Basics of Pain Management Dr. Allistair Dodds Dept. Pain Medicine Sunderland Royal Hospital July. 07 July. 07 Dr. Allistair Dodds Dept. Pain Medicine Sunderland Royal Hospital July. 07 July. 07

3 Types of Pain (temporal) Acute Acute Chronic Chronic Cancer Cancer Acute Acute Chronic Chronic Cancer Cancer

Types of Pain (physiological) A  fibres A  fibres C fibres C fibres Sensitisation Sensitisation A  fibres A  fibres C fibres C fibres Sensitisation Sensitisation

WHO should take the place of Descartes?

WHO ladder Cancer pain Cancer pain Step 3: opioid for moderate to severe pain +/- non opioid +/- adjuvant Step 3: opioid for moderate to severe pain +/- non opioid +/- adjuvant Step 2: opioid for mild to moderate pain +/- non opioid +/- adjuvant Step 2: opioid for mild to moderate pain +/- non opioid +/- adjuvant Step 1: non opioid +/- adjuvant Step 1: non opioid +/- adjuvant Cancer pain Cancer pain Step 3: opioid for moderate to severe pain +/- non opioid +/- adjuvant Step 3: opioid for moderate to severe pain +/- non opioid +/- adjuvant Step 2: opioid for mild to moderate pain +/- non opioid +/- adjuvant Step 2: opioid for mild to moderate pain +/- non opioid +/- adjuvant Step 1: non opioid +/- adjuvant Step 1: non opioid +/- adjuvant

The “5” phrases By mouth By mouth By the clock By the clock By the ladder By the ladder For the individual For the individual Attention to detail Attention to detail By mouth By mouth By the clock By the clock By the ladder By the ladder For the individual For the individual Attention to detail Attention to detail

The “5” phrases By mouth By mouth For the individual For the individual Attention to detail Attention to detail By mouth By mouth For the individual For the individual Attention to detail Attention to detail

Science and Sociology Drugs targeted at the lesion Drugs targeted at the lesion Analgesia targeted to the patients requirements Analgesia targeted to the patients requirements Drugs targeted at the lesion Drugs targeted at the lesion Analgesia targeted to the patients requirements Analgesia targeted to the patients requirements

Cyclo-oxygenase COX converts arachidonic acid to prostaglandin H 2 – a precursor of the inflammatory prostaglandins. COX converts arachidonic acid to prostaglandin H 2 – a precursor of the inflammatory prostaglandins. Type 1 - constitutive maintains the function of gut, kidneys, platelets etc. Type 1 - constitutive maintains the function of gut, kidneys, platelets etc. Type 2 – inducible, expressed during the inflammatory response Type 2 – inducible, expressed during the inflammatory response COX converts arachidonic acid to prostaglandin H 2 – a precursor of the inflammatory prostaglandins. COX converts arachidonic acid to prostaglandin H 2 – a precursor of the inflammatory prostaglandins. Type 1 - constitutive maintains the function of gut, kidneys, platelets etc. Type 1 - constitutive maintains the function of gut, kidneys, platelets etc. Type 2 – inducible, expressed during the inflammatory response Type 2 – inducible, expressed during the inflammatory response

Paracetamol Simple analgesic Simple analgesic Anti-inflammatory - periphery Anti-inflammatory - periphery Anti-pyretic - hypothalamus Anti-pyretic - hypothalamus Simple analgesic Simple analgesic Anti-inflammatory - periphery Anti-inflammatory - periphery Anti-pyretic - hypothalamus Anti-pyretic - hypothalamus

Pharmacology Tablet, effervescent, syrup, suppository, iv infusion Tablet, effervescent, syrup, suppository, iv infusion NNT 3.8 ( ) 50% pain relief acute pain ‡ NNT 3.8 ( ) 50% pain relief acute pain ‡ ‡ Henry McQuay & Andrew Moore; An evidence based resource for pain relief; Oxford Medical Publications 1998 ‡ Henry McQuay & Andrew Moore; An evidence based resource for pain relief; Oxford Medical Publications 1998 Tablet, effervescent, syrup, suppository, iv infusion Tablet, effervescent, syrup, suppository, iv infusion NNT 3.8 ( ) 50% pain relief acute pain ‡ NNT 3.8 ( ) 50% pain relief acute pain ‡ ‡ Henry McQuay & Andrew Moore; An evidence based resource for pain relief; Oxford Medical Publications 1998 ‡ Henry McQuay & Andrew Moore; An evidence based resource for pain relief; Oxford Medical Publications 1998

