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

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

3. What is pain?  Indication of threat  Actual or potential damage  Emotional experience

4.  Short term  Often linked to body structures under threat damaged What is acute pain? threat...damage... Egloff N, Hirschi A, von Känel R. J Pain Research 2013;6:765–70

5.  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 N, Hirschi A, von Känel R. J Pain Research 2013;6:765–70

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

7. Structural changes and ongoing pain

8.  Painful, swollen, stiff left ankle  Imagined exercise of the phantom limb relieved symptoms Haigh et al 2003 Rheumatology Symptoms without the structure

9. Davidson, McEwen. Social influences on neuroplasticity. Nat Neurosci. 2012;15(5):689-95 Chronic stress changes neurons

10. Ongoing pain linked to emotional response to initial injury “Traumatic” memory imprints the brain in a different way Baliki, Apkarian et al. Corticostriatal functional connectivity predicts transition to CBP. Nature Neurosci. 2012 Back pain recovering Back pain persisting Brain changes predict persisting pain

11. Brain habits Sheep tracks Winding up or down

12.  Nervous system  Active treatments  Body structures  Medical treatments For many people the balance is not right A need to restore balance

13. Whole person management 3 Adapted from Hayes & Hodson. A whole person approach to persistent pain. Pain Medicine 2011;12(12):1738-49

14. Brainman’s choices  Think well  Move well  Eat well

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

16. 0 2 4 6 8 Moulin et al. Lancet 1996 time (weeks) Morphine in chronic pain

17.  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

18. STEP 1: Rule out danger  Harmful structural problems?  Red flags – cancer, fracture, infection, nerve pressure STEP 2: Medical treatment as part of broad approach  Medications / procedures  Time limited  Pain recovery plan Biomedical

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

20.  This is normal  Mind & body interweave  Awareness of thoughts  Peace of mind Mindbody Eccleston C. A normal psychology of chronic pain. 2011;24(6):422-425

21. Timeline

22.  People, purpose, place  Isolation & disconnection are common  Reconnecting - part of recovery & wellbeing Connection

23.  Finding the right balance  Body awareness  Awareness of thoughts behind the movement  Ease of movement, ease of mind Activity

24. Nutrition  Fruit & vegetables (2 & 5)  Less sugary drinks  Time limited supplements  Address smoking, alcohol, other drugs Nutrition Inflammatory diet worsening pain

25.  6 months of low back pain after an injury at work  Scan - disc bulge & tear Brian’s story

26.  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

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

28.  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

29.  30 yrs married  Not working due to poor health  Chronic widespread pain & fatigue Anna’s story

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

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

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

33.  Biomedical - wean Norspan over 3 months  Mindbody workbook / local counsellor  Return to work & future education options  Walking program - “pacing”  Continue “anti-inflammatory” eating Anna’s pain recovery plan

34.  Phone call at 1 month Continuing with pain recovery plan  Phone call at 8 months 80% less pain & fatigue Further 5 kg weight loss Work as part-time cleaner TAFE course Mindbody Workbook – forgiveness Anna’s recovery

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

36. 1.Use active treatments 2.Get support 3.Wean pain medication Key messages

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

38.  Small group  Supported self-assessment  Pain assessment & recovery plan biomedical mindbody connection activity nutrition Assessment and Planning

39. Where next?