Agenda

1. Agenda • 6.00pm Dr Ivan Ramos-Galvez, Consultant in Pain Medicine • Complex Regional Pain Syndrome and the Challenges it presents in legal claims • 6.25pm Dr Chris Jenner, Consultant in Pain Medicine • Is the Opioid Crisis coming to the UK? • 6.55pm Short break • 7.05pm Mr Ash Vasireddy, Consultant Orthopaedic Trauma Surgeon • Complex fractures & the Medicolegal implications • 7.30pm Q & A • 8.00pm Hot snacks and informal networking • 9.00pm Close

2. Consultant in Pain Medicine Royal Berkshire Hospital Harley Street, London Complex Regional Pain Syndrome and the Challenges it presents in legal claims 20 June 2019 Dr Ivan Ramos-Galvez LMS, FRCA, FFPMRCA

3. What is CRPS? • Chronic Pain Condition > 6 months • Usually affects 1 limb – arm, leg, foot • Caused by damage to or malfunction of the peripheral andcentral nervous system • CRPS -I and CRPS –II • More common in women, CRPS can occur in anyone at any age, with a peak at age 40.  • CRPS is rare in the elderly. 

4. Symptoms • Prolonged severe pain that may be constant • Described as “burning,” “pins and needles” sensation, or as if affected limb being squeezed under pressure • Pain may spread to the entire arm or leg, even though the injury might have only involved a finger or toe. In rare cases, pain can sometimes even travel to the opposite extremity • Often increased sensitivity in the affected area, known as allodynia, normal contact with the skin is experienced as very painful • Changes in skin temperature, skin colour, or swelling of the affected limb due to abnormal microcirculation caused by damage to the nerves controlling blood flow and temperature • An affected arm or leg may feel warmer or cooler compared to the opposite limb • Affected limb may change colour becoming blotchy, blue, purple, pale, or red and/or texture becomes shiny & thin • Changes in nail and hair growth patterns, abnormal sweating pattern • Abnormal movement in the affected limb, most often fixed abnormal posture (called dystonia) but also tremors in or jerking of the limb.

5. Presentation

6. No specific test can confirm CRPS Diagnosis is based on a person’s medical history, and signs and symptoms that match the definition Other conditions can cause similar symptoms As most people improve gradually over time, the diagnosis may be more difficult later in the course of the disorder The distinguishing feature of CRPS is that of an injury to the affected area Testing also may be used to help rule out other conditions, such as arthritis, Lyme disease, generalised muscle diseases, a clotted vein, or small fibre polyneuropathies Magnetic resonance imaging or triple-phase bone scans may help confirm a diagnosis Budapest Criteria Excellent Clinical History is required Challenges in Diagnosing CRPS

7. Issues which arise in the Claimant’s Case • Complex interaction between the peripheral, autonomic, and central nervous system in this condition makes it challenging to diagnose • The clinical symptoms may be identical in type I & II but type II is associated with and triggered by injury to the peripheral nerve, type I is triggered by injury to the musculoskeletal tissues • The clinical diagnosis of CRPS is established when all the objective findings, including trophic changes in the joints and integument that occur in later stages, are present. There is no laboratory procedure or test capable of yielding findings specific to CRPS • When Budapest criteria, essential for the diagnosis, are not met, the patient is treated merely as a chronic pain sufferer without clear etiology • Treating physician may attach little importance to the symptoms or lack experience to diagnose causing profound medicolegal ramifications and impact on the psychological state of the patient • Signs and symptoms of the disease fluctuate • Clear evidence of the link to the root cause required in most cases

8. It’s all in your head… • The demonstration of clinical abnormalities remains the gold standard in the diagnosis of CRPS • It is a syndrome and not a disease with specific or pathognomonical signs and symptoms • Some patients with CRPS are told by their physicians that their pain is being imagined or fabricated • Some physicians have no experience of CRPS and consequently provide a misleading legally sensitive opinion, thereby jeopardising the validity of patient’s symptomatology • When malingering is suspected for the persistence of pain, the resulting emotional stress and sympathetic overactivity can complicate matters for the pain sufferers who have developed a second debilitating and persistent painful condition as a result of the original injury • It is known that the central nervous system plays a major role in the pathogenesis of the condition • It is difficult to treat because a constellation of symptoms referable to peripheral, autonomic, and central nervous system, all act in conjunction with one another following a physical injury • Unlike other physical disabilities with clear demonstrable laboratory findings, there are no clear unifying guidelines for the diagnosis, treatment, and disability determination of CRPS

9. Defending the Claim!! It’s useful for the Claimant’s solicitor to think like the defendant and be ready with evidence to respond and close down a challenge of malingering… • The easiest form of attack is to allege the claimant is malingering (Burridge v Blighline Ltd, 1999) • Even without damaging video surveillance and the Claimant having undergone invasive procedures and receiving a diagnosis of CRPS from a leading clinicians in the field an ill-informed Judge can hold a Claimant as consciously feigning much of their alleged disability • Attack the Credibility of the Expert • Allege that the Claimant is vulnerable to suffering similar symptoms in response to any minor event, on the basis that “normal” people don’t react adversely to minor incidents … they have somatoform disorder • Forensic analysis of the all the available records and a detailed chronology of the presentation and evolution of symptoms to highlight inconsistencies in presentation to different clinicians • Insist on objective evidence on the claimant’s level of functioning and challenge, challenge, challenge!