Non steroidal anti inflammatory drugs (NSAID’s) Simple analgesic Simple analgesic Anti-inflammatory - periphery Anti-inflammatory - periphery Anti-pyretic – hypothalamus Anti-pyretic – hypothalamus Simple analgesic Simple analgesic Anti-inflammatory - periphery Anti-inflammatory - periphery Anti-pyretic – hypothalamus Anti-pyretic – hypothalamus

Efficacy All common NSAID’s have an NNT of : All common NSAID’s have an NNT of : 2.3 ( ) for 50% acute pain relief ‡ 2.3 ( ) for 50% acute pain relief ‡ No difference between the cox 2 specific (rofecoxib), selective (naproxen) and indiscriminate (ibuprofen) drugs. No difference between the cox 2 specific (rofecoxib), selective (naproxen) and indiscriminate (ibuprofen) drugs. ‡ Henry McQuay &Andrew Moore; An evidence based resource for pain relief; Oxford Medical Publications 1998 ‡ Henry McQuay &Andrew Moore; An evidence based resource for pain relief; Oxford Medical Publications 1998 All common NSAID’s have an NNT of : All common NSAID’s have an NNT of : 2.3 ( ) for 50% acute pain relief ‡ 2.3 ( ) for 50% acute pain relief ‡ No difference between the cox 2 specific (rofecoxib), selective (naproxen) and indiscriminate (ibuprofen) drugs. No difference between the cox 2 specific (rofecoxib), selective (naproxen) and indiscriminate (ibuprofen) drugs. ‡ Henry McQuay &Andrew Moore; An evidence based resource for pain relief; Oxford Medical Publications 1998 ‡ Henry McQuay &Andrew Moore; An evidence based resource for pain relief; Oxford Medical Publications 1998

Side effects Can be partially predicted by the interaction of NSAID’s and COX 1. Can be partially predicted by the interaction of NSAID’s and COX 1. Gastric ulceration Gastric ulceration Heart failure – deteriorates Heart failure – deteriorates Renal failure – deteriorates Renal failure – deteriorates Platelet dysfunction Platelet dysfunction Can be partially predicted by the interaction of NSAID’s and COX 1. Can be partially predicted by the interaction of NSAID’s and COX 1. Gastric ulceration Gastric ulceration Heart failure – deteriorates Heart failure – deteriorates Renal failure – deteriorates Renal failure – deteriorates Platelet dysfunction Platelet dysfunction

Side effects newer drugs Newer Cox 2 specific drugs cause less gastric and platelet effects but just as dangerous in renal and heart failure. Newer Cox 2 specific drugs cause less gastric and platelet effects but just as dangerous in renal and heart failure. The reduction in dyspepsia sometimes improves compliance. The reduction in dyspepsia sometimes improves compliance. Newer Cox 2 specific drugs cause less gastric and platelet effects but just as dangerous in renal and heart failure. Newer Cox 2 specific drugs cause less gastric and platelet effects but just as dangerous in renal and heart failure. The reduction in dyspepsia sometimes improves compliance. The reduction in dyspepsia sometimes improves compliance.

Opioids Bind to mu (μ) receptors in spinal cord and brain inhibiting the transmission of electrical activity that signals pain. Bind to mu (μ) receptors in spinal cord and brain inhibiting the transmission of electrical activity that signals pain. Grouped according to potency Grouped according to potency (weak – strong) Bind to mu (μ) receptors in spinal cord and brain inhibiting the transmission of electrical activity that signals pain. Bind to mu (μ) receptors in spinal cord and brain inhibiting the transmission of electrical activity that signals pain. Grouped according to potency Grouped according to potency (weak – strong)

