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Chronic Pain Again. Dr. MC Chu Anaesthesia and Intensive Care PWH. Agenda. Remember the cases last time? Bear in mind the complexity of chronic pain Let’s try to treat them. Treatment principles. Pain as a symptom Find the cause and fix it Pathology oriented Works well in acute pain

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Chronic pain again l.jpg

Chronic Pain Again

Dr. MC Chu

Anaesthesia and Intensive Care

PWH


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Agenda

  • Remember the cases last time?

  • Bear in mind the complexity of chronic pain

  • Let’s try to treat them


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Treatment principles

  • Pain as a symptom

  • Find the cause and fix it

  • Pathology oriented

  • Works well in acute pain

  • Well accepted by patient and doctor


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Treatment principles

  • Pain as a symptom

  • Find the cause and fix it

  • Works well here


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Treatment principles

  • Pain as a symptom

  • Find the cause and fix it

  • Does all headaches have a pathology?


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Treatment principles

  • Pain as a symptom

  • Control the symptom

  • Passive

  • Long term effects and side effects

  • Case specific

  • What are the options?


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Symptom control

  • Medications

  • Antipyretics (paracetamol)

  • NSAID

  • Opioids

  • Antidepressants

  • Anticonvulsants

  • Steroids, muscle relaxants, etc.


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Symptom control

  • Paracetamol

  • Effective in OA knees

  • Amadio Curr. Ther. Res. 1983

  • Effectiveness ~ Ibuprofen

  • Bradley N. Eng. J. Med. 1991

  • Safe and economical, NSAID sparing for elderly

  • Nikles Am. J. Ther. 2005


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Symptom control

  • Paracetamol

  • Evidence in OA only

  • Hepatic and renal toxicity do occur

  • Medication induced headache


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Symptom control

  • Medications

  • Antipyretics (paracetamol)

  • NSAID

  • Opioids

  • Antidepressants

  • Membrane stabilisers (anticonvulsants)

  • Steroids, muscle relaxants, etc.


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Symptom control

  • NSAID

  • Best evidence from rheumatoid arthritis

  • Also good for cancer pain

  • Effective in 5 out of 10 placebo-trials for LBP

  • Effective in 4 out of 9 Panadol-trials for LBP

  • Doubtful value for non-specific musculoskeletal pain

  • Koes Ann. Rheum. Dis. 1997

  • Eisenberg J. Clin. Onco. 1994


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Symptom control

  • NSAID

  • Annual GI bleed risk: 0.8-18% / year

  • Annual death rate: 0.03-0.1% / year

  • MacDonald BMJ 1997


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Symptom control

  • NSAID

  • Risk increase with age, > 4 week use,

  • history of GI bleed / ulcer / CVS disease

  • Least damaging: Ibuprofen

  • Only effective prophylaxis: PPI

  • Yeomans N. Eng. J. Med. 1998


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Symptom control

  • COX-2 specific NSAID

  • You know what happened to your patients


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Symptom control

  • COX-2 specific NSAID

  • You know what happened to your shares?


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Symptom control

  • Medications

  • Antipyretics (paracetamol)

  • NSAID

  • Opioids

  • Antidepressants

  • Membrane stabilisers (anticonvulsants)

  • Steroids, muscle relaxants, etc.


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Symptom control

  • Opioids

  • Gold standard for cancer pain management

  • (mostly) cheap and readily available

  • Administered at every route


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Symptom control

  • Opioids

  • Controversial for non-cancer pain

  • Limited (but positive) evidence of efficacy

  • Extensive side effects

  • Tolerance

  • Dependence

  • Divergence


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Symptom control

  • Opioids

  • Controversial for non-cancer pain

  • “Physicians should make every effort to control indiscriminate prescribing, even under pressure from patients…”

  • Ballantyne N. Eng. J. Med. 2003


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Symptom control

  • Opioids

  • Controversial for non-cancer pain

  • “Opioids are our most powerful analgesics, but politics, prejudice, and our continuing ignorance still impede optimum prescribing”

  • McQuay Lancet 1999


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Symptom control

  • Opioids

  • Practical guidelines for non-cancer pain

  • Exhaust other methods

  • Aim at functional improvement

  • Limit prescription authority, monitor behavior

  • Slow release, avoid injectables

  • Opioid contract


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Symptom control

  • Medications

  • Antipyretics (paracetamol)

  • NSAID

  • Opioids

  • Antidepressants

  • Membrane stabilisers (anticonvulsants)

  • Steroids, muscle relaxants, etc.


