1. 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

2. 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

3. 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

4. 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

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

6. 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

7. 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

8. 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

9. 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

10. 400mg BD MST
100mg Oramorph daily
MRS M.S.
Pain GP 2019

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

12. 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

13. 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

14. 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

15. Faculty of Pain Medicine Pain Information Leaflets
Pain GP 2019

16. Pain GP 2019

17. 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

18. 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

19. Pain GP 2019

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

21. 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

22. Leg pain
Fibromyalgia
Distress
Thoughts?
Pain GP 2019

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