Chronic pain again
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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

Chronic Pain Again

Dr. MC Chu

Anaesthesia and Intensive Care

PWH


Agenda

Agenda

  • Remember the cases last time?

  • Bear in mind the complexity of chronic pain

  • Let’s try to treat them


Treatment principles

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


Treatment principles1

Treatment principles

  • Pain as a symptom

  • Find the cause and fix it

  • Works well here


Treatment principles2

Treatment principles

  • Pain as a symptom

  • Find the cause and fix it

  • Does all headaches have a pathology?


Treatment principles3

Treatment principles

  • Pain as a symptom

  • Control the symptom

  • Passive

  • Long term effects and side effects

  • Case specific

  • What are the options?


Symptom control

Symptom control

  • Medications

  • Antipyretics (paracetamol)

  • NSAID

  • Opioids

  • Antidepressants

  • Anticonvulsants

  • Steroids, muscle relaxants, etc.


Symptom control1

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


Symptom control2

Symptom control

  • Paracetamol

  • Evidence in OA only

  • Hepatic and renal toxicity do occur

  • Medication induced headache


Symptom control3

Symptom control

  • Medications

  • Antipyretics (paracetamol)

  • NSAID

  • Opioids

  • Antidepressants

  • Membrane stabilisers (anticonvulsants)

  • Steroids, muscle relaxants, etc.


Symptom control4

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


Symptom control5

Symptom control

  • NSAID

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

  • Annual death rate: 0.03-0.1% / year

  • MacDonald BMJ 1997


Symptom control6

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


Symptom control7

Symptom control

  • COX-2 specific NSAID

  • You know what happened to your patients


Symptom control8

Symptom control

  • COX-2 specific NSAID

  • You know what happened to your shares?


Symptom control9

Symptom control

  • Medications

  • Antipyretics (paracetamol)

  • NSAID

  • Opioids

  • Antidepressants

  • Membrane stabilisers (anticonvulsants)

  • Steroids, muscle relaxants, etc.


Symptom control10

Symptom control

  • Opioids

  • Gold standard for cancer pain management

  • (mostly) cheap and readily available

  • Administered at every route


Symptom control11

Symptom control

  • Opioids

  • Controversial for non-cancer pain

  • Limited (but positive) evidence of efficacy

  • Extensive side effects

  • Tolerance

  • Dependence

  • Divergence


Symptom control12

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


Symptom control13

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


Symptom control14

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


Symptom control15

Symptom control

  • Medications

  • Antipyretics (paracetamol)

  • NSAID

  • Opioids

  • Antidepressants

  • Membrane stabilisers (anticonvulsants)

  • Steroids, muscle relaxants, etc.


Symptom control16

Symptom control

  • Antidepressants

  • Analgesic at below mood altering doses

  • NNT for diabetic neuropathy ~ 3.4

  • Collins J. Pain & Sym. Manag. 2000


Symptom control17

Symptom control

  • Antidepressants

  • Analgesic at below mood altering doses

  • NNT for post-herpetic neuralgia ~ 2.1

  • Collins J. Pain & Sym. Manag. 2000


Symptom control18

Symptom control

  • Antidepressants

  • How good is NNT of 2.1 to 3.4?

  • It is not good for this


Symptom control19

Symptom control

  • Antidepressants

  • How good is NNT of 2.1 to 3.4?

  • It is really good for pain


Symptom control20

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


Symptom control21

Symptom control

  • Medications

  • Antipyretics (paracetamol)

  • NSAID

  • Opioids

  • Antidepressants

  • Membrane stabilisers (anticonvulsants)

  • Steroids, muscle relaxants, etc.


Symptom control22

Symptom control

  • Anticonvulsants

  • Carbamazepime for trigeminal neuralgia

  • NNT ~ 2.6

  • NNH ~ 3.4


Symptom control23

Symptom control

  • Anticonvulsants

  • NNT for diabetic neuropathy (red) ~ 2.7

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

  • Collins J. Pain & Sym. Manag. 2000


Symptom control24

Symptom control

  • Anticonvulsants

  • Gabapentin

  • Less organ damage

  • No drug interaction


Chronic pain again

  • Want to have a break?


Symptom control25

Symptom control

  • Intervention

  • Nerve / joint block

  • Counter-stimulation


Symptom control26

Symptom control

  • Nerve block

  • Where to cut

  • How to cut

  • What is left behind


Symptom control27

Symptom control

  • Nerve block

  • Where to cut

  • How to cut

  • What is left behind


Symptom control28

Symptom control

  • Nerve block

  • Where to cut

  • How to cut

  • What is left behind


Symptom control29

Symptom control

  • Nerve block

  • Where to cut

  • How to cut

  • What is left behind


Symptom control30

Symptom control

  • CNS nerve block

  • Physically protected, relatively immobile

  • Synapses are chemically vulnerable

  • Effects (and side effects) are wide spread


Symptom control31

Symptom control

  • Peripheral nerve block

  • Thick bundles of conducting cables

  • Mobile, difficulties with catheters

  • Impairment is profound yet localised


Symptom control32

Symptom control

  • Visceral nerve block

  • Contain visceral pain fibres k

  • Usually deep seated

  • Anatomically diffuse l

  • Visceral functions .


