1. www.hnehealth.nsw.gov.au/pain Hunter Integrated Pain Service (HIPS) Welcome Understanding Pain

2. Everyone can benefit  Pain at any site  Osteoarthritis & rheumatoid arthritis  Migraine & other headaches  Abdominal & pelvic pain, irritable bowel, endometriosis  Neuropathic pain eg. post-shingles, diabetic neuropathy, MS, post-polio  Fibromyalgia  Complex regional pain syndrome  Chronic fatigue syndrome  Post cancer pain  Other

3. 1 2 3 4 Whole person management The new science Introducing HIPS & what next? What is pain? Outline

4. What is pain?  Indication of threat  Actual damage or the feeling of damage  Sensory & emotional experience

5.  Short term  Often linked to body structures under threat damaged What is acute pain? threat...damage... Egloff, Hirschi, von Känel. J Pain Research 2013

6.  Lasts 3 months or more  Often persisting after body structures heal  Wind up of nervous system What is chronic pain? hyper-alert...flea bite feels like the eagles claws Egloff, Hirschi, von Känel. J Pain Research 2013

7. The new science 2 Role of nervous system  Wind up or sensitisation increases pain  Winding down reduces pain

8. Structural changes and pain Treat the person not the scan

9.  Painful, swollen, stiff ankle after amputation  Brain retraining relieved symptoms Haigh. Rheumatology 2003 Symptoms without structure

10. Davidson, McEwen. Nat Neurosci. 2012 Chronic stress changes neurons

11. Ongoing pain linked to emotional response to initial injury “Traumatic” memory imprints the brain in a different way Baliki, Apkarian. Nature Neurosci. 2012 Back pain recovering Back pain persisting Brain changes predict persisting pain

12. Sheep tracks Winding up or down Brain changes

13.  Nervous system  Active treatments  Body structures  Passive medical treatments For many the balance is not right A need to restore balance

14. Whole person management 3 Adapted from Hayes & Hodson. Pain Medicine 2011

15. Brainman chooses

16. “I think the dose needs adjusting. I’m not nearly as happy as the people in the ads.” What is the evidence for medical treatments ?

17. 0 2 4 6 8 Moulin et al. Lancet 1996 time (weeks) Morphine in chronic pain

18.  Well known Constipation Drowsy, clouded thinking Tolerance Addiction  Did you know about ? Worsening pain (opioid induced hyperalgesia) Sexual dysfunction Driving impairment, risk of death (especially with sleeping tablets) Opioid side effects

19. HIPS support you & GP as long as needed to wean opioids Time limited Opioid strategy

20. STEP 1: Rule out danger  Harmful structural problems?  Red flags – cancer, fracture, infection, nerve pressure STEP 2: Clear explanation STEP 3: Pain management plan Biomedical

21.  This is normal  Mind & body interweave Mindbody

22.  Choices  Present moment  Timeline  Peace of mind What else was happening when the pain came on? Mindbody treatment

23.  People & place  Social isolation hurts  Reconnecting - part of recovery & wellbeing Connection

24.  Activity v rest  Strength  Lying down during the day  Healthy sleep Activity

25.  Fruit, vegetables (2 & 5), fibre & protein  Less processed foods eg. sugary drinks  Supplements – omega 3  Address smoking, alcohol, other drugs Healthy food is good medicine Nutrition

26.  6 months of low back pain after an injury at work  Scan - disc bulge & tear Brian’s story

27.  No red flags - spinal structure less relevant  More about changes in brain & spinal cord  Oxycontin not working  ‘Men should get on with it’  Pushing through, ‘boom & bust’ cycle Brian’s assessment

28.  Opioid wean over 4 months  Goal setting – travel & grandchildren  Awareness of thoughts  Pacing activity  Improve flare up management Brian’s pain management plan

29.  Background pain from 8/10 to 6/10  Positive changes in thinking, mood & activity  Less interference with life  Flare ups fewer managing differently Brian’s recovery

30.  30 yrs married  Not working due to poor health  Chronic widespread pain & fatigue Anna’s story

31.  Nutrition less processed food more vegetables omega 3 fish oil weight loss 5 kg  Psychological aspects local counsellor Anna after Understanding Pain

32.  Onset pain & fatigue age 15yrs  Diagnosed with fibromyalgia  Widespread pain in muscles & joints 6-8/10  Long term Norspan – no ongoing benefit  Low mood  Avoidance of activity Anna’s assessment

33.  Large family, Anna eldest child  Father moved away when Anna was 15 yrs; business & marriage failed  “my childhood ended”  “weight of responsibility settled on my shoulders” Anna’s timeline

34.  Biomedical - wean Norspan over 3 months  Local counsellor  Aim to return to work & study  Walking program - “pacing”  Continue “anti-inflammatory” eating Anna’s pain management plan

35.  1 month phone call Continuing with plan  8 month phone call 80% less pain & fatigue Further 5 kg weight loss Work as part-time cleaner TAFE course  Mindbody link Anna’s recovery

36. Hunter Integrated Pain Service  Public system  Types of pain Chronic non-cancer Acute Cancer  General practice links 4

37. 1.Use active treatments 2.Get support 3.Wean pain medication Key messages Getting there takes:  awareness  a choice  commitment

38. HIPS website www.hnehealth.nsw.gov.au/pain www.hnehealth.nsw.gov.au/pain Google: Hunter Integrated Pain Service

39.  Small group  Supported self-assessment  Pain management plan biomedical mindbody connection activity nutrition Assessment and Planning

40. Your choice GP Early community link HIPS Assessment & Planning Community options HIPS options Where next ?