1. "Hypochondria is the only illness I don’t have." And other comments in relation to pain

2. If Medical decision is making based upon: Science Logic Hence EBM

3. I Know How We Take Decisions? Medical decision is making based upon: Science Logic Hence EBM Why opinion and variation?

4. In Chronic pain guiding objective evidence is simply lacking Socioeconomic and psychosocial factors have more bearing on decision making

5. I Know How We Take Decisions Are you more likely to dismiss pain behaviour where there is lack of medical evidence for pain? How do you judge pain associated with psychosocial stressors? And in combination?

6. I Know How We Take Decisions Are you more likely to dismiss pain behaviour where there is lack of medical evidence for pain? How do you judge pain associated with psychosocial stressors? And in combination?

7. I Know Secondary Care is not Well Organised in or Beyond the Trust Currently an epidural or joint injection for pain might be under the care of: Pain clinic Rheumatology Orthopaedics Several other local and distant providers are also encouraging referrals These services are not: Timely Close to the patient (when possible) Integrated and multidisciplinary Has “arms” where the treatments in (and not in) that arm are clear The result: confused referrers sending patients around in circles

8. Chronic Pain Questions Who are we, are we needed? Pain patients: they’re all mad aren’t they? What do X-rays and scans tell us about the cause of back pain? They can’t exercise because it hurts can they? Should I see all patients with pain? Can we treat any of them, can we treat them all?

9. My Home And please help estates with their spelling

10. The Team

11. Epidemiology and Assessment

12. How Do Doctors React When Confronted With a Chronic Pain Patient? “I am pleased to see that you have referred her on to psychiatry. I hope this will end all her pain problems” SAS general surgeon MTW from clinic 29/3/11

13. Should I see all patients with pain? How common is pain? How common are pain specialists? How long have training programmes been in place for pain specialists?

14. Should I see all patients with pain? How common is pain? How common are pain specialists? How long have training programmes been in place for pain specialists? 1 in 8 adults in Europe 1 per 32,000 patients Not long Manchester 13 years MTW 8 years FFPMRCA 7 years

15. Can’t we just cure them? How good are we at diagnosing the cause of back pain? Do injections cure pain? Do physical therapies cure pain? Does surgery have a good evidence base in treating back pain? Are the costs of treatment and range of treatments increasing? Are the outcomes improving?

16. Limitations of Assessment “It is not possible to interpret clinical abnormalities on the basis of only anatomical data” “No lesion seen on MRI can be established as the cause of LBP” Lesions do not predict response for the “evidence based therapies” available “Disc abnormalities on MRI occur in up to 1/3 of asymptomatic patients”

17. Red Flags

18. Up to 25 questions looking at signs of Infection Cancer Cauda equina/ unstable lesions Very sensitive if all questions asked >99% But…………… Specificity <1%

19. When Do Red Flags Matter 71 year old female 5 month on/off history new back pain No radiation Came on after viral illness Poor response to meds Some response to physio (hands on) PMH breast Ca “cured 2010”

20. In This Case

22. Yellow Flags Attitudes/beliefs about pain (NB low recovery expectations) (Illness) behaviour Emotions (anxiety, distress & depression) Family reinforcement Work and compensation issues (blue and black) A belief in passive treatments

23. What Has Happened? On 1 st presentationAfter 2 years of “treatment”

24. Learned Dependency Despite a Lot of Drugs On 1 st presentationAfter 2 years of “treatment”

25. What Do We Accept/Expect? Culture and pain reporting Religion and pain Autonomic nervous system and pain Heart rate (variability) Skin conductance (fluctuations) fMRI What is fear avoidance behaviour?

