Managing chronic pain

1
Pain Management
2
Role of GPs in Pain Management

• GPs can
• improve assessment and treatment of pain
• offer early intervention and treatment
• prevent chronic pain.

3
General Principles of Pain Management

• Unrelieved pain has adverse severe physiological
  / psychological side effects
• Proper assessment and control requires patient
  involvement
• Effective pain relief requires flexible,
  individually tailored treatment
• Pain is best treated early. Established severe
  pain is more difficult to treat
• Whilst it is not always possible to alleviate all
  pain, it can be reduced to a tolerable or
  comfortable level.

NHMRC (1999)
4
Categories of Pain

• Acute monophasic pain
• Recurrent acute non-malignant pain
• Chronic malignant pain
• Chronic pain associated with non-malignancy
  disease identifiable pathology
• Chronic non-malignant pain syndrome.

5
WHO 3-step Pain Relief Ladder
Treat with Opioid for moderatesevere pain /-
non-opioid /- adjuvant
3
Pain persisting or increasing
2
Treat with Opioid for mild-moderate pain /-
non-opioid /- adjuvant
Pain persisting or increasing
1
Treat with non-opioid /- adjuvant
Gill (1997)
6
Pain Cycle
Psychological Social Consequences
Adapted from Gill (1997)
7
Pain Rating Scales

• Most reliable indicator of pain severity is
  patient self-report
• Categorical rating scales use descriptors such
  as no pain / mild pain / worst possible
  pain
• Visual analogue scales
• no pain worst possible pain
• Verbal analogue scales
• rate from 0 (no pain) to 10 (worst possible).

8
The GPPatient Relationship

• Successful management depends on
• patient trust confidence in GP
• complete physical and psychosocial history this
  is essential so allow adequate time
• supportive clear explanations of the pain
  issues
• ability to discuss strategies openly to reduce
  potential for self-medicating
• case management for consistency in management,
  commence treatment with consultation between
  patient and treating staff
• trust avoid placebos at all costs
• adequate relief achieving relief / reducing
  pain level is paramount.

9
A Shared Care / Team Approach

• A team-based, holistic approach tends to be most
  effective for pain management, involving
• nurses
• psychologists psychiatrists
• physiotherapists
• pain specialists.

10
Acute Pain Management and High-risk Drug Use

• Key Principles
• Unless patient uses opioids, treat as normal
  patient with pain
• First do no harm shortest dose, shortest
  duration with minimal side effects, with aim to
  reduce pain to a tolerable level
• Maintain clear communication (prevent anxiety,
  reassure patient)
• Do not withhold analgesia unless medically
  indicated
• Avoid Pethidine
• Allow adequate time for assessment impossible
  in 10 minute consultation.

11
Acute Pain Management People who Inject Opioids

• Consider
• tolerance to opioid analgesics
• e.g., if already on regular prescribed opioid
  medication (iatrogenic dependence), on methadone,
  opioid-dependent, or regularly taking liver
  enzyme-inducing drugs
• real and perceived legal constraints for
  prescribers
• potential adverse interactions with other CNS
  depressants
• difficulties / misunderstandings which arise in
  communications between clinicians and patients.

12
Assessment of Chronic Pain in Drug-dependent
Patients (1)

• Comprehensive assessment required of
• organic pathology and psychosocial history /
  supports
• past / present drug use (alcohol and prescribed
  drugs)
• drug tolerance dependence
• contribution of pain drug use to mood
  lifestyle?
• whether the pain predates the drug(s) problem or
  reverse?
• psychiatric comorbidity chronic pain and
  depression often coincide, but difficult to
  disentangle cause effect
• stressors and coping strategies.

13
Assessment of Chronic Pain in Drug-dependent
Patients (2)

• Obtain information from other sources (p.r.n.)
• e.g., previous GP, other doctors, family, with
  patients consent
• 1/3 or more of patients with chronic pain have no
  obvious organic disease but may feel genuine and
  debilitating pain
• If in doubt, err on the side of the patients
  report.

14
Opioids and Pain Management

• A true opioid allergy is very uncommon
• There is no evidence that use of opioids for
  treatment of severe acute pain leads to
  dependence / addiction
• When opioids provide no relief, the pain may be
  neuropathic in nature
• Opioids for pain relief are most effective when
• tailored to the individual
• used in conjunction with NSAIDS.

