medicine Specialist Physician Elena Yusim – Psychologist Event: Mackay GP & Allied Health Education Day - 2014

1. Interven'onal
Procedures
in
Chronic
Pain
Dr
Brendan
Moore
Specialist
Pain
Medicine
Physician
Adjunct
Associate
Professor
University
of
Queensland

2. Degenera've
Lumbar
Back
Pain

4. Origins
of
lumbar
pain
• Degenera've
Discs
• Vertebral
fractures
• Spinal
/
Foraminal
Stenosis
• Disc
Bulge
/
Prolapse
• Facet
Joint
• Muscle
/
So@
'ssue

5. Invasive
Treatment
Op'ons
• Surgery
• Facet
Joint
Injec'on
• Radiofrequency
medial
branch
abla'on
• Epidural
/
Caudal
steroid
• Vertebroplasty
• Coeliac
/
Lumbar
Sympathe'c
Plexus
Blocks
• Sacro-­‐iliac
Joint
injec'on

6. Posterior
Elements
• Facet
Joints
frequently
implicated
in
pain
• Mechanical
back
pain
with
upper
leg
and
buNock
radia'on

7. Appropriate conditions for
interventional pain procedures
• Aseptic conditions
• Monitored sedation
with anaesthetist in
attendance
• Image intensifying X-
ray or CT guidance
• Appropriate analgesia

10. Procedures
• Epidural injections
– Cervical, Thoracic, Lumbar, Caudal
• Facet joint injections
• Sacroiliac joint injections
• Medial branch blocks
• Radiofrequency nerve ablation

11. Epidural injections
• Most effective in the presence of nerve root
compression and spinal stenosis
• Increased efficacy if given in the first weeks of
the onset of pain
• Effects of the injection tend to be temporary (1
week to 1 year)
• Can be beneficial in providing relief for patients
during an episode of severe back pain
• Allows patients to progress in their rehabilitation

12. Lumbar epidural injection
• 18G or 16G Toohey
needle
• Radio-opaque contrast
to confirm position
• Injection and
distribution of local
anaesthetic and
steroid to nerve root

13. Lumbar
Epidural
Injec'on

14. Caudal
Epidural
Injec'on

15. Facet joint injections
• Back pain originating from facet joints
• Low back pain (unilateral or bilateral) and no
root tension signs or neurological deficits
• Pain usually being aggravated by extension of
the spine
• Facet joint injection may reduce inflammation
and provide pain relief
• Therapeutic goal and potential benefit
– Temporary relief from pain
– Patient may proceed into an appropriate exercise program"

16. Facet
Joint
Injec'on
• Primarily
diagnos'c
• 25G
Spinal
needle
• LA
+
Steroid
• Steroid
confers
possible
longer
term
benefit

17. Sacroiliac joint injection
• Indicated with referred pain
• Pain referral pattern – area around and just
caudal to the posterior superior iliac spine
• Referred pain in the low back, buttocks,
abdomen, groin or legs
• In some patients, S-1 joint injections can
provide significant pain relief"

18. Sacroiliac joint injection
• Diagnostic
• 25G spinal needle
• Local anaesthetic +
steroid
• Steroid indicative of
possible long-term
benefit

19. Sacro-­‐iliac
Joint
Injec'on

20. Medial branch blocks
• Medial branch nerves are the very small nerve
branches that controls sensation of the facet joint
• Indicated in low back pain (unilateral or bilateral)
• Pain usually aggravated by extension of the spine
• Medial branch blocks are a diagnostic procedure
• Can provide temporary pain relief

21. Medial branch nerve ablation
• Diagnostic medial
branch blocks
• Local anaesthetic +
steroid
• Progress to
radiofrequency
ablation if diagnostic
block indicative of
long-term benefit

22. Medial
Branch
Nerve
Abla'on
• Denerva'on
of
Medial
Branch
via
Radiofrequency
Neurotomy

23. Radiofrequency neurotomy
X-ray to confirm needle position – AP and oblique
views
Test stimulation – 2.0 Hz 0–2 volt to test for motor
nerve contact
Lesion 85°C for 90 seconds

24. Cervical radiofrequency neurotomy
Position for C2/3 and C3/4 facet joint
radiofrequency

25. Cervical
Radiofrequency
Neurotomy

26. Cervical radiofrequency neurotomy –
lateral view
Marker shows needle at C2/3 facet joint

27. Coeliac
Plexus
Block

28. Facet joint injection
• Diagnostic
• 25G spinal needle
• Local anaesthetic +
steroid
• Steroid indicative of
possible long-term
benefit

31. Elena Yusim – Pain Psychologist
The Psychology of Pain
Management

32. Strategy
Psychosocial
Assessment
§
medical
history
–
any
flags/concerns/drug
seeking
§ Thinking
paNerns
–
helpful
or
unhelpful
§ Social
interac'ons
-­‐
family,
friends,
spouse
§ Behaviours
-­‐
ac'vity
levels,
avoidance,
anything
harmful
§ Sleep
paNerns
–
any
changes

33. Testing
§ Beck
Depression
Inventory
–
BDI
§ Depression,
Anxiety
and
Stress
Scale
–
DASS
§ Personality
Assessment
Inventory
-­‐
PAI

34. Reality Check
§ Why
is
the
pa'ent
here?
§ Mo'va'on
to
RTW?
§ Any
secondary
gain
from
sick
role?
§ Are
they
prepared
to
do
the
hard
work?
§ Do
they
expect
to
be
fixed?
§ What
do
they
agree
to,
if
they
don’t
comply?