26. What Not to Say (Medical FAB) Hurt = Harm All acute back pain is a “blown disc” You should always rest when in pain The nervous system is hard wired You are mad Something must be done

27. Is Pain impacted by the co-occurrence of Anxiety and/or Depression ? Bair MJ, et.al Psychosomatic Medicine 2008;70:890-897 Brief Pain Inventory Pain Scor e (mean) range : 0-10 Pain + Depression 1 2 4 6 5 3 8 7 Pain SeverityPain Interference Pain only Pain + Anxiety Pain + Anxiety + Depression P <.001

28. Does Anxiety, Depression, or Sleep Problems Predict the Development of Pain? Gupta A, et.al. Rheumatology 2007. 46:666-671 Anxiety (HAD Anxiety sub-score) Depression (HAD Depression sub-score) Sleep (Sleep Problem Scale) 15 month Prospective study, 3171 followed, 324 developed CWP Odds ratio

29. Are My Patients Mad or Representative? Many of our patients have a significant issue with: anxiety (64%) depression (66%)

30. Dividing Patients PathologyPsychology Red flags Radicular Non specific Worsening/Improving Anxiety/depression/ beliefs Risks for chronicity 80% recover vs 40% not settling 10% (near) constant significant limitation

31. Culture and Pain We don’t know much Seems important though! Coggon 2013

32. Investigation(s)/ MRI New or changing symptoms Previous carcinoma Other red flags Reassurance (of who?) Scans do not often change much year on year Bloods if possibly inflammatory X-ray only if suspected fracture

33. Smoke, Mirrors, Psychology and the Brain

34. And Just in Case You Missed That

35. Placebo Mechanisms A positive consultation with a health professional is associated with better outcome. The success rate of a procedure increase by 10% if you give it the hard sell The failures will suffer increased distress and depression Naloxone impairs placebo analgesia Lancet 1978 Analgesia is enhanced by a nurse over a machine Bennetti Lancet 1995 Remifentanil effectives versus placebo nurse and active nurse Tracey et al

36. Imagery and Pain What happens to pain when you view? Flowers, Food, Violence (extreme), Sex

37. Placebo Surgery Trials Mammary arterial Occlusion for refractory angina Arthroscopy and washout for arthritic knee pain Has this evidence changed practice?

38. Treatments

39. NICE Guidelines for Medium Term Non Specific Back Pain No routine scan, no X-rays No diagnostic blocks No therapeutic blocks No intra discal procedures No RF Limited hands on therapy (several types) Scan if considering spinal fusion for treatment failures (they are allowed psychology pre-surgery if they are distressed by this)

40. Why Is the Evidence for Treatments So Poor? Eclectic groups Poor/inaccurate diagnosis Bad trials lacking objectivity and rigor, often with real (and undeclared) conflict of interest issues Many therapies may be effective for small numbers of patients, but we simply aren’t sure which

41. Looking at Outcomes (Going Back To Front) Most effect sizes are low Change in belief, attitudes and coping may dictate whether change occurs regardless of treatment option Guidelines vs patient preference Addressing negative beliefs Weight Smoking Work Relationships Attitude Pain management

42. Outcomes 2 Patient centred outcomes vs objective measures Symptoms Function Well being Social disability Work disability Satisfaction Minimal clinically important change vs cost and inconvenience Remember expectation change Learn to mange expectation Best evidence is more population based campaigns

43. Work Is Good For You(r Mental Health) We now have evidence that work is a positive outcome factor in mental health We have known for years that being out of work was a negative! www.tsoshop.co.uk/flags

44. Occupational health and Pain The Big Black Flag? Defensive practice Time off Denied return Difficulties in arranging phased returns Acceptance that an uncomfortable task is damaging Ergonomics and evidence? Awkward postures Standing and walking Manual handling Pushing and pulling Bending and twisting Lifting and carrying

45. Managing Pain Outside a Pain Clinic Standard drugs Anti inflammatories Anti neuropathics Physiotherapy Osteopathy Alternatives Support, encouragement & reassurance

46. “Hands on Therapies” Traction-a few poor trials failed to demonstrate benefit Manipulation-short term benefit? No better than placebo in long term Acupuncture has widely conflicting reviews in the literature Massage-little literature but that there is suggests a least a short term benefit Magnets-evidence is strongly against an effect Lumbar supports-no evidence TENS-weak evidence at best Hydrotherapy-short term (at least) improvement in function not in pain

47. Evidence in Physiotherapy Lamb et al: Back skills training trial. BMC Musculoskelet Disord. 2007 Feb 22;8:14. Bennell et al: Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ 2010 Activity risk has a U shaped curve (at least in the Dutch) STarT back Cooper et al: Mortality predictors.....BMJ 2010

48. Exercise General exercise can have a modest positive benefit for pain and function Core stability has some promising evidence of benefit Swimming Pilates Tai Chi Yoga? Cycling?

