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Chronic Pain Management: current practices and where we should be heading

Chronic Pain Management: current practices and where we should be heading. Assoc. Professor Michael Nicholas, PhD Pain Management Research Institute University of Sydney at Royal North Shore Hospital. Topics to be covered.

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Chronic Pain Management: current practices and where we should be heading

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  1. Chronic Pain Management: current practices and where we should be heading Assoc. Professor Michael Nicholas, PhD Pain Management Research Institute University of Sydney at Royal North Shore Hospital

  2. Topics to be covered • Improving rehabilitation outcomes through an integrated management approach • Pain/chronic pain management process, especially for those with mental health conditions such as depression, anxiety and PTSD • Management of psychosocial elements in the rehabilitation of clients, especially for those with chronic pain • The management of 'younger clients' who are having to deal with chronic pain while attempting to maintain their general functioning and productive lives

  3. Time-based classification of pain • Acute: short-term; usually due to nociception (tissue damage); resolves with healing. • In back pain, Acute = < 4 wks Sub-acute = 4-12 weeks Chronic = > 12 weeks • Chronic pain: pain lasting > 3-6 months • Persisting pain(NHMRC: acute pain guidelines)

  4. How common is the problem of chronic pain? • Blyth et al. (2001) Pain, 89, 127-134. • 17,000 interviewed (across NSW) • Chronic pain (>3/12) prevalence (NSW): • 17.1% Males • 20.1% Females • Interference in activities reported by ~ 60%

  5. Persistent pain by age and sexNSW 1997 Health Survey (Blyth et al., 2001)

  6. Despite all the advances in medical technology…. • Complete relief of symptoms (pain) often an unrealistic goal once pain becomes chronic • More realistic to seek ways to limit disability despite pain • That is, manage pain to limit its impact Goucke CR. The management of persistent pain. Med J Aust 2003; 178(9): 444-447. Loeser JD. Mitigating the dangers of pursuing cure. In: Cohen MJM, Campbell JN, eds. Pain Treatment Centers at a Crossroads: A Practical and Conceptual Reappraisal. Seattle, IASP Press, 1996:101-108.

  7. “Traditional” Biological model of pain Injury (Nociception or neuropathy) Pain Impact on activity, mood

  8. Treatment implications? Nociception or neuropathy Pain-free Normal activity & mood restored (e.g. Bogduk N. Management of chronic low back pain. Med J Aust 2004; 180 (2): 79-83)

  9. This model works… • (Usually) in acute pain states • (Usually) in some chronic pain cases with orthopaedic procedures (eg. hip replacements) • But not always: Compensation status is associated with poor outcome after surgery(Meta-analysis by Harris et al.. JAMA, April 6, 2005; 293: 1644-52). • Gabbe et al (MJA, 2007): MVA victims with compensation claims in Victoria had worse health outcomes than those without compensation claims. • (Temporarily) in selected (~ 5%) chronic cervical and low back pain cases (with radiofrequency lesions) • But for the rest of those with chronic pain? - On average: 30% reduction in pain. (SeeTurk, Clin J Pain 2002).

  10. What this means • Outcome of treatment is influenced by the context in which it occurs • Most people who develop chronic pain will have to learn to live with it • But pain is rarely only presenting problem

  11. Chronic pain often accompanied by other problems that interact EXCESSIVE SUFFERING & DISABILITY REDUCED ACTIVITY PHYSICAL DETERIORATION (eg. muscle wasting, joint stiffness) UNHELPFUL BELIEFS & THOUGHTS PAIN PERSISTING FEELINGS OF DEPRESSION, HELPLESSNESS, IRRITABILITY REPEATED TREATMENT FAILURES LONG-TERM USE OF ANALGESIC, SEDATIVE DRUGS SIDE EFFECTS (eg. stomach problems lethargy, constipation) LOSS OF JOB, FINANCIAL DIFFICULTIES, FAMILY STRESS • M K Nicholas PhD • Pain Management & Research Centre • Royal North Shore Hospital • St Leonards NSW 2065 • AUSTRALIA A BIOPSYCHOSOCIAL PERSPECTIVE Influence of workplace, home, treatment providers

  12. Pain - current view • Pain is an end-productof many interacting processes in the nervous system (including the brain). • The relationship between injury and painis quite variable. • Knowledge of cause of painis not sufficient to tell us how much pain a person will have or its impact. • Diagnosis(eg. “Lumbar Discogenic Pain”) is a poor guide to prediction of disability(Caragee et al, Spine Journal, 2005)

  13. Implications for injury management

  14. Common Mental Health Complications:Depression, Anxiety, Substance abuse and PTSD • Polatin et al. (1993) reported that 59% of one sample of chronic pain patients demonstrated current symptoms for at least one psychiatric diagnosis, mainly major depression, substance abuse and anxiety disorders • Individuals with chronic neck or back pain are almost three times more likely to have PTSD than those with no pain (Demyttenaere et al., 2007) • The US National Comorbidity Study (using DSM-IV criteria), the 12-month prevalence of PTSD in individuals reporting chronic spinal pain was 7.3% (Von Korff et al., 2005). • Beckham et al (1997) reported that 80% of a sample of 129 Vietnam Veterans presenting with PTSD reported chronic pain

  15. Evidence for impact of Mental disorders in people with chronic pain • Depression: Lower chance of RTW (Dionne, 2005; Pincus et al., 2002; Sullivan & Stanish 2003; Vowles et al. 2004; Rezai & Cote 2005; Sullivan et al. 2005) • PTSD: Increased risk for prolonged disability following whiplash injury (Sterling et al., 2003; 2005) • PTSD:(especially reexperiencing symptoms) in Vietnam Veterans associated with higher levels of pain and pain-related disability (Beckham et al. (1997) and Asmundson et al. (2004) • Substance abuse disorder : Lower chance of RTW; less likely to have good rehabilitation outcomes; more likely to have re-injury. (Burton et al (1997); Evans et al., (2001)

  16. Consequences of co-morbidity • Chronic pain patients who have a co-morbid mental disorder have a more impaired quality of life than those without comorbidity (eg. Bair et al., 2003).

