Pain Future trends and management Pain Management Service - Stamford Hospital Andreas Erdmann – Consultant Pain Medicine Paula Wilkinson – Specialist Pain Occupational Therapist Becky Livings – Specialist Pain Physiotherapist Pain GP 2019

Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. IASP 1994 Pain GP 2019

An aversive sensory and emotional experience typically caused by, or resembling that caused by, actual or potential tissue injury. (under discussion) Requires response Not just associated Damage not required New Insights Pain GP 2019

Does this get Closer to it? Emotional pain Spiritual pain “Aversive” experiences How real is emotional pain? What of existential angst? Identity crisis? Bereavement? Pictures ?positive ?meaning (Shopenhauer) Does this get Closer to it? Pain GP 2019

Individual NARRATIVE Variable Challenges Defining it Explaining it Treating it Individual NARRATIVE Variable Dilemmas we have to tackle and understand Challenges Pain GP 2019

ObjectiveS Part 1 “ Introduction” Part 2 “Q&A” Practical approach to common questions/scenarios Short case histories Summary current guidelines Part 2 “Q&A” Biopsychosocial model Treatment examples - case history Your questions/case histories ObjectiveS Pain GP 2019

What are common problems YOU SEE? Opioids Back pain Complex pain/Fibromyalgia Your experience of patients – what are the dillemmas? Any thoughts. What are common problems YOU SEE? Pain GP 2019

Mrs M.S. Thank you for seeing this 48 yr old lady for pain management. She has severe COPD and is on ambulatory oxygen. She has chronic nonspecific right – sided upper back/thoracic pain, for years. WHAT ANALGESICS COULD BE USED? Mrs M.S. Pain GP 2019

MRS M.S. Could you also see her for management of her opioid use? She is currently on MST, and also oromorph. WHAT DOSE MIGHT BE SUGGESTED HERE? MRS M.S. Pain GP 2019

400mg BD MST 100mg Oramorph daily MRS M.S. Pain GP 2019

DIscussion Initial thoughts - why/what? How effective is treatment? Concerns DIscussion Pain GP 2019

Adverse effects short term – e.g. constipation, nausea, sedation Adverse effects long term Psychological – depression, cognitive slowing Hormonal – reduced libido, impotence Immune – increased infections, possibly increased cancer risk Mortality – all-cause early Dangers Pain GP 2019

ENDOCRINOPATHY Hypothalamus OPIOIDS GnRH Anterior Pituitary Ovaries/testes Testosterone OPIOIDS OPIOIDS 5aR P450 aromatase Dihydrotestosterone Oestradiol Osteoblasts Adrenal OPIOIDS OPIOIDS New bone formation DHEA Pain GP 2019

Opioids IMMUNE ADAPTIVE Reduced T-cell cytokines/activation B-cell antibody production MHC II presentation Increased T-cell death INNATE Reduced activity - macrophages neutrophils mast cell natural killer dendritic Intestinal integrity impaired Pain GP 2019

Faculty of Pain Medicine Pain Information Leaflets Pain GP 2019

Pain GP 2019

MR J.T. 58 years old man, worked as plasterer 30 years Long standing back pain, intermittent buttock/thigh pain Treated for non-specific back pain Simple analgesia Physio Advice “keep active” Retire in 4 years, “in agony last 6 months” – can’t sleep, stand or walk very far Reliably in lower back MR J.T. Pain GP 2019

Mr J.T. Walked slight stoop – “bad day” Extension postures particularly painful Largely predictable constant burning/aching pain right lower back Tenderness paravertebral palpation on right * Possible specific cause back pain – “facet joint syndrome” Medial branch blocks Radiofrequency denervation NON SPECIFIC Mr J.T. Pain GP 2019

Pain GP 2019

COntExt Pain relief (permanent) - not only goal “Enabler” Window of opportunity Multidimensional approach Activity Function Mental health COntExt Pain GP 2019

Mrs HJ 48 year old lady ongoing left leg pain Background longstanding fibromyalgia Physiotherapist thought likely neural irritation – pain did not respond to physiotherapy No help with gabapentin, could not tolerate amilriptyline Distressed - advice Mrs HJ Pain GP 2019

Leg pain Fibromyalgia Distress Thoughts? Pain GP 2019

Need a different approach? HOLISTIC MULTIDIMENSIONAL PSYCHOSOCIAL MULTIDISCIPLINARY Pain GP 2019