1. Professor Milton Cohen St Vincent’s Campus, Sydney, and Faculty of Pain Medicine, ANZCA 9 May 2016 Chronic Pain: understanding paradigm approach New

2. To be covered:  Comprehensive assessment of patients with CNCP  Managing the social and psychological dimensions  Pharmacological management  Opioid prescription: when and how  Other biomedical interventions  Philosophies and types of PMPs  Facilitating self management

3. “To have pain is to have certainty; to hear about pain is to have doubt.” Elaine Scarry, 1985 “Johnny, are you in pain?” “No, Mummy. The pain is in me.” The Advertiser, 1927 Quoted in The Lancet, 30 June 2012 “Your pain is the breaking of the shell that encloses your understanding.” Kahlil Gibran

4. Courtesy of Prof Deborah Schofield

5. Themes  Complex biology of pain  Sociopsychobiomedicala ssessment and management  Therapy of pain, including opioids Not a “broken part” but a changed person “The body” is not the only thing Self-management is the aim

6. P A I N An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage

7. P A I N An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage

8. A dominant paradigm… Biomedical focus Anatomical determinism Dualism Biopsychosocial Sociopsychobiomedical Neural plasticity Interactionism …shift

9. PAIN DISEASE (nervous system) Biomedical Model

10. Problems with Biomedical Model of Pain  Implies hard-wired certainty  Absence of nociception defaults to “psychogenesis”  Excludes narrative of the sufferer

11. CNCP is a complex phenotype [Campbell et al, Pain 2015;156:231-242; NDARC, UNSW Australia] N=1514, CNCP taking prescribed opioids for >6 weeks  Low rates of employment/ income  Multiple “pain conditions”, poor physical health  ~30% abuse/neglect  ~ 50% depression; ~25% anxiety; >40% suicidal ideation  >30% concurrent BZD; >50% concurrent antidepressant  1:8 cannabis use disorder; 1:3 alcohol use disorder

12. Anterior cingulate cortical (ACC) activation  Thermal injury  Rectal distention  Hearing pain words  Viewing facial expressions of pain  Social exclusion

13. A model regarding brain circuitry involved in the transition from acute to chronic pain. Apkarian et al. Pain 2011:152:S49-S64

14. social psycho Bio Socio psycho biomedical

15. BRAIN AND NERVOUS SYSTEM ENVIRONMENT PERSON BODY

16. BRAIN AND NERVOUS SYSTEM ENVIRONMENT PERSON BODY What’s happening to your body (-biomedical”) What’s happening to you as a person (-”psycho-”) What’s happening in your world (“socio-)

17. DISTRESSDISABILITY NOCICEPTION BELIEFS CULTURE MEMORY EDUCATION

18. BLACK FLAGS BLUE FLAGS YELLOW FLAGS ORANGE FLAGS RED FLAGS

19. Early detection of problems? BLACK FLAGS BLUE FLAGS YELLOW FLAGS ORANGE FLAGS RED FLAGS Symptoms persisting past “healing” New pathology Iatrogenic factors Mental health disorders Personality disorders Threats to financial security Sense of injustice Litigation Low social support Unpleasant work Low job satisfaction Excessive work demands Problems outside of work Unhelpful beliefs about injury Poor coping strategies Passive role in recovery

20. Tenderness - Allodynia  Pain in response to a non-noxious mechanical stimulus (touch, pressure, movement)  Increased responsiveness (lower threshold) of nociceptors RED FLAGS Symptoms persisting past “healing” New pathology Iatrogenic factors

21. UNDERSTANDING “TENDERNESS ” Hyperalgesia/allodynia in area of disease, damage or inflammation (1°) Peripheral sensitisation Hyperalgesia/allodynia in clinically normal tissue (2°) Central sensitisation Complaint of pain

22. CENTRAL SENSITISATION OF NOCICEPTION  “Pain…might not necessarily reflect the presence of a peripheral noxious stimulus.”  “Pain could…become the equivalent of an illusory perception…” Woolf C. Pain 2011;152:S2-S15 “Switch-on” of nociceptive pathways in the central nervous system (spinal cord and brain)

23. SENSITISATION OF CENTRAL NOCICEPTIVE PATHWAYS NOCICEPTIVE BARRAGE NERVE DAMAGE SPONTANEOUS PAINALLODYNIA SPREAD OF PAIN UNDAMPENED STRESS RESPONSE