35. Invisible Tool Kit
§ Goal
seng
§ Pacing
§ Journaling
§ Thought
Management
–
CBT,
ACT
§ Relaxa'on
and
self
regula'on
strategies
§ Relapse
preven'on
planning

36. Opioids
in
Chronic
Pain
Dr
Brendan
Moore
Pain
Medicine
Specialist
Physician
Adjunct
Associate
Professor
University
of
Queensland

37. Opioid prescribing:
dose limits and
considerations

38. Suggested maximum opioid dose
• Consult a Pain Medicine Specialist if higher doses
considered necessary
1. Hunter Integrated Pain Service. Opioid use in persistent pain. November 2010
Drug Maximum dose for GP
prescription
Morphine 120mg daily
Oxycodone 80mg daily
Hydromorphone 24 mg daily
Methadone 40mg daily
Fentanyl transdermal patch 25 mcg/hr applied every 3 days
Buprenorphine transdermal patch 40 mcg/hr applied weekly
Tramadol 400 mg daily

39. Dose conversion
Morphine
equivalence to
Ratio
morphine
: named
opioid
Examples of equivalent doses
Codeine 1:6 Morphine 10 mg Codeine 60 mg
Oxycodone 1.5:1 Morphine 60 mg Oxycodone 40 mg
Hydromorphone 5:1 Morphine 60 mg Hydromorphone 12 mg
Tramadol 1:5 Morphine 10 mg Tramadol 50 mg
Fentanyl Morphine 90 mg Fentanyl 25 mcg/h
Buprenorphine 75:1 Morphine 9 mg Buprenorphine 5 mcg/h
Methadone 3:1 Morphine 60 mg Methadone 20 mg
1. Hunter Integrated Pain Service. Opioid use in persistent pain. November 2010

40. Opioid trial guidelines
• Commence trial with low dose sustained-release
opioid
Use a lower dose and titrate slowly in patients
who are:
• Elderly
• Taking other CNS depressants
• Opioid naïve
• Have severe hepatic or renal dysfunction
1. Graziotti & Goucke, 1997.

41. Review of opioid trial
• Discuss progress and outcomes
• Functional goals achieved?
• Medication used responsibly?
• Discuss risks / benefits of continued therapy
• Assess 4 ‘A’s1
– Analgesia
– Activity
– Adverse effects
– Aberrant drug behaviours
1. Gourlay & Heit, 2005.

42. Federal requirements
PBS prescription
Restricted benefit
• Chronic severe disabling pain not responding to non-
narcotic analgesics (treatment <12 months)
• If treatment required beyond 12 months, patient must be
reviewed by a second medical practitioner
• Authority required when prescribing increased quantities
of opioid and/or repeats
– By phone – 1 month’s supply with no repeats
– In writing – 1 month’s supply with 2 repeats
• Short term supply can be prescribed without an authority
Department of Health and Ageing, 2008.

43. State requirements - QLD
• If intend to prescribe S8 drugs for longer than 8 weeks,
forward a “Report to the Chief Executive” through the
Drugs of Dependence Unit (DDU)
• A treatment approval from the Chief Executive is required
prior to treating, for any controlled drug for a patient
considered to be drug dependent
• For approvals and “Reports to the Chief Executive” contact
the Drugs of Dependence Unit
– Phone 3328 9890
– Fax 3328 9821

44. Preventing doctor-shopping
Medicare Australia
Prescription Shopping Information Service
• If patient suspected of getting medicine in excess
of medical need, contact the Prescription
Shopping Information Service:
– Complete and sign the registration form available at
www.medicareaustralia.gov.au
• Registration confirmed within 2 business days (fax) or by
mail
– Information Service available 24/7 for registered GPs to:
• Find out if patient has been identified under the
Prescription Shopping Program
• Receive information on the amount and type of PBS
medicine recently supplied to that patient
(
1800
631
181

45. Summary – opioid pathway
Multidimensional assessment
GP +/– practice nurse +/– others
Opioid trial
Maintenance therapy
Authority to Prescribe
Review
Exit from pathway:
i. Goals of therapy not
achieved in trial or
maintenance phase
ii. Predominance of
psychosocial issues
iii. Evidence of aberrant
drug related
behaviour
Integrated Pain Service, 2008.
Is the patient suitable for opioid therapy?

46. State / territory health departments
State /
territory
Department Contact
ACT Pharmaceutical Services Section, ACT Health ( 02 6207 3974
NSW Pharmaceutical Services Branch, NSW Health ( 02 9879 3214
8 www.health.nsw.gov.au/publichealth/
pharmaceutical
NT Poisons Control Unit, Department of Health &
Community Services
( 08 8922 7341
8 www.health.nt.gov.au
QLD Drugs of Dependency Unit, Queensland Health ( 07 3896 3900
SA Drugs of Dependence Unit, Drug & Alcohol Services,
Department of Health
( 1300 652 584
8 www.health.sa.gov.au
TAS Pharmaceutical Services Branch, Department of
Health & Human Services
( 03 6233 2064
VIC Drugs & Poisons Unit, Department of Human
Services
( 1300 364 545
8 www.health.vic.gov.au/dpu
WA Drugs of Dependency Unit, Department of Health ( 08 9388 4985