10. Supporting Your Claimant through the Litigation • The clinical relevance of CRPS Type I: The emperor’s new clothes. Birchers A, Gershwin M. J aut rev. 2016; 16(1): 9-24 • CRPS is an overdiagnosis. Catch phrase. Diagnosis of last resort. • Questions its existence: • Signs and symptoms are not plausible. • No laboratory test available. • Fluctuations do not have medical explanation. • Inter observer variability. • Criteria based in studies with small samples. • Concludes: If true progress is to be made, CRPS has to be abandoned as a legitimate diagnosis. • The effect of short-term dependency and immobility on skin temperature and colour in the hand. Singh HP, Davis TR. jhsb. 2006; 31(6): 611-5. • Signs and symptoms of CRPS can be mimicked by immobility

11. An Expert’s Primary duty is to assist the Court

12. Supporting Your Claimant through the Litigation • Believe your Client and prepare them for those who won’t! • Help them engage with the litigation process – practically and psychologically e.g. • Deal with mobility issues in getting to appointments • Consider timings if they fatigue easily or find it difficult to concentrate for long periods • Get a good expert who is experienced in treating and diagnosing CRPS – this in itself can be ground-breaking for them • Consider the support they may need for their mental health • Consider the psychosocial impact on them and suggest ways to mitigate or reduce • Funding for treatment during the litigation process • Check in with them regularly

13. Pain medicine specialists – specialised training and expertise in all aspects • of diagnoses and management of painful conditions inc acute, chronic and cancer pain. • Pain medicine is a sub-specialism under the auspices of Royal College of Anaesthetists • Consultant Anaesthetists who have undergone a significant period of specialist training in pain medicine • Accredited full-time pain fellowship as part of RCoA pain   • Trained to provide multi-dimensional assessment and treatment using internationally & well recognised validated scores for pain, function & psychological disorders including CRPS, Fibromylagia and CFS • Their practice combines appropriate pathophysiological knowledge relevant to the nervous system as well as the musculoskeletal • May overlap with other hospital specialisms but no other single speciality combines the scope or range of expertise of a pain expert How can a pain expert help?

14. Medicolegal Partners Limited • www.medicolegal-partners.com • info@medicolegal-associates.com • Twitter ~MedicolegalAssoc@MedicolegalA • 020 7118 0650

15. Dr. Christopher JennerMB BS, FRCA, FFPMRCAConsultant in Pain Medicine 20 June 2019 Is the opioid crisis coming to the UK?

16. What are Opioids? • Natural/ synthetic substances that activate opioid receptors in CNS and PNS • Examples: morphine, oxycodone, buprenorphine, fentanyl, methadone • Cancer pain and chronic pain

17. The US Stats ! • Increased prevalence individuals of lower SES • Opioid use in all age-groups 4 times higher in lower SES & death rates from opioid use increase as SES decreases • Prescriptions peaked in 2010-12, at 280 million • Currently declining • Prevalence of addiction in opioid users for chronic pain 3-16% in the general population/ up to 43% in sub-populations • 2015-2017 40,000 deaths pa • Drug overdoses are now the leading cause of accidental death in the US

18. And the UK! • Substantially lower numbers but UK has seen a similar trend in opioid consumption • In England, opioid prescriptions rose year-on-year from 228 million in 1992 to 1.6 billion in 2009 • UK availability of analgesic opioids increased by nearly 70% between the periods 2011-13 & 2014-16 • OECD 2011 & 2016 opioid-related deaths in England and Wales increased from c.30 deaths per million population to 40 per million -well above the 20% average across all OECD countries

19. US vs UK OpioidPrescribing

20. Doctors role

21. Alternatives to Opioids Multidisciplinary approach to pain medicine • Non opioid analgesic medication • Multimodal analgesia • Clinical pain psychology • Pain Management programmes • Functional restoration programmes • Minimally invasive pain medicine procedures • Alternative therapies • Advanced pain medicine procedures • Physical rehabilitation therapy

22. Averting a UK Crisis • UK published guidelines for prescribing opioids • PHE web-based initiative ‘Opioids Aware’ - assists patients and clinicians to make decisions about treatment with opioids • Emphasis on role of pharmacists in mitigating adverse effects of opioid usage with guidelines for OTC analgesics containing codeine/ DHC • Pharmacists proactive approach by highlighting excessive/ unusual doses and requesting review by primary prescriber

23. Medicolegal Implications • Last 15 years 1600 lawsuits in US chiefly by city/ state/ county versus opioid manufacturers in US • Very few if any, such cases in the UK • Recommendations include parties to reach global settlement, similar to big tobacco in 1998, who agreed to fund educational and enforcement programmes and recover tobacco-related HC costs over 25-years • Reasons why this may not work: • opioids beneficial in those who suffer from severe pain • opioids not prescribed by the manufacturer, company can discharge duty to warn consumers of potentially harmful effects by informing a ‘learned intermediary’, eg: doctor, of the risks associated with the product • defendants do not form homogenous group as cases have targeted various organisations associated with the manufacturing, distribution and sale of opioids, many of whom will have no direct intervention with patients. Defendants may not see themselves as being equally responsible for the crisis • establishing liability in these cases likely to be extremely complex

24. Medicolegal Partners Limited www.medicolegal-partners.com info@medicolegal-associates.com Twitter ~MedicolegalAssoc@MedicolegalA 020 7118 0650