this unbearable pain

“This Unbearable Pain” The Post-‐opera4ve Dilemma

Dr Brendan Moore Pain Medicine Specialist

Physician Adjunct Associate Professor University of Queensland

Topics for today

•  Post opera0ve pain Dilemma

Workshop •  Interven0ons for mechanical back pain •  Opioid issues •  Psychology in pain Pa0ents

3 Messages

•  Early Iden0fica0on and treatment of neuropathic pain

•  Management of post op opioids

•  Example of medica0on regimes

• “An unpleasant sensory and emo0onal experience associated with actual or poten0al 0ssue damage, or described in terms of such damage.”

Defining pain

Interna0onal Associa0on for the Study of Pain Web site. Available at: hIp://www.iasp-‐pain.org/terms-‐p.html. Accessed 30 June, 2006.

Interna0onal Associa0on for the Study of Pain (IASP)

The con(nuum of pain1

<1 month

Time to resolu4on

≥3-‐6 months

Acute Pain

Chronic Pain

•  Usually obvious 0ssue damage

•  Increased nervous system ac0vity

•  Pain resolves upon healing •  Serves a protec0ve func0on

•  Pain for 3-‐6 months or more2

•  Pain beyond expected period of healing2

•  Usually has no protec0ve func0on3

•  Degrades health and func0on3 1. Cole BE. Hosp Physician 2002; 38: 23-‐30. 2. Turk DC and Okifuji A. Bonica’s Management of Pain 2001. 3. Chapman CR and S0llman M. Pain and Touch 1996.

Insult

Classifica(ons of pain

Acute

Chronic Dura4on

Nocicep4ve

Neuropathic Pathophysiology

Biomedical Aspects of Pain1,2

•  Nociceptive pain è noxious stimuli, e.g. ongoing tissue damage

•  Neuropathic pain è neurological injury or dysfunction

•  Clinical features suggesting neuropathic pain: –  Absence of obvious tissue damage or inflammation –  Characteristic descriptors:

•  Burning, shooting, sharp pain –  Sensory findings both

•  Positive e.g. allodynia/hyperalgesia •  Negative e.g. sensory loss

1. Analgesic Expert Group Therapeutic Guidelines: Analgesic. 2007 2. Jensen TS, et al. Eur J Pharmacol 2001;429:1-11.

Nocicep4ve Neuropathic

Nocicep(ve vs neuropathic pain states

•  Arises from s0mulus outside of nervous system

•  Propor0onate to receptor s0mula0on

•  When acute, serves protec0ve func0on

•  Arises from primary lesion or dysfunc0on in nervous system

•  No nocicep0ve s0mula0on required

•  Dispropor0onate to receptor s0mula0on

•  Other evidence of nerve damage

vs

Serra J. Acta Neurol Scand 1999; 173(Suppl): 7-‐11.

Nocicep(ve and neuropathic pain

•  Arthri0s •  Sports/exercise injuries

•  Postopera0ve pain

Neuropathic pain Nocicep4ve pain Mixed

•  Painful DPN •  PHN •  Neuropathic low back pain •  Trigeminal neuralgia •  Central poststroke pain •  Complex regional pain syndrome •  Distal HIV polyneuropathy

Caused by lesion or dysfunc4on in the nervous system

Caused by 4ssue damage

Caused by combina4on of primary injury and secondary effects

•  Low back pain •  Fibromyalgia • Neck pain •  Cancer pain

Interna0onal Associa0on for the Study of Pain. IASP Pain Terminology. Raja SN, et al. in Wall PD, Melzack R (Eds). Textbook of pain. 4th Ed. 1999; 11-‐57.

“Scia(ca”: mixed pain state

Baron R, Binder A. Orthopade 2004; 33: 568-‐75.

Disc C fibre

C fibre A fibre

Nocicep4ve component: Sprou0ng from C-‐fibres into the disc

Neuropathic component I: Damage to a branch of the C fibre due to compression and inflammatory mediators

Neuropathic component II: Compression of nerve root

Neuropathic component III: Damage to nerve root by inflammatory mediators

Central sensi4sa4on

Neuropathic Pain

•  Bad post operative prognostic indicator

•  Early effective treatment plan required

1. Analgesic Expert Group Therapeutic Guidelines: Analgesic. 2007 2. Jensen TS, et al. Eur J Pharmacol 2001;429:1-11.

Management of pain

Belgrade MJ. Postgrad Med 1999; 106: 101-‐40. Ashburn MA, Staats PS. Lancet 1999; 353: 1865-‐69. Abuaisha BB, et al. Diabetes Res Clin Pract 1998; 39: 115-‐21.

