1. Current pain management in Lithuania: system and practice Alfredas Vaitkus, MD, FIPP The In-patient Day Department of Pain Treatment Centre of Anaesthesiology, Intensive Therapy and Pain Management Vilnius University Hospital Santariskiu Clinics Vilnius, Lithuania

2. A piece of history 1953 - 1 st pain clinic in USA 1953 - 1 st pain clinic in USA 1961 - 1 st pain clinic in Europe 1961 - 1 st pain clinic in Europe 1994 - 1 st pain clinic in Lithuania 1994 - 1 st pain clinic in Lithuania

3. A piece of history 1990-1993 - sporadic enthusiasm in the meaning of interests and practice 1990-1993 - sporadic enthusiasm in the meaning of interests and practice 1993-1994 – several anesthesiologist visit to Norwegian hospitals (Oslo and Bergen) with support from Norwegian Cancer Society and Rotary Organization 1993-1994 – several anesthesiologist visit to Norwegian hospitals (Oslo and Bergen) with support from Norwegian Cancer Society and Rotary Organization 1994 - establishment of the 1 st pain clinic in Lithuania (Vilnius University Hospital Santariskiu Clinics) 1994 - establishment of the 1 st pain clinic in Lithuania (Vilnius University Hospital Santariskiu Clinics) Dr. Lorens Gran Dr. Jane Baubliene

4. Short review of presentation Juridical base Juridical base System in work System in work Specialized pain centers Specialized pain centers Medicines Medicines Interventional pain management Interventional pain management Postoperative pain management Postoperative pain management Palliative care Palliative care Organizations Organizations Education Education

5. Juridical base 1997 m. “Patients should receive scientifically based analgesic measures in order not to suffer due to their health disorders“ Law of patients’ rights and compensation for harm (LR) 1997 m. “Patients should receive scientifically based analgesic measures in order not to suffer due to their health disorders“ Law of patients’ rights and compensation for harm (LR) Recognition of patients’rights to receive pain help

6. Juridical base 2001 “Pain is a major healthcare problem. Although acute pain may reasonably be considered a symptom of disease or injury, chronic and recurrent pain is a specific healthcare problem, a disease in its own right.” 2001 “Pain is a major healthcare problem. Although acute pain may reasonably be considered a symptom of disease or injury, chronic and recurrent pain is a specific healthcare problem, a disease in its own right.” European Federations of IASP Chapters (EFIC) Declaration Approved by Minister of Health of Lithuania in 2002. Approved by Minister of Health of Lithuania in 2002. Recognition of pain problem

7. Juridical base 2003 “Concerning invasive pain management procedures for adults and children in health care institutions and base price approval.” Order of Minister of Health (LR) 2003 “Concerning invasive pain management procedures for adults and children in health care institutions and base price approval.” Order of Minister of Health (LR)Legitimation: of invasive procedures of invasive procedures of reimbursement of reimbursement of in-patient day department of in-patient day department

8. Juridical base Neurolytic procedures Neurolytic procedures radiofrequency destruction radiofrequency destruction neurolytic procedures neurolytic procedures Instantaneous curative procedures Instantaneous curative procedures facet blocks facet blocks single epidural injection - cervical, thoracic, sacral single epidural injection - cervical, thoracic, sacral single epidural injection – lumbar single epidural injection – lumbar trigger point injections trigger point injections somatic nerve block somatic nerve block Long-lasting curative procedures Long-lasting curative procedures catheterisation of epidural space catheterisation of epidural space intravenous farmacological test or infusion pump installation intravenous farmacological test or infusion pump installation

9. Juridical base 2004 “Concerning obligatory medicinal help and the order of obligatory medicinal help services and extent.” Order of Minister of Health (LR) Necessity: 2004 “Concerning obligatory medicinal help and the order of obligatory medicinal help services and extent.” Order of Minister of Health (LR) Necessity: to evaluate intensity to evaluate intensity to use pain scales to use pain scales to document pain to document pain to treat to treat