Weak opiods Codeine – pro-drug not metabolised to active agent (morphine) in 17-34% of patients. Codeine – pro-drug not metabolised to active agent (morphine) in 17-34% of patients. Dihydrocodeine – pro-drug, again a wide variation in patient response. Dihydrocodeine – pro-drug, again a wide variation in patient response. Tramadol – active drug. Tramadol – active drug. Codeine – pro-drug not metabolised to active agent (morphine) in 17-34% of patients. Codeine – pro-drug not metabolised to active agent (morphine) in 17-34% of patients. Dihydrocodeine – pro-drug, again a wide variation in patient response. Dihydrocodeine – pro-drug, again a wide variation in patient response. Tramadol – active drug. Tramadol – active drug.

Efficacy NNT’s NNT’s Tramadol 100mg4.8 ( ) Tramadol 100mg4.8 ( ) Dihydrocodeine 30mg 8.1 (4.1 – 540) Dihydrocodeine 30mg 8.1 (4.1 – 540) Codeine 60mg16.7 (11- 48) Codeine 60mg16.7 (11- 48) But… But… paracetamol 1g + codeine 60mg = 2.2 (1.7 –2.9) paracetamol 1g + codeine 60mg = 2.2 (1.7 –2.9) Henry McQuay & Andrew Moore; An evidence based resource for pain relief; Oxford Medical Publications 1998 Henry McQuay & Andrew Moore; An evidence based resource for pain relief; Oxford Medical Publications 1998 NNT’s NNT’s Tramadol 100mg4.8 ( ) Tramadol 100mg4.8 ( ) Dihydrocodeine 30mg 8.1 (4.1 – 540) Dihydrocodeine 30mg 8.1 (4.1 – 540) Codeine 60mg16.7 (11- 48) Codeine 60mg16.7 (11- 48) But… But… paracetamol 1g + codeine 60mg = 2.2 (1.7 –2.9) paracetamol 1g + codeine 60mg = 2.2 (1.7 –2.9) Henry McQuay & Andrew Moore; An evidence based resource for pain relief; Oxford Medical Publications 1998 Henry McQuay & Andrew Moore; An evidence based resource for pain relief; Oxford Medical Publications 1998

Strong opiods No requirement for metabolism No requirement for metabolism 50% oral bioavailability 50% oral bioavailability Fentanyl patch 25 - approx 90mg oral morphine per day Fentanyl patch 25 - approx 90mg oral morphine per day No requirement for metabolism No requirement for metabolism 50% oral bioavailability 50% oral bioavailability Fentanyl patch 25 - approx 90mg oral morphine per day Fentanyl patch 25 - approx 90mg oral morphine per day

Morphine Presentation Presentation Tablets, capsules, solutions, patches, suppositories, iv injection. Tablets, capsules, solutions, patches, suppositories, iv injection. Usually titrated to effect. Usually titrated to effect. Presentation Presentation Tablets, capsules, solutions, patches, suppositories, iv injection. Tablets, capsules, solutions, patches, suppositories, iv injection. Usually titrated to effect. Usually titrated to effect.

Side Effects Common adverse reactions : constipation, nausea and vomiting, drowsiness, dizziness, headache, itch, dry mouth,. Common adverse reactions : constipation, nausea and vomiting, drowsiness, dizziness, headache, itch, dry mouth,. Infrequent adverse reactions include: dose-related respiratory depression, confusion, hallucinations. Infrequent adverse reactions include: dose-related respiratory depression, confusion, hallucinations. Common adverse reactions : constipation, nausea and vomiting, drowsiness, dizziness, headache, itch, dry mouth,. Common adverse reactions : constipation, nausea and vomiting, drowsiness, dizziness, headache, itch, dry mouth,. Infrequent adverse reactions include: dose-related respiratory depression, confusion, hallucinations. Infrequent adverse reactions include: dose-related respiratory depression, confusion, hallucinations.

Chronic Pain An alternative evidence based approach. An alternative evidence based approach.