Pharmacotherapy

Physical rehabilita4on

Interven4onal regional

anesthesia

Complementary/ alterna4ve

Lifestyle

Neuros4mulatory

Psychological

Treatment approaches

Observa4ons and Advice from the clinical “coal face”

Post opera0ve Pain

•  Strong analgesia ceased at 2 to 4 weeks •  Important to plan to cease strong analgesia •  Surgeon doesn’t intend long term con0nua0on of post op analgesia

•  Propor0on of pa0ents fail the plan !!

Need a New Plan !!

•  Change in the Pain •  Mixed pain condi0on

– Nocicep0ve and Neuropathic •  Comprehensive Management plan

– Not medica0ons alone – Aim at restora0on of physiotherapy and func0on

Medica0on Plan

•  Paracetamol / NSAIDs •  Adjuvant Analgesics •  Gabapen0n / Pregabalin •  Tricyclic an0depressants (or others) •  Strong Analgesia

Strong Analgesia

A setback not a sentence!! •  Clear defini0ve plan •  Short term increase, then reduce and cease •  Sustained release only •  By the mouth and by the Clock •  No short term, no breakthrough •  Pre-‐determined dose reduc0on

Favoured Cocktails and Recipes


1.  Paracetamol1gm, qid 2.  NSAIDs

–  Ibuprofen 400mg tds – Celecoxib 200mg bd è 100mg bd

3.  Tricyclic An0depressant – Amitriptyline 10 è50mg nocte – Seda0on and sleep acceptable (oien desirable)


4. Gabapen0noids •  Gabapen0n 300mg, 300mg, 600mg •  Pregabalin 150mg, 300mg

Staged increase in dose Higher dose at night Opioid sparing effect


•  Strong Analgesia Oxycon0n 10 or 20mg x 20 tabs

2tabs x 5days then, 1 tab x 10 days

Hydromorphone 4mg x 20 tabs 8mg daily x 5 days then, 4mg daily x 10 days


•  Strong Analgesia Oxycon0n 10 or 20mg x 20 tabs

2tabs x 5days then, 1 tab x 10 days

Hydromorphone 4mg x 20 tabs 8mg daily x 5 days then, 4mg daily x 10 days

Tramadol Tapentadol

Pain the Fiih Vital Sign™

Need to regularly ask about the presence of pain.

American Pain Society Mashford ML et al, Therapeu0c Guidelines: Analgesics Ed 4, 2002

3 Messages

•  Management of post op opioids

•  Early Iden0fica0on and treatment of neuropathic pain

•  Medica0on regimes

How persistent pain can become a problem

Adapted from: Nicholas, 2008.

Is the Pain Mechanical or Not?

Mechanical Non-Mechanical (red flags)

Pain " Poorly localised " Worse later in the day " Usually worst when sitting, worsens

with movement

" Usually localised " No diurnal variations " Uninfluenced by posture or movement

Spinal movement " Painful limited movement usually of

several segments

" Normal or hypomobility limited to one

or two segments

Tenderness " Diffuse

" Localised

Other features " Patient is essentially well

" Of underlying disease

Neurological signs " May be present

" May be present

Adapted from Mashford. Therapeu0c Guidelines Analgesic; 2002.

Acute and Persistent Pain: Different Clinical Entities1

•  Acute pain: –  Recent onset –  Expected to last a short

time –  Expectation is complete

recovery

•  Persistent pain: –  Persists for > 3 months –  Expectation is not one

of cure

Recurrent acute pain, feature elements of both acute and

persistent pain

1. Analgesic Expert Group Therapeutic Guidelines: Analgesic. 2007

Red Flags1

•  Most clues are in the history

1. Australian Acute Musculoskeletal Pain Guidelines Group. Evidence-based management of acute musculoskeletal pain. A guide for clinicians. 2004.

Feature or Risk Factor Condi4on

Symptoms or signs of infec0on (e.g. fever) Risk of infec0on (e.g. penetra0ng wound)

Infec0on

History of trauma or minor trauma (if > 50 years, osteoporosis + cor0costeroid use)

Fracture

Previous history of cancer Unexplained weight loss Age > 50 years Pain at rest Pain at mul0ple sites Failure to improve with treatment

Tumour

Absence of aggrava0ng factors Aor0c aneurysm

Pain and Impact on Quality of Life1

Physical well-being Psychological well-being Stamina/strength Appetite Sleep Functional capacity Comfort/pain

Coping Control Enjoyment/happiness Sense of usefulness Anxiety/depression/fear

Social well-being Spiritual well-being Social support/family Sexuality/affection Employment Finances Roles and relationships Isolation/dependence/burden

Religion Sense of purpose/meaning/worth Hopefulness Uncertainty Suffering

1. Lynch TJ, Jr. Pain the fifth vital sign. J Intravenous Nursing 2001;24(2):85-94

Factors Associated with Persistent Back Pain1

•  Structural changes on spinal imaging

•  Disc degeneration •  Disc tears / prolapse •  Facet joint degeneration •  Central & lateral canal stenosis

1. Waris E, et al. Spine 2007 15;32(6):681-4. 2. Jarvik JG, et al. Spine 2005;30(13):1541-8. 3. Schenk P, et al. Spine 2006;31(23):2701-6. 4. Videman T, et al. Spine 2003;28(6):582-8.

