Presented by: Dr Brendan Moore — Pain Medicine Specialist Physician Event: GP Education Day - 2013

1. 3/21/2013
1
“This Unbearable Pain”
The Post-operative Dilemma
Dr Brendan Moore
Pain Medicine Specialist
Physician
Adjunct Associate Professor
University of Queensland
Topics for today
• Post operative pain Dilemma
Workshop
• Interventions for mechanical back pain
– Opioid issues
•“An unpleasant sensory and emotional
experience associated with actual or potential tissue
damage, or described in terms of such damage.”
Defining pain
International Association for the Study of Pain Web site.
Availableat:http://www.iasp-pain.org/terms-p.html. Accessed30 June, 2006.
International Association for
the Study of Pain (IASP)
The continuum of pain1
<1 month
Time to resolution
3-6 months
Acute
Pain
Chronic
Pain
• Usually obvious tissue damage
• Increased nervous system activity
• Pain resolves upon healing
• Serves a protective function
• Pain for 3-6 months or more2
• Pain beyond expected period
of healing2
• Usually has no protective
function3
• Degrades health and function3
1. Cole BE. Hosp Physician 2002; 38: 23-30.
2. Turk DC and Okifuji A.Bonica’s Management of Pain 2001.
3. Chapman CR and Stillman M. Pain and Touch 1996.
Insult
Classifications of pain
Acute
Chronic
Duration
Nociceptive
Neuropathic
Pathophysiology
Acute vs chronic pain states
Acute Chronic
• Associated with tissue
damage
• Increased autonomic
nervous activity
• Resolves with healing of
injury
• Serves protective
function
• Extends beyond expected
period of healing
• No protective function
• Degrades health and
functioning
• Contributes to depressed
mood
vs
Turk DC, Okifuji A.In: Bonica’s Management of Pain 2001; Chapman CR, Stillman M.In: Pain and Touch.
Handbook
of Perception and Cognition. 2nd ed. 1996;Fields.Neuropsychiatr Neuropsychol Behav Neurol 1991; 4: 83-
92.

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2
Nociceptive Neuropathic
Nociceptive vs neuropathic pain states
• Arises from stimulus outside
of nervous system
• Proportionate to receptor
stimulation
• When acute, serves
protective function
• Arises from primary lesion or
dysfunction in nervous system
• No nociceptive stimulation
required
• Disproportionate to receptor
stimulation
• Other evidence of nerve damage
vs
Serra J. Acta Neurol Scand 1999; 173(Suppl):7-11.
Nociceptive and neuropathic pain
• Arthritis
• Mechanical low
back pain
• Sports/exercise
injuries
• Postoperative pain
NeuropathicpainNociceptive pain Mixed
• PainfulDPN
• PHN
• Neuropathiclow back pain
• Trigeminal neuralgia
• Central poststrokepain
• Complex regional pain syndrome
• Distal HIV polyneuropathy
Caused by
lesion or dysfunction
in the nervous system
Caused by tissue damage
Caused by
combination
of primary
injury and
secondary
effects
• Low back pain
• Fibromyalgia
• Neck pain
• Cancer pain
International Association for the Study of Pain.IASP Pain Terminology.Raja SN, et al. in
Wall PD, Melzack R (Eds). Textbook of pain.4th Ed. 1999; 11-57.
“Sciatica”: mixed pain state
Baron R, Binder A. Orthopade 2004;33: 568-75.
Disc
C fibre
C fibre
A fibre
Nociceptive component:
Sprouting fromC-fibres into the disc
Neuropathic component I:
Damage to a branch of the C fibre due to
compressionand inflammatory mediators
Neuropathic component II:
Compressionof nerveroot
Neuropathic component III:
Damage to nerveroot by inflammatory mediators
Central sensitisation
The Evolution of
a Persistent Pain
Dr
James
O’Call
aghan
Anaesthetist
andPain
Medicine
Specialist
MaterPrivate
Clinic,
Brisbane
Recovery
Chronic Pain Disability Cycle1
1. Analgesic ExpertGroup Therapeutic Guidelines: Analgesic. 2007
Surgery
Rehabilitation
despite pain
Pain-dependent
behaviour
Behaviour NOT
dependent on pain
ACUTE PAIN
CHRONIC PAIN
DISABILITY CYCLE Desperation
Hopelessness
Anger
Loss of controlInappropriate management
Social stresses
Anxiety
Activity avoidance
Unhelpful beliefs
Passive treatments
Demands for treatment
Deconditioning
Drug tolerances
Transition To Persistent Pain1
Emotionally
charged
Loss of:
• Hope
• Confidence
• Trust
Stressed
relationships
• Family
• Doctor
Poor
communication
Desperation
1. Analgesic ExpertGroup Therapeutic Guidelines: Analgesic. 2007