Symptom control33

Symptom control

  • Nerve block in chronic non-cancer pain

  • Preferably purely sensory block

  • Chemical / thermal neurolysis

  • Minimal dysfunction


Symptom control34

Symptom control

  • Nerve block in chronic cancer pain

  • Cover most abdominal viscera

  • 90% good to excellent relief

  • Eisenberg et al A&A 1995


Symptom control35

Symptom control

  • Joint block


Symptom control36

Symptom control

  • Joint block


Symptom control37

Symptom control

  • Transcutaneous Electrical Nerve Stimulation

  • (TENS)

  • Product of Gate theory

  • Better than placebo in short term

  • Minimal side effects

  • No long term benefit


Symptom control38

Symptom control

  • Spinal cord stimulation

  • Patient controlled

  • No medication

  • Permanent (almost)


Symptom control39

Symptom control

  • Spinal cord stimulation


Symptom control40

Symptom control

  • Spinal cord stimulation

  • Failed back surgery

  • Isolated neuropathy

  • Ischemic heart disease

  • Peripheral vascular disease

  • Pain relief as a therapy


Symptom control41

Symptom control

  • Spinal cord stimulation

  • de Jongste et al Br Heart J 1994


Symptom control42

Symptom control

  • Spinal cord stimulation

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


Symptom control43

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


Symptom control44

Symptom control

  • 6-months cardiac mortality and morbidity

  • MortalityMorbidityStroke

  • CABG (51)778

SCS (53)172

Mannheimer et al Circulation 1998


Symptom control45

Symptom control

  • Spinal cord stimulation

  • Only suitable for smart patients

  • Technical expertise and follow up facilities

  • Complications do occur


Symptom control46

Symptom control

  • Spinal cord stimulation

  • Cost: $ 80,000 HKD

  • Would you take it?


Treatment principles4

Treatment principles

  • Pain as a symptom

  • Find the cause and fix it

  • Symptomatic control

  • Pain as a disease

  • How is this disease like?


Pain as a disease

Pain as a disease

  • Pain

Insomnia

Depression

Socially deprived

Medical

Dependence

Think negative

In-activity


Pain as a disease1

Pain as a disease

  • Our contribution

  • “Degenerative”

  • “Bone spurs”

  • “Nothing wrong”

  • “It is in your mind”


Pain as a disease2

Pain as a disease

  • Our contribution

  • Misunderstanding on Waddell’s signs esp. malingering

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


Pain as a disease3

Pain as a disease

  • Need a multi-disciplinary approach

  • Clinical psychology

  • Physiotherapy

  • Occupational therapy

  • Nursing

  • Social work / vocational training


Pain as a disease4

Pain as a disease

  • Need a multi-disciplinary approach


Pain as a disease5

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


Pain as a disease6

Pain as a disease

  • Cognitive behavioral therapy

  • Pain intensity (VAS)


Pain as a disease7

Pain as a disease

  • Cognitive behavioral therapy

  • Depression (HADS)


Pain as a disease8

Pain as a disease

  • Cognitive behavioral therapy

  • Catastrophising (PCS)


Pain as a disease9

Pain as a disease

  • Cognitive behavioral therapy

  • 40 meter carrying load (pounds)


Pain as a disease10

Pain as a disease

  • Cognitive behavioral therapy

  • Analgesic consumption (types)


Pain as a disease11

Pain as a disease

  • Cognitive behavioral therapy

  • Pain is the same, but

  • More active

  • Less depressed

  • Less doped


Chronic pain again

  • Before we move on to the last bit


Pain as a specialty

Pain as a specialty

  • Anaesthesia and pain

  • Expertise in peri-operative pain relief

  • Analgesics

  • Regional nerve blocks


Pain as a specialty1

Pain as a specialty

  • Anaesthesia and pain

  • Dr. John J. Bonica

  • “Father of pain medicine”


Pain as a specialty2

Pain as a specialty

  • Getting established

  • IASP and its 65 global chapters

  • Over 300000 members of multiple specialties


Pain as a specialty3

Pain as a specialty

  • Anaesthesiology

  • Orthopediac surgery

  • Neurosurgery

  • Oncology / palliative care

  • Neurology

  • Rheumatology

  • Rehabilitative medicine

  • Psychiatry

  • Radiology


Pain as a specialty4

Pain as a specialty

  • … is to specialize in everthing!


Pain as a specialty5

Pain as a specialty

  • Opportunity to work with other doctors


Pain as a specialty6

Pain as a specialty

  • Other activities


Pain as a specialty7

Pain as a specialty

  • Training

  • Diploma in Pain Management (HKCA)

  • Fellowship in Pain Medicine (ANZCA)


Pain as a specialty8

Pain as a specialty

  • Pain centres at HK (2006)

  • AHNHPWH

  • QEHUCH

  • QMHPYNEH

  • Smaller scale ones at DK, PM, etc.


Resources for you

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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