Pain Management Programme Given the multi-dimensional nature of long-standing pain problems, the most effective approach is to treat through multi-professional teams. Given the multi-dimensional nature of long-standing pain problems, the most effective approach is to treat through multi-professional teams. PMP is a psychologically framed, group based rehabilitation treatment that utilises the biopsychosocial model as the philosophical underpinning to assist people in the further development of pain self-management. PMP is a psychologically framed, group based rehabilitation treatment that utilises the biopsychosocial model as the philosophical underpinning to assist people in the further development of pain self-management. Given the multi-dimensional nature of long-standing pain problems, the most effective approach is to treat through multi-professional teams. Given the multi-dimensional nature of long-standing pain problems, the most effective approach is to treat through multi-professional teams. PMP is a psychologically framed, group based rehabilitation treatment that utilises the biopsychosocial model as the philosophical underpinning to assist people in the further development of pain self-management. PMP is a psychologically framed, group based rehabilitation treatment that utilises the biopsychosocial model as the philosophical underpinning to assist people in the further development of pain self-management.

Pain Management Programme Programme Structure Programme Structure PMP is a 12 session (x3.5 hrs) treatment delivered over a year: PMP is a 12 session (x3.5 hrs) treatment delivered over a year: 8 intensive sessions (weekly) 8 intensive sessions (weekly) 4 consolidation sessions over next 10 months (1, 2, 4 and 6 months). 4 consolidation sessions over next 10 months (1, 2, 4 and 6 months). “Graduate programme” “Graduate programme” Programme Structure Programme Structure PMP is a 12 session (x3.5 hrs) treatment delivered over a year: PMP is a 12 session (x3.5 hrs) treatment delivered over a year: 8 intensive sessions (weekly) 8 intensive sessions (weekly) 4 consolidation sessions over next 10 months (1, 2, 4 and 6 months). 4 consolidation sessions over next 10 months (1, 2, 4 and 6 months). “Graduate programme” “Graduate programme”

The Treatment Components 1. Educational: eg. gate-control theory, active neuro-matrix. 2. Cognitive Restructuring: Skills to modify unhelpful pain and negative affective state related cognitions. 3. Problem Solving: Developing solutions to carry out desired goals. 4. Coping Skills Training: Behavioural management (baselines, pacing). 5. Relaxation: Assisting people gain increased control over heightened physiological arousal. 6. Exposure to Feared Activities: Reduction of avoidance and testing out activities to reverse de-conditioning. 1. Educational: eg. gate-control theory, active neuro-matrix. 2. Cognitive Restructuring: Skills to modify unhelpful pain and negative affective state related cognitions. 3. Problem Solving: Developing solutions to carry out desired goals. 4. Coping Skills Training: Behavioural management (baselines, pacing). 5. Relaxation: Assisting people gain increased control over heightened physiological arousal. 6. Exposure to Feared Activities: Reduction of avoidance and testing out activities to reverse de-conditioning.

Acessing the Service Referal to the Pain clinic. Referal to the Pain clinic. Intitail MDT assessment. Intitail MDT assessment. Those wishing to be considered for the PMP offered an education session about this treatment. Those wishing to be considered for the PMP offered an education session about this treatment. Patients then offered a short PMP assessment to determine their therapeutic goals. Patients then offered a short PMP assessment to determine their therapeutic goals. Formal assessments are taken of key clinical parameters (defined from the biopsychosocial model) that are targeted for active change. Formal assessments are taken of key clinical parameters (defined from the biopsychosocial model) that are targeted for active change. Following the successful completion of these procedures, patients enter the treatment (structured in a group based format). Following the successful completion of these procedures, patients enter the treatment (structured in a group based format). Referal to the Pain clinic. Referal to the Pain clinic. Intitail MDT assessment. Intitail MDT assessment. Those wishing to be considered for the PMP offered an education session about this treatment. Those wishing to be considered for the PMP offered an education session about this treatment. Patients then offered a short PMP assessment to determine their therapeutic goals. Patients then offered a short PMP assessment to determine their therapeutic goals. Formal assessments are taken of key clinical parameters (defined from the biopsychosocial model) that are targeted for active change. Formal assessments are taken of key clinical parameters (defined from the biopsychosocial model) that are targeted for active change. Following the successful completion of these procedures, patients enter the treatment (structured in a group based format). Following the successful completion of these procedures, patients enter the treatment (structured in a group based format).