3. 3/21/2013
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Psychosocial Yellow Flags1
Work Behaviours
Believe pain is harmful 
fear avoidance behaviour
Believe pain must be
abolished before returning to
work
Compensation issues
Passive attitude to rehab.
Use of extended rest
 activity
Avoidance normal activities
 alcohol consumption
Beliefs Affective
Catastrophising, thinking of
the worst
Misinterpreting bodily
symptoms
Believe pain is uncontrollable
Depression
Feeling useless, not needed
Irritability
Anxiety
Lack of support
Overprotective partner
1. Jensen S. Aust Fam Physician 2004;33(6):393-401
Factors Associated with Persistent Back Pain1
• Premorbid factors
– Older age
– High levels of psychological distress
– Below average self rated health
– Low levels of physical activity
– A history of low back pain
– Not being employed, dissatisfaction with current employment
• Episodic factors
– The presence of widespread pain
– Long duration of symptoms prior to consultation
– Radiating leg pain
– Restriction of spinal movement
1. Thomas E, etal. BMJ 1999;318(7199):1662-7.
Influences on Progress and Outcome1
• Negative influences
– Maladaptive ‘treatment’
style
– Maladaptive family
‘support’
– Maladaptive work
environment
– Conflict
– Unrealistic expectations
– Maladaptive response to
life stressors
• Positive influences
(on early response)
– Adequate assessment,
treatment and support
– Early pain relief
– Appropriate style
• Patient, family, GP
– Understanding their
situation
– Realistic expectations
– Adaptive response to life
stressors
1. As adapted from Analgesic ExpertGroup Therapeutic Guidelines: Analgesic. 2007
Persistent Postoperative Pain1
• Preoperative factors
– Moderate – severe pain lasting more than 1 month
– Repeat surgery
– Psychological vulnerability
– Worker’s compensation
• Intraoperative factors
– Nerve damage during surgery
• Postoperative factors
– Pain (acute, moderate – severe)
– Depression
– Psychological vulnerability
– Anxiety
– Neuroticism
1. Perkins FM, Kehlet H.Anesthesiology 2000;93(4):1123-33.
Persistent Pain Requires a Different Approach1,2
Acute pain Persistent pain
Cure the illness causing the pain Restore physical, psychological, social
function, minimise distress
Symptom relief Control pain to tolerable level,  distress
Focus on the painful part “Whole person” rehabilitation
Expectation: return to previous health
status
Adjustment is necessary,
new skills/lifestyle
Passive dependent patient Active coping, participating patient
Active “hands on” practitioner Practitioner who acts as a “coach”
Analgesics given according to current
level of pain, dose reviewed frequently
Regular, predictable schedule of
analgesics
Medication and physical modalities Multidisciplinary approach
Short-term focus Long-term focus
Rest is often appropriate Activity is generally appropriate
1. Analgesic ExpertGroup Therapeutic Guidelines: Analgesic. 2007. 2. NSW TAG. Prescribing guidelines for
primary care clinicians. General principles. 2002.
Observations and Advice
from the clinical “coal face”

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Post operative Pain
• Strong analgesia ceased at 2 to 4 weeks
• Important to plan to cease strong analgesia
• Surgeon doesn’t intend long term
continuation of post op analgesia
• Proportion of patients fail the plan !!
Need a New Plan !!
• Change in the Pain
• Mixed pain condition
– Nociceptive and Neuropathic
• Comprehensive Management plan
– Not medications alone
– Aim at restoration of physiotherapy and function
Medication Plan
• Paracetamol / NSAIDs
• Adjuvant Analgesics
• Gabapentin / Pregabalin
• Tricyclic antidepressants (or others)
• Strong Analgesia
Strong Analgesia
A setback not a sentence!!
• Clear definitive plan
• Short term increase, then reduce and cease
• Sustained release only
• By the mouth and by the Clock
• No short term, no breakthrough
• Pre-determined dose reduction
Favoured Cocktails and
Recipes
Favoured Cocktails and Recipes
1. Paracetamol1gm, qid
2. NSAIDs
– Ibuprofen 400mg tds
– Celebrex 200mg bd  100mg bd
3. Tricyclic Antidepressant
– Amitriptyline 25 50mg nocte
– Sedation and sleep acceptable (often desirable)