24. CLINICAL FEATURES SUGGESTING CENTRAL SENSITISATION  Absence of obvious tissue damage or disease  Sensitivity to touch, movement  Worsening pain after repetitive use (hyperpathia)

25. DIAGNOSTIC IMPLICATIONS OF CENTRAL SENSITISATION “Top-down” AND “bottom-up” Avoid chasing nociception in region of pain No language (yet)

26. “NOCICEPTIVE” “ NEUROPATHIC ” A FALSE DICHOTOMY

27. “NOCICEPTIVE” “NEUROPATHIC” REPLACING THE DICHOTOMY See Kosek E et al. Do we need a third mechanistic descriptor for chronic pain states? Pain 2016, in press “NOCIPLASTI C”

28. THERAPEUTIC IMPLICATIONS OF CENTRAL SENSITISATION Avoid chasing nociception in region of pain Nervous system re-education Pharmacological modification of symptoms and excitability

29. A dominant paradigm shift Biomedical focus Anatomical determinism Dualism Sociopsychobiomedical Neural plasticity Interactionism

30. Adolphs & Damasio 1995 Our point of view as observers does not allow us to know what it is like to be the system being observed

31. Risks – to the patient - of having chronic pain  Challenge observers’ view of the world  Reinforce clinicians’ uncertainty  Fail to validate health professionals’ effectiveness Marginalisation Discrimination Stigmatisation

32. Risks – to the clinician – of chronic pain  View of the world challenged  Uncertainty reinforced  Effectiveness not validated “Negempathy” Conscious avoidance of compassion Negative projection

33. CLINICAL ENCOUNTER SOCIAL DETERMINANTS LANGUAGELANGUAGE

34. CLINICAL ENCOUNTER EXPERIENCE ATTITUDES & BELIEFS PSYCHOLOGICAL DISTRESS ILLNESS BEHAVIOUR KNOWLEDGE ATTITUDES & BELIEFS AFFECT CLINICAL BEHAVIOUR EMPATHY HONESTY TOLERANCE PREJUDICE HOSTILITY SUSPICION

35. REFRAMING THE ENCOUNTER Shared expertise Neurobiology Empathy Language

36. To be covered:  Comprehensive assessment of patients with CNCP  Managing the social and psychological dimensions  Pharmacological management  Opioid prescription: when and how  Other biomedical interventions  Philosophies and types of PMPs  Facilitating self management

37. The clinician’s trilemma  Our patients believe that they can be “fixed”  Not all our patients get better  Our treatments have unpredictable effects

38. PRINCIPLES OF THERAPY AIMS Decrease pain as much as possible Increase function as much as possible Minimise adverse effects of treatment MODALITIES Psychological Physical Pharmacological Procedural

39. PHARMACO- THERAPY PROCEDURES PSYCHOTHERAPY PHYSICAL THERAPY

40. What’s happening to your body What’s happening to you as a person What’s happening in your world “Treatment” of person with chronic pain Exploring the body Movement ?Medications ?Procedures Reframing New learning ?Medications Relationships Security Work

41. CLINICAL IMPROVEMENT  Natural history  Spontaneous symptom fluctuation  Regression to the mean  Sampling bias  Hawthorne effect  Specific effects of therapy  “Non-specific” effects of therapy

42. PLACEBO (CONTEXTUAL) EFFECT(S) Change(s) in illness attributable not to a specific pharmacological or physiological effect of a treatment but rather to the sociocultural context in which the treatment occurs

43. PLACEBOS AND CONTEXTUAL EFFECT Contextual effect does not require a placebo Non-placebo characteristic effect + contextual effect Powerful non-placebo increased contextual effect Weak non-placebo or placebo decreased contextual effect

44. Pharmacotherapy of Chronic Pain

45. Post Synaptic Element NK -1 NMDAAMPA NK - 1 22        Primary Afferent Fibre 22 GABA B GABA A Adn 5HT 1B R - Pia Neca Damgo Morphine Clonidine Opioids Baclofen Ca ++ Na + Ketamine Tricyclics Midazolam SP Glu 5 - HT 3 5 - HT 2 Ketanserin KetocyclazocineBaclofenOpioidsClonidine2 - Methyl - serotonin Unconditional, Fast and Strong. Locally adapting. Contingent, Medium speed and Medium strength. Wind - up. Adaptable, Slow Weak. Subject to inhibition by K channel activation. Cl - K+K+ K+K+ K+K+ K+K+ PRIME

