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

2. People experiencing …  Back pain  Arthritis  Headaches  Abdominal & pelvic pain  Neuropathic pain eg. post-shingles, diabetic neuropathy  Fibromyalgia  Complex regional pain syndrome  Post cancer pain  Other … have reported benefit

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

4. What is pain?  It comes from the brain  Brain weighs up ‘danger’ v ‘safety’  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 repair  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  Evidence of danger or safety  Wind up increases pain  Wind down reduces pain

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

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

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

11. Neurons that fire together wire together Winding up or down Brain changes Sheep tracks

12.  Active treatments  Passive treatments Changing the approach

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

14. Brainman chooses

15. “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 ?

16. Morphine for chronic pain Time (weeks) Pain intensity Moulin et al. Lancet 1996

17.  Well known Constipation Foggy thinking Tolerance Withdrawal Addiction  Did you know about ? End of dose withdrawal Worsening pain Sexual dysfunction Car crashes Increased deaths Opioid side effects

18. HIPS will support you & GP to wean & cease opioids Time limited Opioid strategy

19. STEP 1: Rule out danger  Red flags – cancer, fracture, infection, nerve pressure? STEP 2: Clear explanation STEP 3: Active treatments Biomedical

20.  Exit from passive treatments  Strong foundations (healthy habits)  Build for the future Getting off the medical roundabout

21.  This is normal  Mind & body are linked Mindbody

22.  Timeline  Present moment  Wind down the nervous system What else was happening when the pain came on? Mindbody treatment

23.  People & place  Disconnection hurts  from others  from country  Reconnecting - part of recovery & wellbeing Connection

24.  Activity v rest  Healthy sleep  Strength Activity Mindful movement brings a message of safety

25.  Plenty of vegetables (5) & only 2 fruit  Avoid sugary drinks/foods & processed meats  Address smoking, alcohol & other drugs =Less inflammation & pain Healthy food is good medicine Nutrition

26.  45 years  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  Aware of thoughts  Mindful movement  Building strength  Improve flare up management Brian’s pain recovery 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 years  Not working due to poor health  Chronic widespread pain & fatigue Anna’s story

31.  Nutrition less processed food more vegetables 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  Strength & walking program  Continue “anti-inflammatory” eating  Aim to return to work & study Anna’s pain recovery plan

35.  HIPS support over 8 months 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 related medication Key messages This takes time

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 recovery plan Assessment and Planning

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