Pain Management Module Learning Session 1

2 Agenda 1.Welcome/Introductions (15 mins) 2.What are we trying to accomplish? (45 mins) The Biopsychosocial Approach Patient Voice 3.The 7 Pain Tools (45 mins) Break (15 mins) 4.Case Study Application (60mins) 5.Wrap up (30 mins) Action Period Planning Session Assessment

3 Faculty/Presenter Disclosure Faculty’s Name: Speaker’s Name Relationship with commercial interest: - Grants/Research Support: PharmaCorp ABC - Speakers Bureau/Honoraria: XYZ Biopharmaceuticals Ltd - Consulting Fees: MedX Group Inc. - Other: Employee of XYZ Hospital Group

4 Disclosure of Commercial Support This program has received financial support from [organization name] in the form of [desribe support here – e.g. educational grant] This program has received in-kind support from [organization name] in the form of [describe the support here – e.g. logistical support] Potential for conflicts(s) of interest: - [Speaker/Faculty name] has received [payment/funding, etc.] from [organization supporting this program AND/OR organization whose products are being discussed in this program]. - [Supporting organization name] [developed/licenses/distributes/benefits from the sale of, etc.] a product that will be discussed in this program. [Enter generic and brand name here].

5 Mitigating Potential Bias [Explain how potential sources of bias identified in slides 1 and 2 have been mitigated]. Refer to “Quick Tips” document

6  The aim of this module is to improve the quality of patient care available in non-pain specialized physician practices for patients living with chronic pain. This will be measured by an increase in function, or reduced decline in function, as indicated by a change in the Brief Pain Inventory Scores.  Through this work we expect:  The experiences of patients and their families to improve through better management of chronic pain  Improve physician experience through increased confidence in identifying and managing patients with persistent pain  Reduced health care utilization costs to the system through optimal use of general and specialist services. Aim

7  Describe a rationale for using a bio-psychosocial approach to assessing and managing pain  Identify the 10 Pain tools available through the EMR template  Select the appropriate tool(s) for addressing a pain scenario  Report increased confidence in supporting patients that experience chronic pain Learning Objectives

8  The Heartsink Patient The Situation

9  17-31% of Canadians report chronic pain (Canadian Pain coalition)  18% of Canadians suffer from severe chronic pain –more than diabetes or heart disease. (Chronic pain association of Canada)  Chronic pain prevalence is approximately 33% in those over 55 years old (Moulin et al)  38% of institutionalized seniors experience pain on a regular basis (Stats. Can. 2008) The Situation

10  The single biggest cause of disability in Canada  It affects the elderly the most  The elderly are about to become the largest cohort of patients The Situation

11  70% of cancer patients experience moderate to severe pain during their illness  The majority reported that they had not been asked about their pain by doctors or nurses (Chronic pain association of Canada) The Situation

12  Chronic pain is a strong independent predictor of health resource use  “There was a strong association between pain-related disability and greater use of services” (Blyth et al. Pain 2004) The Situation

13  The cost of pain to the Canadian economy is estimated at $6 Billion annually (Jovey)  Pain is almost unmentioned in medical schools (Chronic pain association of Canada)  “Funding for research, training and treatment of pain in Canada is woefully inadequate” (Jovey) The Situation

14 CHRONIC PAIN IS AN EPIDEMIC THAT AFFECTS UP TO A THIRD OF ALL CANADIANS WE ARE NOT ASKING ABOUT IT WE DON’T KNOW HOW TO TREAT IT

15  People with chronic pain have a three times the average risk of developing psychiatric symptoms, mainly depression  Depressed people have three times the average risk of developing chronic pain  Nearly all medications for depression also help reduce chronic pain (Harvard Health Publications 2004) Chronic Pain and Depression

16 Women with chronic pain are three times more likely to commit suicide than matches in the general population without chronic pain (Fishbain et al) Chronic Pain and Suicide

CHRONIC PAIN IS A DISEASE THAT WILL LARGELY BE TREATED BY FAMILY DOCTORS

18  Denial  Lack of time  Lack of resources  Lack of knowledge  Lack of effective “cures”  Not wanting to open a “Pandora's Box” Barriers for GPs

19 So what do I do with my chronic pain patients?

20 Shift paradigm:  Sole pursuit of tissue pathology…  ….to reasonable attempt to exclude pathology and reach diagnosis. What are we trying to accomplish?

21 Shift paradigm:  Sole pursuit of pain reduction…  ….to whole person centered approach aiming at functional gain and pain reduction. What are we trying to accomplish?

22 Shift paradigm  “There’s nothing that I can do”…  ….to “we can together work as a team to reduce the alarm (pain) in your nervous system and increase your function.” What are we trying to accomplish? freedigitalimages.net

23 Shift paradigm  “I only have one tool (prescriptions)”…  ….to “there are a toolbox of options we can use to help reduce your pain and increase your function.” What are we trying to accomplish?

24  Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. - International Association for the Study of Pain(1979) What is Pain?

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26 Central Nervous System Sensitization Pro-nociceptiveAnti-nociceptive

27 Social Class Financial Relationships Job Culture Beliefs Life experiences Other health issues Report: “I have pain.” Observe: Behaviour

28  Pain in not a “thing”  Pain is not in the tissues  No pain receptors  No pain pathways  No pain centres  It’s a multidimensional, lived, experience constructed by the brain. What is Pain?

29 Diagnostic Framework Peripheral Inputs Central Sensitization Psychological Inputs Social Inputs +++ = Pain Genetic Factors

30 Activity Gentle Progressive Pacing Goals Mood Coaching Bounce Back Coping Resilience Sleep Sleep hygiene Aids Medication Toolbox of Supports

31 Mindfulness Meditation Yoga Tai Chi Breathing Medications TCAs Anti- convulsants Opioids Other… Interventions Injections Surgery Manipulation Toolbox of Supports

32 Knowledge Pain Body Self awareness Concepts Support Family Friends Work SM groups Support groups Psychology CBT ACT BAP Coaching Group Medical Visits Toolbox of Supports