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Favoured Cocktails and Recipes
4. Gabapentinoids
• Gabapentin 300mg, 300mg, 600mg
• Pregabalin 150mg, 300mg
Staged increase in dose
Higher dose at night
Opioid sparing effect
Favoured Cocktails and Recipes
• Strong Analgesia
Hydromorphone 4mg x 20 tabs
8mg daily x 5 days
then, 4mg daily x 10 days
Oxycontin 10 or 20mg x 20 tabs
2tabs x 5days
then, 1 tab x 10 days
Pain the Fifth Vital Sign™
“Pain is not a normal part of ageing,
and should be evaluated as in
any other age group”
We need to regularly ask about the
presence of pain.
American Pain Society
Mashford MLet al, Therapeutic Guidelines: Analgesics Ed 4, 2002
How persistent pain can
become a problem
Adapted from: Nicholas, 2008.
Management of pain
Belgrade MJ. Postgrad Med 1999; 106: 101-40.
Ashburn MA, Staats PS. Lancet 1999; 353: 1865-69.
Abuaisha BB,et al. Diabetes Res Clin Pract 1998; 39: 115-21.
Pharmacotherapy
Physical
rehabilitation
Interventional
regional
anesthesia
Complementary/
alternative
Lifestyle
Neurostimulatory
Psychological
Treatment approaches

6. 3/21/2013
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Is the Pain Mechanical or Not?
Mechanical Non-Mechanical
(red flags)
Pain
Poorly localised
Worse later in the day
Usually worst when sitting, worsens
with movement
Usually localised
No diurnal variations
Uninfluenced by posture or movement
Spinal movement
Painful limited movement usually of
several segments
Normal or hypomobility limited to one
or two segments
Tenderness
Diffuse Localised
Other features
Patient is essentially well Of underlying disease
Neurological signs
May be present May be present
Adapted from Mashford. Therapeutic Guidelines Analgesic; 2002.
Acute and Persistent Pain:
Different Clinical Entities1
• Acute pain:
– Recent onset
– Expected to last a short
time
– Expectation is complete
recovery
• Persistent pain:
– Persists for > 3 months
– Expectation is not one
of cure
Recurrent acute pain,
feature elements of both acute and
persistent pain
1. Analgesic ExpertGroup Therapeutic Guidelines: Analgesic. 2007
Biomedical Aspects of Pain1,2
• Nociceptive pain  noxious stimuli, e.g.
ongoing tissue damage
• Neuropathic pain  neurological injury or
dysfunction
• Clinical features suggesting neuropathic pain:
– Absence of obvious tissue damage or inflammation
– Characteristic descriptors:
• Burning, shooting, sharp pain
– Sensory findings both
• Positive e.g. allodynia/hyperalgesia
• Negative e.g. sensory loss
1. Analgesic ExpertGroup Therapeutic Guidelines: Analgesic. 2007
2. Jensen TS, etal. Eur J Pharmacol 2001;429:1-11.
Red Flags1
• Most clues are in the history
1. Australian Acute Musculoskeletal Pain Guidelines Group. Evidence-based managementofacute musculoskeletal pain.Aguide for clinicians. 2004.
Feature or Risk Factor Condition
Symptoms or signs of infection (e.g. fever)
Risk of infection (e.g. penetrating wound)
Infection
History of trauma or minor trauma (if > 50 years,
osteoporosis + corticosteroiduse)
Fracture
Previous history of cancer
Unexplainedweight loss
Age > 50 years
Pain at rest
Pain at multiplesites
Failure to improve with treatment
Tumour
Absence of aggravatingfactors Aortic aneurysm
Pain and Impact on Quality of
Life1
Physical well-being Psychological well-being
Stamina/strength
Appetite
Sleep
Functional capacity
Comfort/pain
Coping
Control
Enjoyment/happiness
Sense of usefulness
Anxiety/depression/fear
Social well-being Spiritual well-being
Social support/family
Sexuality/affection
Employment
Finances
Roles and relationships
Isolation/dependence/burden
Religion
Sense of
purpose/meaning/worth
Hopefulness
Uncertainty
Suffering
1. Lynch TJ, Jr. Pain the fifth vital sign. J Intravenous Nursing 2001;24(2):85-94
Factors Associated with Persistent Back Pain1
• Structural changes on spinal imaging
• Disc degeneration
• Disc tears / prolapse
• Facet joint degeneration
• Central & lateral canal stenosis
1. Waris E, et al. Spine 2007 15;32(6):681-4. 2. Jarvik JG, et al. Spine 2005;30(13):1541-8.
3. Schenk P, et al. Spine 2006;31(23):2701-6. 4. Videman T, et al. Spine 2003;28(6):582-8.
Common
as we age
but not
associated
with pain

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GP’s Role1
• Patient education and motivating change
• Biopsychosocial assessment
– Red and yellow flags
– Periodical reassessment and whenever new
symptoms are reported
• Coordination of care and appropriate referral
• Discouraging inappropriate searches for a cure
• Discouraging prolonged treatment that is not
leading to improved function
1. Analgesic ExpertGroup Therapeutic Guidelines: Analgesic. 2007