10. Juridical base 2007 „Inventory for requirements of palliative care services for adults and children.“ Order of Minister of Health (LR) 2007 „Inventory for requirements of palliative care services for adults and children.“ Order of Minister of Health (LR) Legitimation of palliative care services

11. System in work Nonmedical help – patient education Nonmedical help – patient education General help General help general practitioners general practitioners ambulatory specialists ambulatory specialists hospital specialist hospital specialist Specialized help Specialized help pain centres and consultations pain centres and consultations postoperative pain services postoperative pain services palliative care institutions palliative care institutions rehabilitations centres rehabilitations centres surgical centers surgical centers

12. 7 hospital based pain clinics (in-patient day departments) 2 of them - C-arm fluoroscopy several ambulatory pain consultations ~15 physicians of different specialties 2/3 of them – anesthesiologists 0 to 2 nurses available for 1 physician Pain centres and consultations in Lithuania

13. Specialized pain help in Lithuania ~ 12.000/year visits to pain centres and consultations ~ 12.000/year visits to pain centres and consultations ~ 2/3 visits are due to back pain and joint pain ~ 2/3 visits are due to back pain and joint pain ~ 20% visits due to oncological pain ~ 20% visits due to oncological pain ~ 6.000/year interventional procedures ~ 6.000/year interventional procedures 2008 year data

14. Medicines availability Opioids Opioids Injections Injections tramadol, morphine, pentazocine, pethidine, buprenorphine tramadol, morphine, pentazocine, pethidine, buprenorphine Oral Oral tramadol, morphine, methadon tramadol, morphine, methadon Rectal Rectal tramadol tramadol Transdermal Transdermal fentanyl fentanyl Reimbursement Oncological: morphine (inj., oral), tramadol (inj., oral), fentanyl (transdermal) Non-oncological for disabled: tramadol (inj., oral)

15. Medicines availability Non-steroidal antiinflammatory medicines Non-steroidal antiinflammatory medicines over 15 chemical substances over 15 chemical substances Antiepileptics Antiepileptics Antidepressants Antidepressants Other ( Flupirtine ) Other ( Flupirtine ) Reimbursement Oncological: several NSAIDs Trigeminal neuralgia: carbamazepine Reumatological: several NSAIDs Diabetic polineuropathy: pregabaline, duloxetine For disabled: several NSAIDs, amitriptiline

16. Interventional pain management Trigger point inj. Trigger point inj. Intraarticular inj. Intraarticular inj. Facet joint block & radiofrequency denervation Facet joint block & radiofrequency denervation Peripheral nerves Peripheral nerves Sacroiliac joint block & radiofrequency denervation Sacroiliac joint block & radiofrequency denervation Epidural steroid inj. Epidural steroid inj. Selective transforaminal epidural steroid inj. Selective transforaminal epidural steroid inj. Stellate ganglion, thoracic sympathetic, splanchnic nerves, coeliac plexus, hypogastric plexus, ganglion impar Stellate ganglion, thoracic sympathetic, splanchnic nerves, coeliac plexus, hypogastric plexus, ganglion impar Long-term epidural catheters Long-term epidural catheters Long-term subcutaneous & intravenous infusions Long-term subcutaneous & intravenous infusions Intravenous farmacological tests: opioids, lidocaine, ketamine etc. Intravenous farmacological tests: opioids, lidocaine, ketamine etc. Intradiscal procedures (coblation nucleoplasty) Intradiscal procedures (coblation nucleoplasty) Vertebroplasty Vertebroplasty

17. Postoperative pain services No uniform model of postoperative pain service No uniform model of postoperative pain service Available models of services: Available models of services: Intermitent analgesics according to patient request Intermitent analgesics according to patient request Intermitent analgesics according to schedule Intermitent analgesics according to schedule Continuous analgesic methods with separate postoperative pain service Continuous analgesic methods with separate postoperative pain service Decision is upon the hospital Decision is upon the hospital Larger hospitals tend to provide more consistent services Larger hospitals tend to provide more consistent services Pain service availability University hospitalsRegional cetres hospitalsLocal hospitals Yes82% 42  19% dr.G.Laurinenas data, 2004