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Symptom control

  • Antidepressants

  • Analgesic at below mood altering doses

  • NNT for diabetic neuropathy ~ 3.4

  • Collins J. Pain & Sym. Manag. 2000


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Symptom control

  • Antidepressants

  • Analgesic at below mood altering doses

  • NNT for post-herpetic neuralgia ~ 2.1

  • Collins J. Pain & Sym. Manag. 2000


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Symptom control

  • Antidepressants

  • How good is NNT of 2.1 to 3.4?

  • It is not good for this


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Symptom control

  • Antidepressants

  • How good is NNT of 2.1 to 3.4?

  • It is really good for pain


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Symptom control

  • Antidepressants

  • Major problem: side effects

  • NNH (minor) ~ 2.7

  • No consensus which one is best

  • Classically TCA

  • SSRI: seemed more specific on mood


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Symptom control

  • Medications

  • Antipyretics (paracetamol)

  • NSAID

  • Opioids

  • Antidepressants

  • Membrane stabilisers (anticonvulsants)

  • Steroids, muscle relaxants, etc.


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Symptom control

  • Anticonvulsants

  • Carbamazepime for trigeminal neuralgia

  • NNT ~ 2.6

  • NNH ~ 3.4


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Symptom control

  • Anticonvulsants

  • NNT for diabetic neuropathy (red) ~ 2.7

  • NNT for post-herpetic neuralgia (white) ~ 3.2

  • Collins J. Pain & Sym. Manag. 2000


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Symptom control

  • Anticonvulsants

  • Gabapentin

  • Less organ damage

  • No drug interaction


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  • Want to have a break?


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Symptom control

  • Intervention

  • Nerve / joint block

  • Counter-stimulation


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Symptom control

  • Nerve block

  • Where to cut

  • How to cut

  • What is left behind


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Symptom control

  • Nerve block

  • Where to cut

  • How to cut

  • What is left behind


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Symptom control

  • Nerve block

  • Where to cut

  • How to cut

  • What is left behind


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Symptom control

  • Nerve block

  • Where to cut

  • How to cut

  • What is left behind


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Symptom control

  • CNS nerve block

  • Physically protected, relatively immobile

  • Synapses are chemically vulnerable

  • Effects (and side effects) are wide spread


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Symptom control

  • Peripheral nerve block

  • Thick bundles of conducting cables

  • Mobile, difficulties with catheters

  • Impairment is profound yet localised


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Symptom control

  • Visceral nerve block

  • Contain visceral pain fibres k

  • Usually deep seated

  • Anatomically diffuse l

  • Visceral functions .


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Symptom control

  • Nerve block in chronic non-cancer pain

  • Preferably purely sensory block

  • Chemical / thermal neurolysis

  • Minimal dysfunction


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Symptom control

  • Nerve block in chronic cancer pain

  • Cover most abdominal viscera

  • 90% good to excellent relief

  • Eisenberg et al A&A 1995


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Symptom control

  • Joint block


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Symptom control

  • Joint block


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Symptom control

  • Transcutaneous Electrical Nerve Stimulation

  • (TENS)

  • Product of Gate theory

  • Better than placebo in short term

  • Minimal side effects

  • No long term benefit


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Symptom control

  • Spinal cord stimulation

  • Patient controlled

  • No medication

  • Permanent (almost)


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Symptom control

  • Spinal cord stimulation


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Symptom control

  • Spinal cord stimulation

  • Failed back surgery

  • Isolated neuropathy

  • Ischemic heart disease

  • Peripheral vascular disease

  • Pain relief as a therapy


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Symptom control

  • Spinal cord stimulation

  • de Jongste et al Br Heart J 1994


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Symptom control

  • Spinal cord stimulation

  • How does it compare with the “golden standard”?