  17. Treatment outcomes compromised • Treatment outcomes can be compromised when both pain and a mental disorder are present but only one of them is targeted for treatment. • Higher levels of depression have been shown to be predictive of poorer treatment outcomes for chronic pain patients (eg. Cherkin et al., 1996), as well as higher health care costs over time (Engel et al., 1996).

  18. Opportunity • Improving our understanding of how chronic pain and mental disorders relate to each other offers the prospect of much greater joint treatment effects than we may obtain from just improving treatments for either alone (eg. Haythornthwaite, Neurology, 2006).

  19. Intervening in psychosocial aspects before chronicity sets in (controlled studies from 2000)

  20. When pain has become chronic? • Is it too late?

  21. Pain management plan for chronic pain may need to be adjusted for severity/complexity of case • ‘Dose-response’ relationship for CBT pain management programs and chronic pain • Basic message: More distressed/disabled cases need more extensive treatment • Evidence: Guzman et al., BMJ 2002: systematic review Williams et al. Pain 1999: RCT Marhold and Linton, Pain 2001: RCT Haldorsen et al., Pain 2002: RCT

  22. Getting workers with chronic pain back to work?Haldorsen et al. (2002): More extensive CBT pain management >> ‘light’ pain management with more disabled cases

  23. Implications • When psychosocial risk/prognostic factors low, usual care is sufficient (Usual care seems effective in “uncomplicated cases of LBP” – Jallema et al. Pain 2006) • When psychosocial risk/prognostic factors high, interventions targeting these aspects often more effective than usual care

  24. Neuro Ablation Implantable Therapy (Spinal Cord Stimulator) Implantable Therapy (Intrathecal Pump) Long Term Oral Narcotics Behavioural Programs Cognitive & Behavioural Therapies Nerve Blocks NSAID’s (& over the counter drugs) Meditation and Relaxation Physical Therapy (TENS) Traditional “Pain Treatment Ladder” Krames E.S J Pain Symptom Manage; 1996: 333 - 352 Basic rule: “failure” of earlier treatments leads to consideration of next in ladder

  25. Neuro Ablation Implantable Therapy (Spinal Cord Stim) Implantable Therapy (Intrathecal Pump) Long Term Oral Narcotics Behavioural Programs Cognitive & Behavioural Therapies Nerve Blocks NSAID’s (& OTC drugs) Meditation and Relaxation Physical Therapy (TENS) Traditional “Pain Treatment Ladder” Krames E.S J Pain Symptom Manage; 1996: 333 - 352 Suggests that “failure” of earlier treatments is indication for next in line.

  26. Better to assess the whole situation and plan treatment from there EXCESSIVE SUFFERING & DISABILITY REDUCED ACTIVITY PHYSICAL DETERIORATION (eg. muscle wasting, joint stiffness) UNHELPFUL BELIEFS & THOUGHTS PAIN PERSISTING FEELINGS OF DEPRESSION, HELPLESSNESS, IRRITABILITY, SLEEP LOSS REPEATED TREATMENT FAILURES LONG-TERM USE OF ANALGESIC, SEDATIVE DRUGS SIDE EFFECTS (eg. stomach problems lethargy, constipation) WORKPLACE, FINANCIAL DIFFICULTIES, FAMILY STRESS • M K Nicholas PhD • Pain Management & Research Centre • Royal North Shore Hospital • St Leonards NSW 2065 • AUSTRALIA A BIOPSYCHOSOCIAL PERSPECTIVE Influence of workplace, home, treatment providers

  27. Combining medical and psychological interventions for chronic pain • Haythornthwaite (2005)Clinical trials studying pharmacotherapy and psychological treatments alone and together. Neurology 2005; 65(suppl 4): S20-S31. • Holroyd et al. (1995; 2001): Treatment of headaches – combination of medication & cbt • Kishino et al. (2000) Psychological intervention plus exercise for post-surgical pain • Leibing et al. (1999); Sharpe et al. (2001): rheumatoid arthritis patients: combined rheumatology treatment & cbt more effective

  28. Could we learn from other fields that deal with chronic illnesses/diseases? • “Medical care for chronic illness is rarely effective in the absence of adequate self-care (by patient)”. Von Korff et al. (1997) Ann Int Med, 127, 1097-1102

  29. Workplace-based interventions Workplace-based Return-to-work Interventions:A Systematic Review of the Quantitative Literature Franche et al. J. Occupational Rehabilitation 2005; 15 (4)

  30. Key findings (Franche et al. 2005) Workplace intervention strategiesStrength of Evidence (less) Work loss • Early contact with the worker by the workplace Moderate • Work accommodation offer Strong • Contact between healthcare provider Strong and the workplace • RTW coordination Moderate • Super-numerary replacements Insufficient

  31. Some conclusions • Chronic pain is common (1 in 5 people) • It is a risk factor for disability • The presence of mental disorders increases risk of disability in those with chronic pain • Curative treatment is unlikely (no magic bullet) • Interventions need to be targeted against identified risk factors (bio – psycho – social) • Challenge: Collaborative approach offers best chance of success • All stakeholders must play active, informed roles

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