15
Prescribing Opioids and Drug-dependent Patients
(1)

• Use opioids with caution
• if opioid-dependent, high tolerance is likely,
  and therefore need higher doses (not lower doses)
• potential for adverse events /excessive sedation
• avoid injections and Pethidine (poor clinical
  outcomes)
• aim for regular fixed doses (better, cheaper
  response compared with on-demand)
• consider sustained-release forms.

16
Prescribing Opioids and Drug-dependent Patients
(2)

• Controversy re prescribing methadone for the
  opioid-dependent
• Separate prescribing for dependence from pain
  management issues (e.g., via shared care) so
  that
• patients are not confused about dose, types
  purpose of prescribed drugs
• drug doses can be adjusted to accommodate the
  separate problems
• staff fears of malingering can be allayed
• Analgesics are just part of an effective
  management plan for chronic pain.

17
Chronic Pain and Iatrogenic Dependence

• Definition
• dependence on medication following a period of
  medically-initiated pain management
• true extent of the problem is difficult to gauge
• treatment dose tapering or methadone
• prevention
• close supervision and monitoring of pain patients
• review medication frequently
• encourage alternative (non-drug) treatments to
  complement medication.

18
Chronic Pain Patients and Risk of Drug
Dependence

• Risk indicators may include
• personal / family history of high-risk patterns,
  problems or therapy (including receiving MMT)
• demonstrating abnormal illness behaviour, low
  frustration tolerance, premorbid personality
  problems, or poor coping skills
• history of childhood abuse
• patients who describe euphoric effect from
  prescribed opiates
• current stressors
• complex compensable patients
• young patients with obscure pathology.

19
Chronic Pain Patients and Suspected Drug
Dependence

• The following signs should alert you
• tolerance to prescribed opiates /- BZDs and
• intoxication, deterioration in function, ?
  pain-associated distress
• requesting scripts early
• withdrawal symptoms and signs medication(s) not
  being taken
• increased use of alcohol (increases sedation)
• requesting opiate-based analgesics (rather than
  NSAIDS)
• preoccupation with obtaining opioids despite
  analgesia
• evidence of doctor shopping, visits to E.D.,
  hoarding supplies.

20
Non-drug Complementary Strategies (1)

• Medications
• Other analgesics, antidepressants, anxiolytics,
  tranquillisers and hypnotics, muscle relaxants,
  antispasmodics, antihistamines, corticosteriods,
  local anaesthetics etc.
• Lifestyle adjustment
• exercise
• ergonomic work stations / change in tasks / roles
  
• relaxation / meditation
• Physiotherapy / hydrotherapy / radiotherapy
• Supportive counselling/CBT.

21
Non-drug Complementary Strategies (2)

• Cognitive therapy
• changing beliefs / expectations, blocking
  negative thinking
• Behaviour therapy
• goal setting / problem-solving
• self-reinforcement
• diversion techniques
• Stimulation to relieve pain
• Transcutaneous Electrical Nerve Stimulation
  (TENS)
• acupuncture
• vibration / massage.

22
Pain Relief is the Overriding Consideration

• For the very elderly
• The terminally ill with a short life expectancy

Concerns of exacerbating drug dependence in
these situations are secondary
23
10 Tips for Managing Patients with Chronic Pain
(1)

• 1. Define pain syndrome and treat cause (where
  evident)
• 2. Ensure Mx by single practitioner
• 3. Validate and accept patients pain experience
• 4. Establish clear, honest, open relationship
• 5. Make, and agree on, a clear treatment contract
  
• (cont)

24
10 Tips for Managing Patients with Chronic Pain
cont. (2)

• 6. Educate and inform about your approach to pain
  Mx
• 7. Treat comorbidity with shared care team
• 8. Encourage alternatives to pharmacotherapy
• 9. Medication Mx one doctor, close monitoring
• 10. Monitor progress, compliance and symptoms and
  maintain vigilance for evidence of dependence.

25
Strategies for Managing Aberrant Behaviour

• Re-assess medication, expectations, underlying
  cause
• Consider changing drugs / ? interval between
  supply
• Reinforce discussions / contract
• Consider urine testing / warn of consequences of
  continued behaviour
• Wean or cease opioid use
• Notify health department / joint management with
  drug treatment agency
• Consider very frequent medication supply / MMT.