www.pspbc.ca

Management of Function for Patients with Pain

Westin Wall Centre, Richmond

December 5, 2013

What are we trying to accomplish?

Drs. David May and Michael Negraeff

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The Heartsink Patient

The Burden

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17-31% of Canadians report chronic pain (Canadian Pain coalition)

18% of Canadians suffer from severe chronic pain –more than diabetes or heart disease. (Chronic pain association of Canada)

Chronic pain prevalence is approximately 33% in those over 55 years old (Moulin et al)

38% of institutionalized seniors experience pain on a regular basis (Stats. Can. 2008)

The Burden

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The single biggest cause of disability in Canada

It affects the elderly the most

The elderly are about to become the largest cohort of patients

The Burden

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70% of cancer patients experience moderate to severe pain during their illness

The majority reported that they had not been asked about their pain by doctors or nurses (Chronic pain association of Canada)

The Burden

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Chronic pain is a strong independent predictor of health resource use

“There was a strong association between pain-related disability and greater use of services” (Blyth et al. Pain 2004)

The Burden

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The cost of pain to the Canadian economy is estimated at $6 Billion annually (Jovey)

Pain is almost unmentioned in medical schools (Chronic pain association of Canada)

“Funding for research, training and treatment of pain in Canada is woefully inadequate” (Jovey)

The Burden

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CHRONIC PAIN IS AN EPIDEMIC THAT AFFECTS UP TO A THIRD OF ALL

CANADIANS

WE ARE NOT ASKING ABOUT IT

WE DON’T KNOW HOW TO TREAT IT

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People with chronic pain have a three times the average risk of developing psychiatric symptoms, mainly depression

Depressed people have three times the average risk of developing chronic pain

Nearly all medications for depression also help reduce chronic pain (Harvard Health Publications 2004)

Chronic Pain and Depression

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Women with chronic pain are three times more likely to commit suicide than matches in the general population without chronic pain (Fishbain et al)

Chronic Pain and Suicide

CHRONIC PAIN IS A DISEASE THAT WILL LARGELY BE TREATED BY FAMILY DOCTORS

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Denial

Lack of time

Lack of resources

Lack of knowledge

Lack of effective “cures”

Not wanting to open a “Pandora's Box”

Barriers for GPs

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So what do I do with my chronic pain patients?

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Shift paradigm:

Sole pursuit of tissue pathology…

….to reasonable attempt to exclude pathology and reach diagnosis.

What are we trying to accomplish?

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Shift paradigm:

Sole pursuit of pain reduction…

….to whole person centered approach aiming at functional gain and pain reduction.

What are we trying to accomplish?

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Shift paradigm

“There’s nothing that I can do”…

….to “we can together work as a team to reduce the alarm (pain) in your nervous system and increase your function.”

What are we trying to accomplish?

freedigitalimages.net

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Shift paradigm

“I only have one tool (prescriptions)”…

….to “there are a toolbox of options we can use to help reduce your pain and increase your function.”

What are we trying to accomplish?

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Scope

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"I'm not a magician, Spock, just an old country doctor."

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What is Pain?

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Central Nervous System Sensitization

Pro-nociceptive Anti-nociceptive

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Social Class Financial

Relationships

Job

Culture

Beliefs

Life experiences

Other health issues

Report: “I have pain.”

Observe: Behaviour

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Pink?Flower?

Pink Flower

“Pretty”I’m calm.

Pink FlowerBees?I’m allergicI’m afraid

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Pain in not a “thing”

Pain is not in the tissues

No pain receptors No pain pathways No pain centres

It’s a multidimensional, lived, experience constructed by the brain.

What is Pain?

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Diagnostic Framework

Peripheral

Inputs

Central

Sensitization

Psychological

Inputs

Social

Inputs+ + + =

PainGenetic Factors

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Toolbox of Supports

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Toolbox of Supports

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Toolbox of Supports