1. REDUCING REFERRALS TO THE CHRONIC PAIN CLINIC
Dr Damien Smith FRCA, FFPMRCA
Consultant Anaesthesia & Pain Management
Hillingdon NHS Trust

2. RECENT NATIONAL PAPERS & REPORTS
Report by Chief Medical Officer 2009
Nice guidelines for management of lower back pain
Review of chronic pain services (Wales)

3. HEALTH SECRETARY AND CMO

4. CMO REPORT 2009 PAIN : BREAKING THROUGH THE BARRIER
United Kingdom : Pain in numbers
7.8 million people live with chronic pain
NHS spent £584 million on 67 million prescriptions for analgesia
1 million women suffer with chronic pelvic pain
1.6 million adults suffer with chronic LBP
49% adults with CP experience depression
25% of sufferers lose their jobs
500 pain specialists in the UK
Roughly 1 specialist per 250,000 people
(1 specialist per 32,000 sufferers????)

5. CMO REPORT
When pain becomes chronic, normal damping mechanisms stop working
Biological, psychological and social factors combine to exacerbate symptoms
Modern pain management should address all these elements with an “Integrated Approach”
Treatments involve activity, rehab, drug therapy, psychological therapy, TENS, acupuncture and interventions
Key is to ensure all aspects are INTEGRATED and joined up rather than instigated in isolation

6. IDEAL MODEL

7. CMO REPORT : IDEAL MODEL?
Complex Pain Relief Procedures
Level 1 Specialiast Care
Pain management programmes
Community Care
Level 2
Education programmes
Treatment guidelines
Out patient physio,
Primary Care
Level 3

8. WAYS TO REDUCE REFERRALS
More level 3 services in the community?
Educational programme for GP’s
Prescribing guidelines
Pharmacy teaching of community pharmacists

9. WAYS TO REDUCE REFERRALS
More level 2 care
Community screening teams
Interdisciplinary CBT based programmes
Patient support groups
Physio
? TENS clinics
? Acupuncture clinics
? Consultant sessions in the community

10. NICE GUIDELINES MAY 2009
Early Management of Persistant Lower Back Pain
Patients must have back pain for LESS than a YEAR
Does NOT cover SUSPECTED :
Malignancy
Infection
Fracture
Radiculopathy
Inflammatory disorder

11. NICE GUIDELINES Care should be patient centred
Give patients advice and information to promote self management
Exercise
Manipulation
Acupuncture
Psychology

12. EXERCISE PROGRAMMES

13. EXERCISE PROGRAMMES 8 sessions over 12 weeks Groups of 10
Aerobic activity
Muscle Strengthening
Posture Control
Stretching

14. MANUAL THERAPY

15. MANUAL THERAPY

16. SPINAL MANIPULATION!!

17. MANUAL THERAPY Spinal manipulation Spinal mobilisation Massage
MAY be performed by osteopaths and chiropractors
9 sessions over 12 weeks

18. ACUPUNCTURE

19. ACUPUNCTURE Advises 10 sessions over 12 weeks
Does not advise injection of therapeutic substances into the back

20. COMBINED WITH PSYCHOLOGY

21. PROBLEMS WITH THE GUIDELINES
NICE summary: we recommend acupuncture and manipulation because they work every bit as good as placebo but we don't recommend injections as they only work as well as placebo.
Advise patients to have osteopathy and chiropractor services?????
Lack of regulation concerns!!!
Concerns from medical profession about potential damage from poorly practiced spinal manipulation.

22. PROBLEMS WITH GUIDELINES
No discussion with The British Pain Society
Multidisciplinary body
Conflict of interest with BPS chairman
Chairman had to resign
NEXT MONTH BPS & NICE will meet to look at ‘reformulating’ the guidelines.

23. WAYS OF REDUCING REFERRALS
Do not refer patients with NON specific back pain
Do not refer patients with less than 1 year history
Offer patients exercise, manual therapy, acupuncture and psychology
DO REFER patients with known specific back pain
DO REFER patients with potential mailignancy, infection, fracture, radiculopathy or inflammatory disorder

24. RECENT SURVEY OF GP’S ABOUT SERVICES
Questionnaire about local chronic pain services and questions exploring ways to improve pain services.
48% satisfied with service
15% dissatisfied
37% neither

25. WAYS TO IMPROVE THE SERVICE
GP’s wanted:-
More pain education in GP surgeries
More advise through the internet
More hospital based study days

26. WAYS TO REDUCE NEW REFERRALS
GP’s requested a telephone helpline
Different triage system
helpline
More psychological training for community staff
Stricter criteria to accept patients to pain clinic

27. PRESCRIBING GUIDELINES FOR PREGABALIN
Based on a guideline produced by the European Federation of Neurological Studies
Algorithm for treatment of neuropathic pain

28. Neuropathic pain
Localised
Lignocaine patch
Satisfactory
TCA
Gabapentinoid
Pain Clinic
Lignocaine patch
TCA
Gabapentinoid

29. TRICYCLIC ANTIDEPRESSANTS
Amitriptyline starting dose mg nocte
Dose may be increased to 50 mg nocte
Not an antidepressant dose and will not interact with concurrent antidepressants
Convert to Nortriptyline if problems with drowsiness (not licensed for pain / /equivalent dose)
Contraindications include glaucoma, hypertension and may lower seizure threshold in epileptics

30. GABAPENTIN Starting dose 300 mg od
Gradual increase over days up to 900 mg tds
Requires a lot of patient compliance
Usually safe to take with other medications
Effects may be seen in WEEKS
Dosage needs to be adjusted in patients with renal dysfunction
Do not stop abruptly, needs to be done over weeks

31. PREGABALIN Starting dose 75 mg bd Increase to 150 mg bd if tolerated
Can work up to 300 mg bd in some cases
Effects may be seen in DAYS
Safe in patients with renal dysfunction

32. LEICESTERSHIRE MEDICINES STRATEGY GROUP

33. Neuropathic pain
Localised
Lignocaine patch
Satisfactory
TCA
Gabapentinoid
Pain Clinic
Lignocaine patch
TCA
Gabapentinoid

34. OTHER GUIDELINES RCGP uses CREST guidelines (2006) www.rcgp.org.uk
NICE guidelines (March 2010)

35. ANY QUESTIONS?