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Symptom control

  • Angina attacks per week

  • PreopPost-opp-value

  • CABG (51)16.25.2<0.001

SCS (53)14.64.4<0.001

Mannheimer et al Circulation 1998


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Symptom control

  • 6-months cardiac mortality and morbidity

  • MortalityMorbidityStroke

  • CABG (51)778

SCS (53)172

Mannheimer et al Circulation 1998


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Symptom control

  • Spinal cord stimulation

  • Only suitable for smart patients

  • Technical expertise and follow up facilities

  • Complications do occur


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Symptom control

  • Spinal cord stimulation

  • Cost: $ 80,000 HKD

  • Would you take it?


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Treatment principles

  • Pain as a symptom

  • Find the cause and fix it

  • Symptomatic control

  • Pain as a disease

  • How is this disease like?


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Pain as a disease

  • Pain

Insomnia

Depression

Socially deprived

Medical

Dependence

Think negative

In-activity


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Pain as a disease

  • Our contribution

  • “Degenerative”

  • “Bone spurs”

  • “Nothing wrong”

  • “It is in your mind”


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Pain as a disease

  • Our contribution

  • Misunderstanding on Waddell’s signs esp. malingering

  • Incorrect attempts to test for placebo e.g. saline test


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Pain as a disease

  • Need a multi-disciplinary approach

  • Clinical psychology

  • Physiotherapy

  • Occupational therapy

  • Nursing

  • Social work / vocational training


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Pain as a disease

  • Need a multi-disciplinary approach


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Pain as a disease

  • Alleviate their depression

  • Motivate them to mobilise despite pain

  • Encourage active coping

  • Reduce dependency on medical input

  • Stop searching for a cause

  • Stop giving analgesics together with side effects

  • Cognitive behavioral therapy


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Pain as a disease

  • Cognitive behavioral therapy

  • Pain intensity (VAS)


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Pain as a disease

  • Cognitive behavioral therapy

  • Depression (HADS)


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Pain as a disease

  • Cognitive behavioral therapy

  • Catastrophising (PCS)


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Pain as a disease

  • Cognitive behavioral therapy

  • 40 meter carrying load (pounds)


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Pain as a disease

  • Cognitive behavioral therapy

  • Analgesic consumption (types)


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Pain as a disease

  • Cognitive behavioral therapy

  • Pain is the same, but

  • More active

  • Less depressed

  • Less doped


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  • Before we move on to the last bit


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Pain as a specialty

  • Anaesthesia and pain

  • Expertise in peri-operative pain relief

  • Analgesics

  • Regional nerve blocks


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Pain as a specialty

  • Anaesthesia and pain

  • Dr. John J. Bonica

  • “Father of pain medicine”


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Pain as a specialty

  • Getting established

  • IASP and its 65 global chapters

  • Over 300000 members of multiple specialties


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Pain as a specialty

  • Anaesthesiology

  • Orthopediac surgery

  • Neurosurgery

  • Oncology / palliative care

  • Neurology

  • Rheumatology

  • Rehabilitative medicine

  • Psychiatry

  • Radiology


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Pain as a specialty

  • … is to specialize in everthing!


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Pain as a specialty

  • Opportunity to work with other doctors


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Pain as a specialty

  • Other activities


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Pain as a specialty

  • Training

  • Diploma in Pain Management (HKCA)

  • Fellowship in Pain Medicine (ANZCA)


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Pain as a specialty

  • Pain centres at HK (2006)

  • AHNHPWH

  • QEHUCH

  • QMHPYNEH

  • Smaller scale ones at DK, PM, etc.


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Resources for you

  • Internation Association for the Study of Pain

  • www.iasp-pain.org

  • HK College of Anaesthesiologists

  • www.hkca.edu.hk

  • Oxford pain Internet site

  • www.jr2.ox.ac.uk/bandolier/booth/painpag/index.html


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