Common as we age but not associated with pain

GP’s Role1

•  Patient education and motivating change •  Biopsychosocial assessment

–  Red and yellow flags –  Periodical reassessment and whenever new

symptoms are reported •  Coordination of care and appropriate referral •  Discouraging inappropriate searches for a cure •  Discouraging prolonged treatment that is not

leading to improved function


The Evolution of a Persistent Pain

Dr James O’Callaghan Anaesthetist and Pain Medicine Specialist

Mater Private Clinic,

Brisbane

Recovery

Chronic Pain Disability Cycle1


Surgery

Rehabilitation despite pain

Pain-dependent behaviour

Behaviour NOT dependent on pain

ACUTE PAIN

CHRONIC PAIN DISABILITY CYCLE Desperation

Hopelessness

Anger

Loss of control Inappropriate management

Social stresses Anxiety Activity avoidance

Unhelpful beliefs

Passive treatments

Demands for treatment

Deconditioning

Drug tolerances

Transition To Persistent Pain1

Emotionally charged

Loss of: •  Hope •  Confidence •  Trust

Stressed relationships •  Family •  Doctor

Poor communication Desperation


Psychosocial Yellow Flags1

Work Behaviours

Believe pain is harmful è fear avoidance behaviour Believe pain must be abolished before returning to work Compensation issues

Passive attitude to rehab. Use of extended rest ê activity Avoidance normal activities é alcohol consumption

Beliefs Affective Catastrophising, thinking of the worst Misinterpreting bodily symptoms Believe pain is uncontrollable

Depression Feeling useless, not needed Irritability Anxiety Lack of support Overprotective partner

1. Jensen S. Aust Fam Physician 2004;33(6):393-401

Factors Associated with Persistent Back Pain1

•  Premorbid factors –  Older age –  High levels of psychological distress –  Below average self rated health –  Low levels of physical activity –  A history of low back pain –  Not being employed, dissatisfaction with current employment

•  Episodic factors –  The presence of widespread pain –  Long duration of symptoms prior to consultation –  Radiating leg pain

–  Restriction of spinal movement

1. Thomas E, et al. BMJ 1999;318(7199):1662-7.

Influences on Progress and Outcome1

•  Negative influences –  Maladaptive ‘treatment’

style –  Maladaptive family ‘support’

–  Maladaptive work environment

–  Conflict –  Unrealistic expectations –  Maladaptive response to

life stressors

•  Positive influences (on early response) –  Adequate assessment,

treatment and support –  Early pain relief –  Appropriate style

•  Patient, family, GP –  Understanding their

situation –  Realistic expectations –  Adaptive response to life

stressors

1. As adapted from Analgesic Expert Group Therapeutic Guidelines: Analgesic. 2007

Persistent Postoperative Pain1

•  Preoperative factors –  Moderate – severe pain lasting more than 1 month –  Repeat surgery –  Psychological vulnerability –  Worker’s compensation

•  Intraoperative factors –  Nerve damage during surgery

•  Postoperative factors –  Pain (acute, moderate – severe) –  Depression –  Psychological vulnerability –  Anxiety –  Neuroticism

1. Perkins FM, Kehlet H. Anesthesiology 2000;93(4):1123-33.

Persistent Pain Requires a Different Approach1,2

Acute pain Persistent pain Cure the illness causing the pain Restore physical, psychological, social

function, minimise distress Symptom relief Control pain to tolerable level, ê distress

Focus on the painful part “Whole person” rehabilitation Expectation: return to previous health status

Adjustment is necessary, new skills/lifestyle

Passive dependent patient Active coping, participating patient Active “hands on” practitioner Practitioner who acts as a “coach” Analgesics given according to current level of pain, dose reviewed frequently

Regular, predictable schedule of analgesics

Medication and physical modalities Multidisciplinary approach Short-term focus Long-term focus Rest is often appropriate Activity is generally appropriate

1. Analgesic Expert Group Therapeutic Guidelines: Analgesic. 2007. 2. NSW TAG. Prescribing guidelines for primary care clinicians. General principles. 2002.

this unbearable pain

Health & Medicine