Pain Rounds

February 2010

A convergence of pain and morbid obesity

Chris Hayes John HambridgeDebbie Harper

26 years female: persistent pain in the context of morbid obesity

A tale of 2 admissions related to obesity April – June 2009 (discharge against medical

advice) July 2009 – ongoing

The preceding chapters Difficult developmental history and adolescence

A complex story Multiple medical and psychosocial problems Input from multiple health care professionals

PSYCHOLOGICAL ASPECTS OF MORBID OBESITY

It’s no laughing matter…….

Morbid obesity: brief overview

BMI ≥ 40 (or ≥ 35 with serious co-morbidities) 180cm, 129kg, BMI=40 160cm, 102kg, BMI=40

2.4% Australian adults morbidly obese ≈275,000 people, more women than men

25% of population obese (BMI 30-40) Prevalence doubling every 5-10 years Pre-pubescent onset Associated with socioeconomic

disadvantage

PEOPLE OVERWEIGHT OR OBESE ≥ 18 YRS

Australian National Health Survey, 2007-8

Health consequences

Obesity vs. morbid obesity? Increased all cause mortality Morbidity

CVD; type 2 diabetes; musculoskeletal disorders; endometrial, breast & colon cancers; respiratory disorders

Risks of chronic conditions increases progressively with BMI

What’s it like being morbidly obese?

Survey of formerly morbidly obese who had undergone surgery

Given forced choices between obesity & variety of other conditions 42% preferred blindness to obesity 40% preferred BKA

Negative stereotypes held by children, adults, medics, employers etc

Mixed findings regarding psychopathology

Binge eating

32%-49% BED in surgery presenters

Issues faced by morbidly obese in hospital and community

Stigma “Freak show” One of few remaining “safe” prejudices Made worse by number of staff required for

care needs “Chinese whispers”

Lack of dignity Difficulty in getting weighed

Morgue only option in JHH Patients are often weighed at vet’s or

weighbridge when home

Multiple levels of overt and covert discrimination Ultrasound, CT & MRI impossible Even BP difficult Lack of appropriate bariatric equipment Door width! Special equipment can also add to stigma e.g.

throne-like appearance of special chairs Transport issues (within & outside hospital) Clothing

Morbid obesity - treatment

No current good evidence for psychological interventions

No current good evidence for pharmacotherapy Appetite suppressants Reduced nutrient absorption (orlistat)

Bariatric surgery is recommended treatment

Surgery outcomes

Dramatic reduction in medical co-morbidities in Swedish study (n > 4000)

Sjöström et al., 2007

At two years 32x reduction in diabetes 2.6 – 10x reduction for others

At eight years 5x reduction in diabetes

Weight loss typically 40kg

Does surgery improve psychosocial functioning?

Improved QoL Decreased depression Decreased psychopathological

symptoms Binge eating impact depends on type of

surgery Vomiting seems to increase though

Improvements in social/vocational/sexual domains

Generally, improvements are dose dependent

Herpertz, 2003

The early years

No information regarding early childhood 1995 aged 12 years – admission for a weight

reduction program (paediatric endocrinologist and psychiatrist) Obesity (150 kg) Obstructive sleep apnoea (OSA): mild – moderate

(Camperdown Children's Hospital). CPAP recommended but not accepted.

Skin infection (intertrigo) School non-attendance Dysfunctional family

The initial outcomesThe initial outcomes

Weight loss 150 to 135 kg over 6 week admission

Non-attendance at F/U appointments with dietician, physiotherapist

DOCS notification

Usual themes

Dysfunctional relationship with mother Sabotage of medical treatment Restricted social milieu Eating to regulate all types of emotions Adolescent intervention School refusal / bullying Genetics

Ongoing ProblemsOngoing Problems

Depression Agoraphobia – not left home since age 17

years Period of high alcohol use Asthma Worsening OSA, pulmonary hypertension,

right heart failure, leg oedema Increasing weight (340 kg)

Admission 1: April-June 2009

Presenting problem Fall at home Ambulance transport after help from fire brigade

and ambulance officers Precipitating problem - Community acquired

pneumonia Initial treatment

BiPAP Antibiotics

Admission 1: Other problems

Morbid obesity Poor mobility Depression, agoraphobia OSA, pulmonary hypertension, right heart

failure Asthma Fe deficiency anaemia (menorrhagia)

Admission 1: More other problems

Abnormal LFTs (cholelithiasis, hepatosplenomegaly)

Cellulitis of legs Heparin induced thrombocytopaenia

syndrome (HITS) Hypothyroidism

Admission 1: Progress

Weight loss of 80 kg (340 to 260 kg) Some gains in mobility and other problems Transferred to rehabilitation ward to address

broader goals Discharged home against medical advice

One month later: July 2009

Re-admitted with cellulitis of left leg and abdominal wall

Broad themes

Ulceration/infection over hip region bilaterally Antibiotics Unsuitable for debridement under general

anaesthetic Maggot therapy

Nutrition Nasogastric and oral feeds Now down to 160 kg Albumin 13 up to 29 g/l (33-41)

Broad themes

Respiratory status Variable compliance with CPAP

Mobility and posture Physiotherapy Slings, beds and other specialised equipment

Psychology Social aspects

Mother’s presence Co-ordination of care

PhysicalMental

EmotionalDysfunctional

SpiritualDignity

Challenging the SensesBeliefs

“A Sizeable Issue” The J3 Experience

Pain issues

Pain sites Areas of ulceration Surrounding areas Related to postural factors Dressing changes

Focus on external layers and external solutions

Balance of medication V meditation

Pain treatment

Entonox (nitrous oxide, laughing gas) Escalating requirements

Ketamine infusion Escalating requirements

The power of the case conference Limit setting

More pain treatment

Gabapentin Escitalopram, venlafaxine Lorazepam Oral opioids (oral morphine equivalent

240mg) Oxycontin 20 mg bd Endone 15 mg q 3 hours Trialled rotation (hydromorphone, methadone)

Medication adverse effects

Constipation Sedation Tolerance Opioid induced hyperalgesia ?

Where to next ?

Which battles to fight Balancing empathy with boundaries