1. Chronic Pain Again Dr. MC Chu Anaesthesia and Intensive Care PWH

2. Agenda Remember the cases last time? Bear in mind the complexity of chronic pain Let’s try to treat them

3. Treatment principles Pain as a symptom Find the cause and fix it Pathology oriented Works well in acute pain Well accepted by patient and doctor

4. Treatment principles Pain as a symptom Find the cause and fix it Works well here

5. Treatment principles Pain as a symptom Find the cause and fix it Does all headaches have a pathology?

6. Treatment principles Pain as a symptom Control the symptom Passive Long term effects and side effects Case specific What are the options?

7. Symptom control Medications Antipyretics (paracetamol) NSAID Opioids Antidepressants Anticonvulsants Steroids, muscle relaxants, etc.

8. Symptom control Paracetamol Effective in OA knees Amadio Curr. Ther. Res. 1983 Effectiveness ~ Ibuprofen Bradley N. Eng. J. Med. 1991 Safe and economical, NSAID sparing for elderly Nikles Am. J. Ther. 2005

9. Symptom control Paracetamol Evidence in OA only Hepatic and renal toxicity do occur Medication induced headache

10. Symptom control Medications Antipyretics (paracetamol) NSAID Opioids Antidepressants Membrane stabilisers (anticonvulsants) Steroids, muscle relaxants, etc.

11. Symptom control NSAID Best evidence from rheumatoid arthritis Also good for cancer pain Effective in 5 out of 10 placebo-trials for LBP Effective in 4 out of 9 Panadol-trials for LBP Doubtful value for non-specific musculoskeletal pain Koes Ann. Rheum. Dis. 1997 Eisenberg J. Clin. Onco. 1994

12. Symptom control NSAID Annual GI bleed risk: 0.8-18% / year Annual death rate: 0.03-0.1% / year MacDonald BMJ 1997

13. Symptom control NSAID Risk increase with age, > 4 week use, history of GI bleed / ulcer / CVS disease Least damaging: Ibuprofen Only effective prophylaxis: PPI Yeomans N. Eng. J. Med. 1998

14. Symptom control COX-2 specific NSAID You know what happened to your patients

15. Symptom control COX-2 specific NSAID You know what happened to your shares?

16. Symptom control Medications Antipyretics (paracetamol) NSAID Opioids Antidepressants Membrane stabilisers (anticonvulsants) Steroids, muscle relaxants, etc.

17. Symptom control Opioids Gold standard for cancer pain management (mostly) cheap and readily available Administered at every route

18. Symptom control Opioids Controversial for non-cancer pain Limited (but positive) evidence of efficacy Extensive side effects Tolerance Dependence Divergence

19. Symptom control Opioids Controversial for non-cancer pain “Physicians should make every effort to control indiscriminate prescribing, even under pressure from patients…” Ballantyne N. Eng. J. Med. 2003

20. Symptom control Opioids Controversial for non-cancer pain “Opioids are our most powerful analgesics, but politics, prejudice, and our continuing ignorance still impede optimum prescribing” McQuay Lancet 1999

21. Symptom control Opioids Practical guidelines for non-cancer pain Exhaust other methods Aim at functional improvement Limit prescription authority, monitor behavior Slow release, avoid injectables Opioid contract

22. Symptom control Medications Antipyretics (paracetamol) NSAID Opioids Antidepressants Membrane stabilisers (anticonvulsants) Steroids, muscle relaxants, etc.

23. Symptom control Antidepressants Analgesic at below mood altering doses NNT for diabetic neuropathy ~ 3.4 Collins J. Pain & Sym. Manag. 2000

24. Symptom control Antidepressants Analgesic at below mood altering doses NNT for post-herpetic neuralgia ~ 2.1 Collins J. Pain & Sym. Manag. 2000

25. Symptom control Antidepressants How good is NNT of 2.1 to 3.4? It is not good for this

26. Symptom control Antidepressants How good is NNT of 2.1 to 3.4? It is really good for pain

27. Symptom control Antidepressants Major problem: side effects NNH (minor) ~ 2.7 No consensus which one is best Classically TCA SSRI: seemed more specific on mood

28. Symptom control Medications Antipyretics (paracetamol) NSAID Opioids Antidepressants Membrane stabilisers (anticonvulsants) Steroids, muscle relaxants, etc.