49. “They can’t exercise because it hurts” So they can’t lose weight Is the weight the problem Do any of our patients lose the weight How does weight loss surgery work What does it achieve in our patients? Licenced to fail

50. Pharmacological Treatment Options (for Neuropathic Pain) Gabapentin Pregabalin TCAs (many) Venlafaxine Duloxetine Fluoxetine Sertraline Paroxetine Citalopram escitalopram Lorazepam Clonazepam alprazolam Benzo s SSRIs α 2 δ ligands SNRIs

51. Initial Treatment of Neuropathic Pain (West Kent guidelines)

52. Case: Smokey Management 24 year old female Chronic fatigue Widespread pain Multiple opinions Poor response to “treatments” Oxycodone 2-250mg Tramadol 400 Amitriptyline 100 Citalopram 40 Duloxetine 60 Diazepam Zopliclone

53. Case: Smoky Management Tertiary orthopaedic referral Further pain clinic referral gave a “plan” Increase duloxetine Add Gabapentinoid Lignocaine infusions Long term hydrotherapy Long term acupuncture Consider psychology Allow local clinic to sort this

54. Is Morphine the Answer?

55. Side Effects Constipation Nausea Xs sweating Dry mouth Poor concentration Drowsiness Libido/?fertility ?Immune function (Driving)

