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This Unbearable Pain
- 1. 3/21/2013 1 “This Unbearable Pain” ThePost-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.
- 2. 3/21/2013 2 Nociceptive Neuropathic Nociceptive vsneuropathic 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 3 Psychosocial Yellow Flags1 WorkBehaviours 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”
- 4. 3/21/2013 4 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)
- 5. 3/21/2013 5 Favoured Cocktails andRecipes 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 6 Is the PainMechanical 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
- 7. 3/21/2013 7 GP’s Role1 • Patienteducation 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