46. PHARMACOTHERAPY Non-opioid analgesicsparacetamol, NSAIDs Weak µ-opioid agonistscodeine, tramadol, tapentadol Strong µ-opioid agonistsmorphine, oxycodone, methadone, hydromorphone, fentanyl Mixed opioid ant/agonistbuprenorphine Adjuvant analgesicsantidepressants, anticonvulsants

47. Finnerup et al. The evidence for pharmacological treatment of neuropathic pain. Pain 2010, 150:573-581

48. The “Opioid Epidemic” Australia 1990-2010 Population 29% Pharmaceutical opioid base supply228% Per capita morphine equivalent 50 350mg

49. Ethics of Opioid Analgesia for Chronic Non-Cancer Pain OPIOPHILIA  Patients’ right to pain relief  Unpredictability of opioid-responsiveness  Adverse effects, including addiction, not a problem OPIOPHOBIA  Patients’ motivations  Sanctions on clinicians  More realistic view of addiction See also: Rich BA. Pain Clinical Updates 2007, vol XV, issue 9 Ballantyne JC, Fleisher LA. Pain 2010;148:365

50. Evidence for Efficacy of Opioids in Chronic Non-Cancer Pain  Diversity of subjects  Complexities of non-somatic influences  Variability with respect to substance abuse  Primary outcomes  Generally poor quality Ballantyne JC, Shin NS. Efficacy of Opioids for Chronic Pain: A Review of the Evidence. Clin J Pain 2008; 24:469- 478

51. Evidence for Efficacy of Opioids in Chronic Non-Cancer Pa in  Extrapolation to real-life situations  Risks and benefits vary over time  Opioid-responsiveness always a trial Ballantyne JC, Shin NS. Efficacy of Opioids for Chronic Pain: A Review of the Evidence. Clin J Pain 2008; 24:469- 478

52. Principles of Opioid Therapy for Chronic Non-Cancer Pain 1.Comprehensive assessment 2.Failure of adequate trial of other therapies 3.Contractual approach to opioid usage 4.Practical considerations 5.Response to apparent increase in dosage requirements RACP. Prescription Opioid Policy. 2009. www.racp.edu.au/page/health-policy-and-advocacywww.racp.edu.au/page/health-policy-and Cohen ML, Wodak AD. Medicine Today 2010; 11:10-18 & 2012; 13:24-32 Faculty of Pain Medicine, ANZCA. Professional Document PM1, 2015. anzca.edu.au/fpm/resources/professional-documents

53. Response To Difficulty Achieving Goals in an Opioid Trial  No change in pain despite improvement in function  Opioid non-responsive  Unsanctioned use  Comprehensive reassessment

54. To be covered:  Comprehensive assessment of patients with CNCP  Managing the social and psychological dimensions  Pharmacological management  Opioid prescription: when and how  Other biomedical interventions  Philosophies and types of PMPs  Facilitating self management

55. “More studies are needed…”  Shoulder pain “There is some evidence from methodologically weak trials to indicate that some physiotherapy interventions are effective for some specific shoulder disorders.” (Green et al. Cochrane Database of Systematic Reviews 2003, Issue 2. Art. No.: CD004258)  Low back pain “In this systematic review, we present information relating to the effectiveness and safety of the following interventions: acupuncture, analgesics, antidepressants, back schools, behavioural therapy, electromyographic biofeedback, exercise, injections (epidural corticosteroid injections, facet joint injections, local injections), intensive multidisciplinary treatment programmes, lumbar supports, massage, muscle relaxants, non-steroidal anti-inflammatory drugs (NSAIDs), non-surgical interventional therapies (intradiscal electrothermal therapy, radiofrequency denervation), spinal manipulative therapy, surgery, traction, and transcutaneous electrical nerve stimulation (TENS).” (Chou R. Clinical Evidence [Clin Evid (Online)] 2010 Oct 08)

56. Regarding “interventions” ? Rationale ? Evidence ? Ethics  Central problem  No sham controls  Charging for placebo

57. Harris IA, Buchbinder R. Time to reconsider steroid injections in the spine? Med J Aust 2013;199:237 “In our opinion, withdrawal of public funding for spinal steroid injections for low back pain and/or radiculopathy should be considered on the basis of our knowledge of the placebo nature of the treatment, the costs and, not least, because of the likelihood of harm.”

59. “More studies [may not be] the answer…”  “ …the positive studies are false positives…”  “No matter how many studies showed negative results, they would not persuade true believers to give up their beliefs.”  Hall, H. Commentary. Pain 2011;152:711-712.