56. Practical prescribing  Morphine is the opioid analgesic of choice. (consider laxative & antiemetic cover at dose initiation)  Long-acting (LA) formulations given at regular intervals are preferred & are associated with a lower risk of problem behaviour. These should never be taken as required.  Dose should be started low and titrated upwards reviewing regularly for efficacy, side effects & signs of problem behaviour  Warn the patient it may take some time to determine if the drug will be effective.  Upward titration of the dose should stop when either pain is relieved or side effects become intolerable. Optimal dose is when patient experiences analgesic efficacy (10-30% pain reduction), minimal benefit from further dose increases and no major side effects. Increasing the dose above this will merely increase side effects.  Occasionally short-acting preparations taken as required (alone or in combination with LA formulation) may give a better result. eg pain varies in intensity during the day or pain is intermittent. (Note:The combination of regular LA and PRN short-acting is often used in palliative care)  Injectable opioids should not be used in the management of patients with persistent noncancer pain BUT are widely used in palliative care and cancer related pain.  If patients do not achieve useful relief of pain symptoms at doses between 120-180mg morphine equivalent in 24 hours, referral to a specialist in pain medicine is strongly recommended. Morphine (mg/24hrs)102030406090120180270 Oxycontin (mg/24hrs) 10 20304560100160 Fentanyl (mcg/hr) ~121212-2525 5075 Buprenorphine (mcg/hr)510 203552.570 Key points to remember before prescribing opioids for long term pain Opioids are not first line drugs for chronic pain conditions. Simpler therapies, (drug & non-drug), should have been tried first and proved ineffective. Complete relief of pain is rarely achieved. Strong opioids should never be viewed as monotherapy but as part of a broader approach to improve patient function. The goal should be to reduce pain sufficiently to facilitate engagement with rehabilitation and the restoration of useful function. A clear diagnosis should be available if possible. It is recommended that there is a sole or restricted number of prescribers Develop a treatment plan prior to starting opiods; these should involve clear goals with a steady plan to progress towards them. Most types of chronic pain may respond, however there are around 30% of non-responders. If in doubt, consider specialist referral at an early stage Opioid choice if morphine is ineffective or not tolerated. No opioid has demonstrated a clear clinical advantage in either efficacy or a reduction in side effects over others Many opioids are available; it is better to become familiar with only a few. Surveys suggest patients prefer patches but they restrict water based activity, do not stick well in hot weather and are expensive. Compound preparations are not recommended If no response/intolerable side effects, consider switching to another opioid. Do not continue with opioid treatment if patient has failed on 3 different preparations. Opioid equivalent for long-acting formulations on a 24 hour period Remember: These are approximate. If you switch opioid, start on 50-75% equivalence of the previous drug; remember re-titration may be necessary. Please note this conversion chart has been simplified; no conversion is exact and other charts may vary. Conversion ratios: 24 hour PO morphine to fentanyl: divide by 4 PO morphine to PO oxycodone : divide by 2 PO tramadol to PO morphine: multiply by 0.1 PO codeine/dihydrocodeine to PO morphine: multiply by 0.1 Take great care at higher dose conversions and seek advice if necessary. Monitoring Patients need regular review (at least monthly during dose titration) until well established on treatment. Review for both: Efficacy. (Improved function, well being & sleep are as important as reduced pain) Side effects. These will occur in 80% of patients. Common side effects include constipation, nausea, itching, somnolence, poor memory & dizziness Points to note: Remember to consider laxative & antiemetic cover at dose initiation. Most side effects will settle except constipation & itching Tolerance to pain relieving effects may occur and often this seems to happen early in treatment; it may limit opioid use. Patients on stable doses who are not affected by drowsiness are able to drive. Patients should not drive during dose titration. The likelihood of unwanted effects & interactions increase when opioids, (including tramadol) are used in conjunction with other centrally acting drugs, such as antidepressants, anticonvulsants & alcohol Exercise extreme care in the elderly and those with known renal impairment Remember to review the agreed treatment plan as part of the monitoring process. This is important as this focuses on goals such as increased function and return to normal activities as well as pain control. Problem drug use Physical dependence is a normal physiological response; however psychological dependence is not. Addiction is a drug craving when a patient knows that the effects are harmful. If concerned, shorten prescription & review times, consider dose reduction and referral for a specialist opinion. The rate of problem drug use in this group of patients is unclear A past history of problem drug use is only a relative contra-indication for prescribing Special situations Low dose long-acting morphine is recommended as first line in most situations In renal failure morphine and pethidine (and their metabolites) may accumulate and should not be used. Fentanyl, tramadol and buprenorphine are considered safer options in renal failure however use with caution. Butrans patch may be a sensible choice when (1) patient is frail/elderly (2) there is a marked & troublesome on/off effect with codeine or (3) codeine resistance is suspected and an alternative opioid is indicated prior to the use of strong opioids. There is evidence of opioid induced hyperalgesia in some patients and this should be considered especially if increasing doses seem to be needed to control pain when previously a stable dose was used. Stopping opioids Around half of patients trialled on strong opioids will discontinue them within 2 years. This may be due to lack of or loss of effects, side effects, problem behaviour, resolution of the pain If opioids are stopped suddenly about half of patients will suffer withdrawal effects. These can be dangerous. Tapering the dose by 25-50% every few days is adequate to avoid this for most patients. If pain flares markedly or symptoms of withdrawal still occur temporarily, slow or reverse changes If in doubt, seek specialist advice WEST KENT GUIDELINES FOR PRESCRIBING STRONG OPIOIDS IN ADULT NON-CANCER CHRONIC PAIN

57. Opioid equivalent for long-acting formulations on a 24 hour period Morphine (mg/24hrs) oral 102030406090120180270 Oxycontin (mg/24hrs) oral 510 2030 4560100160 Fentanyl (mcg/hr) patch ~ 1212 12-25 25 5075 Buprenorphine (mcg/hr) patch 510 203552.570 Remember: These are approximate. If you switch opioid, start on 50-75% equivalence of the previous drug; remember re-titration may be necessary. Take great care at higher dose conversions and seek advice if unsure Please note this conversion chart has been simplified; no conversion is exact and other charts may vary.

