REDUCING REFERRALS TO THE CHRONIC PAIN CLINIC

1. REDUCING REFERRALS TO THE CHRONIC PAIN CLINIC Dr Damien Smith FRCA, FFPMRCA Consultant Anaesthesia & Pain Management Hillingdon NHS Trust

2. RECENT NATIONAL PAPERS & REPORTS • Report by Chief Medical Officer 2009 • Nice guidelines for management of lower back pain • Review of chronic pain services (Wales)

3. HEALTH SECRETARY AND CMO

4. CMO REPORT 2009PAIN : BREAKING THROUGH THE BARRIER • United Kingdom : Pain in numbers • 7.8 million people live with chronic pain • NHS spent £584 million on 67 million prescriptions for analgesia • 1 million women suffer with chronic pelvic pain • 1.6 million adults suffer with chronic LBP • 49% adults with CP experience depression • 25% of sufferers lose their jobs • 500 pain specialists in the UK • Roughly 1 specialist per 250,000 people • (1 specialist per 32,000 sufferers????)

5. CMO REPORT • When pain becomes chronic, normal damping mechanisms stop working • Biological, psychological and social factors combine to exacerbate symptoms • Modern pain management should address all these elements with an “Integrated Approach” • Treatments involve activity, rehab, drug therapy, psychological therapy, TENS, acupuncture and interventions • Key is to ensure all aspects are INTEGRATED and joined up rather than instigated in isolation

6. IDEAL MODEL

7. CMO REPORT : IDEAL MODEL?

8. WAYS TO REDUCE REFERRALS • More level 3 services in the community? • Educational programme for GP’s • Prescribing guidelines • Pharmacy teaching of community pharmacists

9. WAYS TO REDUCE REFERRALS • More level 2 care • Community screening teams • Interdisciplinary CBT based programmes • Patient support groups • Physio • ? TENS clinics • ? Acupuncture clinics • ? Consultant sessions in the community

10. NICE GUIDELINES MAY 2009 • Early Management of Persistant Lower Back Pain • Patients must have back pain for LESS than a YEAR • Does NOT cover SUSPECTED : • Malignancy • Infection • Fracture • Radiculopathy • Inflammatory disorder

11. NICE GUIDELINES • Care should be patient centred • Give patients advice and information to promote self management • Exercise • Manipulation • Acupuncture • Psychology

12. EXERCISE PROGRAMMES

13. EXERCISE PROGRAMMES • 8 sessions over 12 weeks • Groups of 10 • Aerobic activity • Muscle Strengthening • Posture Control • Stretching

14. MANUAL THERAPY

15. MANUAL THERAPY

16. SPINAL MANIPULATION!!

17. MANUAL THERAPY • Spinal manipulation • Spinal mobilisation • Massage • MAY be performed by osteopaths and chiropractors • 9 sessions over 12 weeks

18. ACUPUNCTURE

19. ACUPUNCTURE • Advises 10 sessions over 12 weeks • Does not advise injection of therapeutic substances into the back

20. COMBINED WITH PSYCHOLOGY

21. PROBLEMS WITH THE GUIDELINES • NICE summary: we recommend acupuncture and manipulation because they work every bit as good as placebo but we don't recommend injections as they only work as well as placebo. • Advise patients to have osteopathy and chiropractor services????? • Lack of regulation concerns!!! • Concerns from medical profession about potential damage from poorly practiced spinal manipulation.

22. PROBLEMS WITH GUIDELINES • No discussion with The British Pain Society • Multidisciplinary body • Conflict of interest with BPS chairman • Chairman had to resign • NEXT MONTH BPS & NICE will meet to look at ‘reformulating’ the guidelines.

23. WAYS OF REDUCING REFERRALS • Do not refer patients with NON specific back pain • Do not refer patients with less than 1 year history • Offer patients exercise, manual therapy, acupuncture and psychology • DO REFER patients with known specific back pain • DO REFER patients with potential mailignancy, infection, fracture, radiculopathy or inflammatory disorder

24. RECENT SURVEY OF GP’S ABOUT SERVICES • Questionnaire about local chronic pain services and questions exploring ways to improve pain services. • 48% satisfied with service • 15% dissatisfied • 37% neither

25. WAYS TO IMPROVE THE SERVICE • GP’s wanted:- • More pain education in GP surgeries • More advise through the internet • More hospital based study days

26. WAYS TO REDUCE NEW REFERRALS • GP’s requested a telephone helpline • Different triage system • Email helpline • More psychological training for community staff • Stricter criteria to accept patients to pain clinic

27. PRESCRIBING GUIDELINES FOR PREGABALIN Based on a guideline produced by the European Federation of Neurological Studies Algorithm for treatment of neuropathic pain

28. Neuropathic pain Localised Lignocaine patch Satisfactory TCA Gabapentinoid Pain Clinic Lignocaine patch TCA Gabapentinoid

29. TRICYCLIC ANTIDEPRESSANTS • Amitriptyline starting dose 10-25 mg nocte • Dose may be increased to 50 mg nocte • Not an antidepressant dose and will not interact with concurrent antidepressants • Convert to Nortriptyline if problems with drowsiness (not licensed for pain / /equivalent dose) • Contraindications include glaucoma, hypertension and may lower seizure threshold in epileptics

30. GABAPENTIN • Starting dose 300 mg od • Gradual increase over days up to 900 mg tds • Requires a lot of patient compliance • Usually safe to take with other medications • Effects may be seen in WEEKS • Dosage needs to be adjusted in patients with renal dysfunction • Do not stop abruptly, needs to be done over weeks

31. PREGABALIN • Starting dose 75 mg bd • Increase to 150 mg bd if tolerated • Can work up to 300 mg bd in some cases • Effects may be seen in DAYS • Safe in patients with renal dysfunction

32. LEICESTERSHIRE MEDICINES STRATEGY GROUP

33. Neuropathic pain Localised Lignocaine patch Satisfactory TCA Gabapentinoid Pain Clinic Lignocaine patch TCA Gabapentinoid

34. OTHER GUIDELINES • RCGP uses CREST guidelines (2006) • www.rcgp.org.uk • NICE guidelines (March 2010) • www.nice.org.uk

35. ANY QUESTIONS? • Damian.smith@thh.nhs.uk