60. To be covered:  Comprehensive assessment of patients with CNCP  Managing the social and psychological dimensions  Pharmacological management  Opioid prescription: when and how  Other biomedical interventions  Philosophies and types of PMPs  Facilitating self management

61. What does a good pain management program look like?  Not for “pain” but a person experiencing pain (PEP)  Reframes the problem  By provider  Of PEP  Recognises the context  Sociopsychobiomedical framework  Interaction  Respects the nervous system  Allodynia  Drug effects

62. What physical treatments are you recommending? What’s happening to your partient as a person? What’s happening in your patient’s world? Trouble-shooting Relationships Work Recreation Movement ?Medications ?Procedures Understanding Mood ?Medications

63. To be covered:  Comprehensive assessment of patients with CNCP  Managing the social and psychological dimensions  Pharmacological management  Opioid prescription: when and how  Other biomedical interventions  Philosophies and types of PMPs  Facilitating self management

64. Themes  Complex biology of pain  Sociopsychobiomedicala ssessment and management  “Treatment” of (the person with) pain Not a “broken part” but a changed person “The body” is not the only thing Self-management is the aim

66. Acute painChronic pain Active tissue damage Altered nervous system Changed person

67. ALTERED NOCICEPTION “HYPERALGESIA” ALTERED ATTENTION “HYPERVIGILANCE” TRAUMA

68. CNS CONTEXT PERSON BODY Exploring the body Movement ?Medications ?Procedures Reframing New learning ?Medications Relationships Security Work

69. FACTORS INFLUENCING PLACEBO RESPONSES  Patient expectation  Conditioning  Physician expertise  Treatment impressive and expensive

70. Placebo response (= response to placebo) in the experimental setting is a model for contextual effect in the clinical setting

71. Case 1: F45  Ankle injury 2y ago: “sprained”  “CRPS” diagnosed 4m later  4w inpatient PMP: physio/hydro/benzo/pregabalin/nortriptyline/opioid/int rathecal  Suicidal ideation 6m later  5+w admission for (long-standing) depression: drugs/psychotherapy/TMS/ECT  Personality and interpersonal issues identified…

72. Case 1: analysis Bio psycho social Socio psycho biomedical Biomedical diagnosis (?) One-size-fits-all approach Medicalisation: psychological issues drugs/procedures Trivial biomedical component Why no return to work? Delayed recognition of context

73. Case 2: F55  Fell off chair 3y ago: “lumbar sprain”  Massage/“physiotherapy”/heat/TENS  Palexia/Lyrica/Maxigesic  “Denervation” -?repeat  “Adjustment reaction with depression”  Antidepressant drugs/counselling  “Pain management not helpful”

76. ALTERED NOCICEPTION “HYPERALGESIA” ALTERED ATTENTION “HYPERVIGILANCE”

77. ALTERED NOCICEPTION “HYPERALGESIA” AL TERED ATTENTION “HYPERVIGILANCE” STRESSOR THREAT TO HOMEOSTASIS CWP PAIN is one way, among many, that threats to homeostasis are signalled

78. Fear avoidance A behavioural response to pain characterised by a person excessively restricting involvement in activities and exercises due to heightened fear or anxiety about pain or re- injury (i.e. worry that any pain could cause tissue damage). Clinical Framework for the Delivery of Health Services TAC & WorkSafe Victoria

79. RTW Twin Goals Injury Rx

80. CLINICAL FRAMEWORK PRINCIPLES 1.Measure and demonstrate the effectiveness of treatment 2.Adopt a biopsychosocial approach 3.Empower the injured person to manage their injury 4.Implement goals focused on optimising function, participation and return to work 5.Base treatment on the best available research evidence

81. CLINICAL FRAMEWORK PRINCIPLES - from a clinical perspective - 1.Adopt a sociopsychobiomedical approach 2. Implement goals focused on optimising function, participation and return to work 3. Empower the injured person to manage their injury 4. Base treatment on the best available research evidence 5.Measure and demonstrate the effectiveness of management

82. Terminology  Inappropriate prescriber behaviour  Unsanctioned opioid use  Problematic use (patients)  Illicit use (third parties)

83. Problems Diagnosis Tolerance Hyperalgesia Pseudoaddiction (Hormonal changes) (Immune modulation)

84. Unanswered Questions  Is opioid therapy beneficial in the long term?  Is there a differential effect on efficacy and safety?  Is there a ceiling dose?  How likely is unsanctioned use?