4CMO REPORT 2009 PAIN : BREAKING THROUGH THE BARRIER United Kingdom : Pain in numbers7.8 million people live with chronic painNHS spent £584 million on 67 million prescriptions for analgesia1 million women suffer with chronic pelvic pain1.6 million adults suffer with chronic LBP49% adults with CP experience depression25% of sufferers lose their jobs500 pain specialists in the UKRoughly 1 specialist per 250,000 people(1 specialist per 32,000 sufferers????)
5CMO REPORTWhen pain becomes chronic, normal damping mechanisms stop workingBiological, psychological and social factors combine to exacerbate symptomsModern pain management should address all these elements with an “Integrated Approach”Treatments involve activity, rehab, drug therapy, psychological therapy, TENS, acupuncture and interventionsKey is to ensure all aspects are INTEGRATED and joined up rather than instigated in isolation
8WAYS TO REDUCE REFERRALS More level 3 services in the community?Educational programme for GP’sPrescribing guidelinesPharmacy teaching of community pharmacists
9WAYS TO REDUCE REFERRALS More level 2 careCommunity screening teamsInterdisciplinary CBT based programmesPatient support groupsPhysio? TENS clinics? Acupuncture clinics? Consultant sessions in the community
10NICE GUIDELINES MAY 2009Early Management of Persistant Lower Back PainPatients must have back pain for LESS than a YEARDoes NOT cover SUSPECTED :MalignancyInfectionFractureRadiculopathyInflammatory disorder
11NICE GUIDELINES Care should be patient centred Give patients advice and information to promote self managementExerciseManipulationAcupuncturePsychology
21PROBLEMS WITH THE GUIDELINES NICE summary: we recommend acupuncture and manipulation because they work every bit as good as placebo but we don't recommend injections as they only work as well as placebo.Advise patients to have osteopathy and chiropractor services?????Lack of regulation concerns!!!Concerns from medical profession about potential damage from poorly practiced spinal manipulation.
22PROBLEMS WITH GUIDELINES No discussion with The British Pain SocietyMultidisciplinary bodyConflict of interest with BPS chairmanChairman had to resignNEXT MONTH BPS & NICE will meet to look at ‘reformulating’ the guidelines.
23WAYS OF REDUCING REFERRALS Do not refer patients with NON specific back painDo not refer patients with less than 1 year historyOffer patients exercise, manual therapy, acupuncture and psychologyDO REFER patients with known specific back painDO REFER patients with potential mailignancy, infection, fracture, radiculopathy or inflammatory disorder
24RECENT SURVEY OF GP’S ABOUT SERVICES Questionnaire about local chronic pain services and questions exploring ways to improve pain services.48% satisfied with service15% dissatisfied37% neither
25WAYS TO IMPROVE THE SERVICE GP’s wanted:-More pain education in GP surgeriesMore advise through the internetMore hospital based study days
26WAYS TO REDUCE NEW REFERRALS GP’s requested a telephone helplineDifferent triage systemhelplineMore psychological training for community staffStricter criteria to accept patients to pain clinic
27PRESCRIBING GUIDELINES FOR PREGABALIN Based on a guideline produced by the European Federation of Neurological StudiesAlgorithm for treatment of neuropathic pain
29TRICYCLIC ANTIDEPRESSANTS Amitriptyline starting dose mg nocteDose may be increased to 50 mg nocteNot an antidepressant dose and will not interact with concurrent antidepressantsConvert to Nortriptyline if problems with drowsiness (not licensed for pain / /equivalent dose)Contraindications include glaucoma, hypertension and may lower seizure threshold in epileptics
30GABAPENTIN Starting dose 300 mg od Gradual increase over days up to 900 mg tdsRequires a lot of patient complianceUsually safe to take with other medicationsEffects may be seen in WEEKSDosage needs to be adjusted in patients with renal dysfunctionDo not stop abruptly, needs to be done over weeks
31PREGABALIN Starting dose 75 mg bd Increase to 150 mg bd if tolerated Can work up to 300 mg bd in some casesEffects may be seen in DAYSSafe in patients with renal dysfunction