18. Palliative care situation Services are at the very begining of systemic development Services are at the very begining of systemic development Many long-term nursing and supportive treatment hospitals are licenced to provide palliative care Many long-term nursing and supportive treatment hospitals are licenced to provide palliative care Not many of them provide palliative care in its full extend Not many of them provide palliative care in its full extend Lack of education is considerable Lack of education is considerable

19. Organizations related to pain management Lithuanian Society of Anaesthesiology and Intensive Care Lithuanian Pain Society (chapter of IASP) Association of Pain Clinics Lithuanian Society of Palliative Medicine

20. Information sources “Pain medicine” (Lithuanian Pain Society, journal in Lithuanian) “Pain medicine” (Lithuanian Pain Society, journal in Lithuanian) “Pain News” (Lithuanian Pain Society, bulletin in Lithuanian) “Pain News” (Lithuanian Pain Society, bulletin in Lithuanian) “Pain conception and management” (J.Baubliene, book in Lithuanian) “Pain conception and management” (J.Baubliene, book in Lithuanian) “Chronic non-oncological pain and its treatment with opioid analgesics” (A. Sciupokas, book in Lithuanian) “Chronic non-oncological pain and its treatment with opioid analgesics” (A. Sciupokas, book in Lithuanian) “Pain treatment with opioid analgesics” (A.Vaitkus, book in Lithuanian) “Pain treatment with opioid analgesics” (A.Vaitkus, book in Lithuanian) “Postoperative pain management – good clinical practice” (Lithuanian translation of ESRA recommendations) “Postoperative pain management – good clinical practice” (Lithuanian translation of ESRA recommendations) “Principals of diagnostics and treatment of malignant tumors of main localizations” (group of authors, book in Lithuanian) “Principals of diagnostics and treatment of malignant tumors of main localizations” (group of authors, book in Lithuanian) “Diseases of nervous system” (group of authors, book in Lithuanian) “Diseases of nervous system” (group of authors, book in Lithuanian)

21. Education Patient education Patient education several programs (e.g. arthritic, diabetic patients) several programs (e.g. arthritic, diabetic patients) individual education in the course of treatment individual education in the course of treatment Medical students: Medical students: Incorporated in Anesthesiology programme (during 5 th year) Incorporated in Anesthesiology programme (during 5 th year) Incorporated in Neurology programme (during 5 th year) Incorporated in Neurology programme (during 5 th year) Residency: Residency: Anesthesiology-reanimatology: 2 months obligatory round in pain clinic Anesthesiology-reanimatology: 2 months obligatory round in pain clinic Neurology: obligatory round in pain clinic Neurology: obligatory round in pain clinic Nursing studies Nursing studies

22. Continuous medical education (CME) Anesthesiology: Anesthesiology: children postoperative pain, postoperative pain management children postoperative pain, postoperative pain management specialized pain management specialized pain management General therapeutics: General therapeutics: acute, chronic pain, oncological acute, chronic pain, oncological Neurological Neurological pain in neurology practice, headaches pain in neurology practice, headaches Rehabilitation Rehabilitation back pain back pain Palliative care Palliative care Vilnius University and Kaunas University of Medicine

23. Conclusions During 15 years of development many systemic changes achieved During 15 years of development many systemic changes achieved Continuous development & growing Continuous development & growing Data from Vilnius University Hospital Santariskiu Clinics

24. Conclusions Still, improvement needed in: Still, improvement needed in: pain education, pain education, specialist preparation, specialist preparation, reimbursements for pain medicines and services, reimbursements for pain medicines and services, palliative care, palliative care, introduction of modern technologies. introduction of modern technologies.

25. Thank you !