Pain Future trends and management - PowerPoint Presentation

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Pain

Future trends and managementPain Management Service - Stamford HospitalAndreas Erdmann – Consultant Pain MedicinePaula Wilkinson – Specialist Pain Occupational TherapistBecky Livings – Specialist Pain Physiotherapist

Pain GP 2019

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Pain

An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. IASP 1994

Pain GP 2019

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New Insights

An aversive sensory and emotional experience typically caused by, or resembling that caused by, actual or potential tissue injury. (under discussion)

Requires

res

ponse

Not just associated

Damage not required

Pain GP 2019

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Does this get Closer to it?

Emotional pain Spiritual pain“Aversive” experiences

Pain GP 2019

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Challenges

Defining itExplaining itTreating it

Individual

NARRATIVE

Variable

Pain GP 2019

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ObjectiveS

Part 1 “ Introduction”Practical approach to common questions/scenariosShort case historiesSummary current guidelines Part 2 “Q&A”Biopsychosocial modelTreatment examples - case historyYour questions/case histories

Pain GP 2019

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What are common problems YOU SEE?

OpioidsBack painComplex pain/FibromyalgiaPain GP 2019

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Mrs M.S.

Thank you for seeing this 48 yr old lady for pain management.She has severe COPD and is on ambulatory oxygen. She has chronic nonspecific right –sided upper back/thoracic pain, for years.WHAT ANALGESICS COULD BE USED?

Pain GP 2019

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MRS M.S.

Could you also see her for management of her opioid use?She is currently on MST, and also oromorph.WHAT DOSE MIGHT BE SUGGESTED HERE?

Pain GP 2019

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MRS M.S.

400mg BD MST100mg Oramorph dailyPain GP 2019

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DIscussion

Initial thoughts - why/what?How effective is treatment?ConcernsPain GP 2019

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Dangers

Adverse effects short term – e.g. constipation, nausea, sedationAdverse effects long termPsychological –

depression, cognitive slowingHormonal – reduced libido, impotence

Immune

–

increased infections, possibly increased cancer risk

Mortality

– all-cause early

Pain GP 2019

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Hypothalamus

Anterior PituitaryOvaries/testes

Testosterone

Dihydrotestosterone

Oestradiol

Osteoblasts

New bone formation

Adrenal

DHEA

5aR

P450 aromatase

OPIOIDS

GnRH

OPIOIDS

OPIOIDS

OPIOIDS

OPIOIDS

ENDOCRINOPATHY

Pain GP 2019

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Opioids

INNATEReduced activity - macrophages neutrophils mast cell

natural killer dendritic Intestinal integrity impaired

ADAPTIVE

Reduced

T-cell

cytokines/activation

B-cell

antibody production

MHC II presentation

Increased

T-cell death

IMMUNE

Pain GP 2019

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Faculty of Pain Medicine Pain Information Leaflets

Pain GP 2019

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Pain GP 2019

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MR J.T.

58 years old man, worked as plasterer 30 yearsLong standing back pain, intermittent buttock/thigh painTreated for non-specific back pain Simple analgesiaPhysio Advice “keep active”Retire in 4 years, “in agony last 6 months” –

can’t sleep, stand or walk very far Reliably in lower back

Pain GP 2019

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Mr J.T.

Walked slight stoop – “bad day”Extension postures particularly painfulLargely predictable constant burning/aching pain right lower backTenderness paravertebral palpation on right *Possible specific cause back pain

– “facet joint syndrome”Medial branch blocks

Radiofrequency denervation

Pain GP 2019

NON SPECIFIC

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Pain GP 2019

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COntExt

Pain relief (permanent) - not only goal“Enabler” Window of opportunityMultidimensional approachActivity Function Mental health

Pain GP 2019

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Mrs HJ

48 year old lady ongoing left leg painBackground longstanding fibromyalgiaPhysiotherapist thought likely neural irritation – pain did not respond to physiotherapyNo help with gabapentin, could not tolerate amilriptylineDistressed - advice

Pain GP 2019

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Thoughts?

Pain GP 2019

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Pain GP 2019

Need a different approach?

HOLISTIC

MULTIDIMENSIONAL

PSYCHOSOCIAL

MULTIDISCIPLINARY