58. The “cost” of managing opioid-induced constipation Targinact tablets 10/5 mg b.d. OxyContin + Docusol ® + Senokot ® syrup OxyContin + Docusol ® OxyContin + Movicol ® OxyContin + Dioctyl ® +senna tabs OxyContin + Dioctyl ® OxyContin + lactulose (500 ml) + senna tabs OxyContin + lactulose (500 ml

59. Injections What Are They For? Cure Palliation Obtunding an acute inflammatory response Creating a window of opportunity Avoiding drugs and side effects Making money

60. Injections can have complications

61. Injections Steroids have an evidence base for radiculopathy Epidurals do not for chronic back pain (NNT 10) Epidurolysis has no evidence in its favour either blind or via endoscope and can make you blind In the long term repeat injections will run out of steam

62. But There are situations where we might help

63. Discography Does Discography Cause Accelerated Progression of Degeneration Changes in the Lumbar Disc: A Ten-year Matched Cohort Study Carragee et al Spine. 2009;34(21):2338-2345

64. Case-Disc Disease 26 year old man Manual job Low back/left leg pain Some improvement with hydrotherapy RNS-not for surgery “Seeking a cure”

65. At Pain Clinic Straight to discography And…..

66. Disc Treatments At this stage the available evidence for all intra-discal therapies is poor and they should be viewed as experimental not proven Dubious trials exist that got some therapies a license The American guidelines conclude this (ASA 2010)

67. Surgery in LBP Place for surgery in non specific LBP? (fusion vs rehab) Supposed superiority of surgery vs EBM superiority of PMP? Newer treatments and better outcomes MRC collaborative BMJ 2005 Louisiana vs New York FDA license for disc replacements

68. Is Surgery Becoming More Common for LBP 1990-2000 220% increase in spinal operations in US 1997-2002 procedures per year 320,000- 1,000,000 5x lower in UK All this despite fusion being an unproven operation and ethics of disc replacement surgery trials questionable

69. Costs of Failed Surgery Direct medical appointments, scans, treatments, drugs (1998 est 1.6billion/year) Indirect transport, adaptions, social care, lost productivity, DLA (1998 est 6.6-12 billion/year) Rate of FBSS is unknown (but est 10-40% AAPM 2001)

70. Failed Surgery versus Other Chronic Diseases Brit Med J 2010; 340: c221 Similar Qol with NIDDM and CCF ( Pain 2010; 149: 338–344) FBSSRheumatoid Pain scorehigher QoL (EQ-5D)0.160.4-0.75 Disability (Oswestry) 5627 Employmentlower Brit Med J 2010; 340: c221 Similar Qol with NIDDM and CCF (Pain 2010; 149: 338–344)

71. Factors Predicting Poor Outcome From Surgery Chronicity (the “deconditioning syndrome”) Not first operation Scale of operation Psychological factors/disorders Non specific “signs” Smoking

72. Disc Prolapse

73. Disc “Surgery”

74. Possibly the Best Fusion in the World

75. Case-Expectation Management 17 year old female Heavy landing show jumping Immediate hip pain Admitted via A+E and single split disc on scan Improved 5-60% with analgesia and an epidural Improvement cessed Referred to Kings despite already having had 2 opinions locally No change Re-referred with no mention of long term drug problem

76. Managing Difficult Patients Do not doctor shop or cure seek or use scatter guns Order the right tests at the right time (agree guidance) Know who to refer to and when Manage expectation Manage fear But if you do…..

77. Pain Management Programmes

78. Open Access Psychology?

80. Recommendations From the British Pain Society Excerpts from the BPS Consensus Guidelines in Pain Management in Adults 2007 “Pain management programmes bases on cognitive behavioural principles, are the treatment of choice…” “Evaluation of outcomes should be standard practice, assessing distress/emotional impact of pain…” Better than placebo up to at least 2 years Not everyone is suitable Back school is not a pmp

81. Elomaa MM et al. European Journal of Pain. 2009 Cognitive Behavioural Management of Chronic Pain (data for individuals completing 6 month follow-up) n=41 Six weekly 90 minute group sessions Based on CBT Attention management manual * * * * **

82. Barriers to Improving Care Self interest Self importance Inaccurate selling Lazy or friendly referring Poor management Failing to spot the obvious/lack of insight

83. Those Who Try Tend To Do Better

84. I know Unhappy Back Pain Patients Get Brain Rot Apkarian AV,et.al. J Neurosci.2004;24(46)P10410-10415 Patients with chronic back pain (CBP) had 5- 11 % less whole brain gray matter, equivalent to 10-20 years of normal aging