29. Symptom control Anticonvulsants Carbamazepime for trigeminal neuralgia NNT ~ 2.6 NNH ~ 3.4

30. Symptom control Anticonvulsants NNT for diabetic neuropathy (red) ~ 2.7 NNT for post-herpetic neuralgia (white) ~ 3.2 Collins J. Pain & Sym. Manag. 2000

31. Symptom control Anticonvulsants Gabapentin Less organ damage No drug interaction

32. Want to have a break?

33. Symptom control Intervention Nerve / joint block Counter-stimulation

34. Symptom control Nerve block Where to cut How to cut What is left behind

35. Symptom control Nerve block Where to cut How to cut What is left behind

36. Symptom control Nerve block Where to cut How to cut What is left behind

37. Symptom control Nerve block Where to cut How to cut What is left behind

38. Symptom control CNS nerve block Physically protected, relatively immobile Synapses are chemically vulnerable Effects (and side effects) are wide spread

39. Symptom control Peripheral nerve block Thick bundles of conducting cables Mobile, difficulties with catheters Impairment is profound yet localised

40. Symptom control Visceral nerve block Contain visceral pain fibres k Usually deep seated Anatomically diffuse l Visceral functions.

41. Symptom control Nerve block in chronic non-cancer pain Preferably purely sensory block Chemical / thermal neurolysis Minimal dysfunction

42. Symptom control Nerve block in chronic cancer pain Cover most abdominal viscera 90% good to excellent relief Eisenberg et al A&A 1995

43. Symptom control Joint block

44. Symptom control Joint block

45. Symptom control Transcutaneous Electrical Nerve Stimulation (TENS) Product of Gate theory Better than placebo in short term Minimal side effects No long term benefit

46. Symptom control Spinal cord stimulation Patient controlled No medication Permanent (almost)

47. Symptom control Spinal cord stimulation

48. Symptom control Spinal cord stimulation Failed back surgery Isolated neuropathy Ischemic heart disease Peripheral vascular disease Pain relief as a therapy

49. Symptom control Spinal cord stimulation de Jongste et al Br Heart J 1994

50. Symptom control Spinal cord stimulation How does it compare with the “golden standard”?

51. Symptom control Angina attacks per week PreopPost-opp-value CABG (51)16.25.2<0.001 SCS (53)14.64.4<0.001 Mannheimer et al Circulation 1998

52. Symptom control 6-months cardiac mortality and morbidity MortalityMorbidityStroke CABG (51)778 SCS (53)172 Mannheimer et al Circulation 1998

53. Symptom control Spinal cord stimulation Only suitable for smart patients Technical expertise and follow up facilities Complications do occur

54. Symptom control Spinal cord stimulation Cost: $ 80,000 HKD Would you take it?

55. Treatment principles Pain as a symptom Find the cause and fix it Symptomatic control Pain as a disease How is this disease like?

56. Pain as a disease Pain Depression Think negative In-activity Medical Dependence Insomnia Socially deprived

57. Pain as a disease Our contribution “Degenerative” “Bone spurs” “Nothing wrong” “It is in your mind”

58. Pain as a disease Our contribution Misunderstanding on Waddell’s signs esp. malingering Incorrect attempts to test for placebo e.g. saline test

59. Pain as a disease Need a multi-disciplinary approach Clinical psychology Physiotherapy Occupational therapy Nursing Social work / vocational training

60. Pain as a disease Need a multi-disciplinary approach

61. Pain as a disease Alleviate their depression Motivate them to mobilise despite pain Encourage active coping Reduce dependency on medical input Stop searching for a cause Stop giving analgesics together with side effects Cognitive behavioral therapy

62. Pain as a disease Cognitive behavioral therapy Pain intensity (VAS)

63. Pain as a disease Cognitive behavioral therapy Depression (HADS)

64. Pain as a disease Cognitive behavioral therapy Catastrophising (PCS)

65. Pain as a disease Cognitive behavioral therapy 40 meter carrying load (pounds)

66. Pain as a disease Cognitive behavioral therapy Analgesic consumption (types)

67. Pain as a disease Cognitive behavioral therapy Pain is the same, but More active Less depressed Less doped

68. Before we move on to the last bit

69. Pain as a specialty Anaesthesia and pain Expertise in peri-operative pain relief Analgesics Regional nerve blocks

70. Pain as a specialty Anaesthesia and pain Dr. John J. Bonica “Father of pain medicine”

71. Pain as a specialty Getting established IASP and its 65 global chapters Over 300000 members of multiple specialties

72. Pain as a specialty Anaesthesiology Orthopediac surgery Neurosurgery Oncology / palliative care Neurology Rheumatology Rehabilitative medicine Psychiatry Radiology

73. Pain as a specialty … is to specialize in everthing!

74. Pain as a specialty Opportunity to work with other doctors

75. Pain as a specialty Other activities

76. Pain as a specialty Training Diploma in Pain Management (HKCA) Fellowship in Pain Medicine (ANZCA)

77. Pain as a specialty Pain centres at HK (2006) AHNHPWH QEHUCH QMHPYNEH Smaller scale ones at DK, PM, etc.

78. Resources for you Internation Association for the Study of Pain www.iasp-pain.org HK College of Anaesthesiologists www.hkca.edu.hk Oxford pain Internet site www.jr2.ox.ac.uk/bandolier/booth/painpag/index.html