1. Pain Management Service Royal Bolton Hospital Dr Ian Waite Consultant in Anaesthesia and Pain Medicine

2. Who are we? Service established in 1999 Multidisciplinary pain management team working together for the local population Based at Royal Bolton Hospital Most outpatient services at Bolton One Interventional and physiotherapy treatments at RBH

3. Who are we? Multidisciplinary pain management team 2 consultants – Drs Miller and Waite 2 nurses – Srs Owen and Sedwell 3 physiotherapists – E Beveridge, R Harwood and M Wood 1 clinical psychologist – Dr Twiddy 2 secretaries – Jane and Pat All have sessional commitment

4. What do we do? Treat patients with chronic pain Chronic pain - pain duration greater than 3 to 6 months Conditions better treated in other services already excluded Not a diagnostic service Usually manage rather than cure

5. What do we do? Accept referrals from Primary care Patients from Bolton and surrounding area Assessment questionnaire posted Do not see patients unless Q filled in or assessment questionnaire inappropriate

6. Questionnaire Contents History Measurements (pain, depression, anxiety, disability) Patients triaged according to results of psychological questionnaires

7. Questionnaire Why use a questionnaire? Enables patients to see appropriate professional More efficient use of clinic time Provides measurements which contribute to assessment Provides audit data

8. Clinics New and review patient clinics 2 distressed clinics per week Doctor and physiotherapist 45 minute appointments 2 non-distressed clinics per week Doctor and physiotherapist 30 minute appointments Clinical psychology referral as appropriate for further assessment / treatment

9. Nurse Lead Clinics Medication/block review Commence and review medication Review following interventional procedures Changes to treatment TENS New and review patients Acupuncture New and repeat

10. Nurse telephone review Nurses provide a telephone review service Easier for patients Reduces demand for outpatient appointments Any patient/professional can telephone for advice

11. Clinical psychology clinics New patient assessments Referral from doctor / physiotherapy clinics Referral from nurse Referral from physiotherapy Treatment clinics

12. Medical model of pain Pain is a signal of tissue damage Pain is a warning Investigate the cause Diagnosis Treatment Cure Pain goes away

13. Acute Pain Examples of acute pain Cut, bruise or graze Broken wrist Twisted ankle Tonsillitis Appendicitis Pain after surgery

14. Chronic pain What is chronic pain? pain persisting for more than 3 to 6 months usually the original stimulus has gone tissue healing is expected to have taken place few, if any, physical signs consequences of pain begin to dominate

15. Chronic pain On-going multiple investigations not always helpful Pain no longer acting as a warning Little or no evidence of tissue damage or inflammation Poor correlation between scans/x-rays etc. and pain

16. Chronic pain Impact of chronic pain Physical abilities/fitness Work Leisure activities Family Mood Frequent visits to GP/ hospital Side effects from medication Hopes/plans for the future

17. Treatments - medication Paracetamol Non-specific NSAIDS Oral Topical COX-2 inhibitors Etoricoxib Celecoxib Weak Opioids Codeine Tramadol Buprenorphine Strong opioids Morphine Oxocodone Fentanyl Topical Capsaicin Lidocaine plaster Tricyclic antidepressants Anticonvulsants Ketamine

18. Medications Problems Not always effective Tolerance may develop Side effects Interactions Allergy Need to constantly take tablets

19. Treatments Physiotherapy Individual pain management physiotherapy Pain management programme Nursing Nurse prescribing Pain management programme TENS Acupuncture

20. Treatments Clinical psychology Individual pain management clinical psychology Pain management programme

21. Treatments Interventional procedures Trigger points Cervical/thoracic/lumbar facet jt injections Cervical/thoracic/lumbar/caudal epidurals Sympathetic block Stellate ganglion Thoracic paravertebral Lumbar sympathectomy Hypogastric plexus block IVRSB - guanethidine

22. Treatments Interventional procedures Paravertebral blocks Peripheral nerve blocks Nerve root blocks Radiofrequency (RF) lesioning Botulinum toxin A Joint injections – eg hip

23. Injections Carried out in context of a MDT Eg Epidural steroids for sciatica Need to have a specific target to inject into Complications of procedure Side effects of drugs/x- rays Repeat?

24. Treatments Pain management programme Evidence based treatment CBT based rehabilitation programme for chronic pain patients who have exhausted all other reasonable treatment options Delivered by full multidisciplinary team Two days per week for 4 weeks

25. Treatments Pain management programme 25 to 30 hrs required for efficacy Outcome measures Reduced distress/emotional impact Normalising of beliefs and information processing Increased range and level of activity Reduced pain Reduced healthcare use Improved work status (where relevant)

26. Audit On-going audit of every patient that attends our service Brief audit questionnaire completed by the patient at every attendance Results stored on computer and documented in the patient’s notes

27. Audit Examples of specific audits Lumbar sympathectomy - vascular Epidural steroids Radiofrequency lesioning of lumbar facet joints Botulinum toxin type A for headaches TENS Pain management programme Lidocaine 5% medicated plasters Physiotherapy treatment

28. Summary We work closely as a MDT Aim to give the patient the “tools” to manage pain long term Process can take time Reduce pain where possible and improve coping Improve quality of life