1. Pain Management

2. Role of GPs in Pain Management GPs can: improve assessment and treatment of pain offer early intervention and treatment prevent chronic pain.

3. Pain Management General Principles of Pain Management Unrelieved pain has adverse severe physiological / psychological side effects Proper assessment and control requires patient involvement Effective pain relief requires flexible, individually tailored treatment Pain is best treated early. Established severe pain is more difficult to treat Whilst it is not always possible to alleviate all pain, it can be reduced to a tolerable or comfortable level. NHMRC (1999)

4. Pain Management Categories of Pain Acute monophasic pain Recurrent acute non-malignant pain Chronic malignant pain Chronic pain associated with non-malignancy disease – identifiable pathology Chronic non-malignant pain syndrome.

5. Pain Management WHO 3-step Pain Relief Ladder Mild Pain Pain persisting or increasing Pain persisting or increasing Treat with non-opioid +/- adjuvant Treat with Opioid for mild- moderate pain +/- non-opioid +/- adjuvant Treat with Opioid for moderate–severe pain +/- non-opioid +/- adjuvant 3 2 1 Freedom from Pain Gill (1997)

6. Pain Management Pain Cycle (Chronic) Injury / Insult Treatment Failure of Treatment Loss of Control Dependence Reliance on Medication Pain Psychological & Social Consequences Adapted from Gill (1997)

7. Pain Management Most reliable indicator of pain severity is patient self-report Categorical rating scales: use descriptors such as ‘no pain’ / ‘mild pain’ / … ‘worst possible pain’ Visual analogue scales: no painworst possible pain Verbal analogue scales: rate from 0 (no pain) to 10 (worst possible). Pain Rating Scales

8. Pain Management The GP–Patient Relationship Successful management depends on: patient trust & confidence in GP complete physical and psychosocial history – this is essential so allow adequate time supportive & clear explanations of the pain issues ability to discuss strategies openly to reduce potential for ‘self-medicating’ case management – for consistency in management, commence treatment with consultation between patient and treating staff trust – avoid placebos at all costs adequate relief – achieving relief / reducing pain level is paramount.

9. Pain Management A Shared Care / Team Approach A team-based, holistic approach tends to be most effective for pain management, involving: –nurses –psychologists & psychiatrists –physiotherapists –pain specialists.

10. Pain Management Acute Pain Management and High-risk Drug Use Key Principles Unless patient uses opioids, treat as ‘normal’ patient with pain ‘First do no harm’ – shortest dose, shortest duration with minimal side effects, with aim to reduce pain to a tolerable level Maintain clear communication (prevent anxiety, reassure patient) Do not withhold analgesia unless medically indicated Avoid Pethidine Allow adequate time for assessment – impossible in 10 minute consultation.

11. Pain Management Acute Pain Management: People who Inject Opioids Consider: tolerance to opioid analgesics –e.g., if already on regular prescribed opioid medication (iatrogenic dependence), on methadone, opioid-dependent, or regularly taking liver enzyme-inducing drugs real and perceived legal constraints for prescribers potential adverse interactions with other CNS depressants difficulties / misunderstandings which arise in communications between clinicians and patients.

12. Pain Management Assessment of Chronic Pain in Drug-dependent Patients (1) Comprehensive assessment required of: organic pathology and psychosocial history / supports past / present drug use (+alcohol and prescribed drugs) drug tolerance & dependence contribution of pain & drug use to mood & lifestyle? whether the pain predates the drug(s) problem or reverse? psychiatric comorbidity; chronic pain and depression often coincide, but difficult to disentangle cause & effect stressors and coping strategies.

13. Pain Management Obtain information from other sources (p.r.n.) –e.g., previous GP, other doctors, family, with patient’s consent 1/3 or more of patients with chronic pain have no obvious organic disease but may feel genuine and debilitating pain If in doubt, err on the side of the patient’s report. Assessment of Chronic Pain in Drug-dependent Patients (2)

14. Pain Management Opioids and Pain Management A true ‘opioid allergy’ is very uncommon There is no evidence that use of opioids for treatment of severe acute pain leads to dependence / addiction When opioids provide no relief, the pain may be neuropathic in nature Opioids for pain relief are most effective when: –tailored to the individual –used in conjunction with NSAIDS.

15. Pain Management Prescribing Opioids and Drug-dependent Patients (1) Use opioids with caution: if opioid-dependent, high tolerance is likely, and therefore need higher doses (not lower doses) potential for adverse events /excessive sedation avoid injections and Pethidine (poor clinical outcomes) aim for regular fixed doses (better, cheaper response compared with ‘on-demand’) consider sustained-release forms.

16. Pain Management Controversy re prescribing methadone for the opioid- dependent Separate prescribing for dependence from pain management issues (e.g., via shared care) so that: –patients are not confused about dose, types & purpose of prescribed drugs –drug doses can be adjusted to accommodate the separate problems –staff fears of malingering can be allayed Analgesics are just part of an effective management plan for chronic pain. Prescribing Opioids and Drug-dependent Patients (2)

17. Pain Management Chronic Pain and Iatrogenic Dependence Definition : dependence on medication following a period of medically-initiated pain management true extent of the problem is difficult to gauge treatment: dose tapering or methadone prevention: –close supervision and monitoring of pain patients –review medication frequently –encourage alternative (non-drug) treatments to complement medication.

18. Pain Management Chronic Pain Patients and Risk of Drug Dependence Risk indicators may include: personal / family history of high-risk patterns, problems or therapy (including receiving MMT) demonstrating abnormal illness behaviour, low frustration tolerance, premorbid personality problems, or poor coping skills history of childhood abuse patients who describe euphoric effect from prescribed opiates current stressors complex compensable patients young patients with obscure pathology.

19. Pain Management Chronic Pain Patients and Suspected Drug Dependence The following signs should alert you: tolerance to prescribed opiates +/- BZDs and; –intoxication, deterioration in function,  pain-associated distress requesting scripts early withdrawal symptoms and signs medication(s) not being taken increased use of alcohol (increases sedation) requesting opiate-based analgesics (rather than NSAIDS) preoccupation with obtaining opioids despite analgesia evidence of ‘doctor shopping’, visits to E.D., hoarding supplies.

20. Pain Management Non-drug Complementary Strategies (1) Medications –Other analgesics, antidepressants, anxiolytics, tranquillisers and hypnotics, muscle relaxants, antispasmodics, antihistamines, corticosteriods, local anaesthetics etc. Lifestyle adjustment –exercise –ergonomic work stations / change in tasks / roles –relaxation / meditation Physiotherapy / hydrotherapy / radiotherapy Supportive counselling/CBT.

21. Pain Management Cognitive therapy –changing beliefs / expectations, blocking negative thinking Behaviour therapy –goal setting / problem-solving –self-reinforcement –diversion techniques Stimulation to relieve pain –Transcutaneous Electrical Nerve Stimulation (TENS) –acupuncture –vibration / massage. Non-drug Complementary Strategies (2)

22. Pain Management Pain Relief is the Overriding Consideration For the very elderly The terminally ill with a short life expectancy Concerns of exacerbating drug dependence in these situations are secondary

23. Pain Management 10 Tips for Managing Patients with Chronic Pain (1) 1.Define pain syndrome and treat cause (where evident) 2.Ensure Mx by single practitioner 3.Validate and accept patient’s pain experience 4.Establish clear, honest, open relationship 5.Make, and agree on, a clear treatment contract (cont…)

24. Pain Management 6.Educate and inform about your approach to pain Mx 7. Treat comorbidity with shared care team 8. Encourage alternatives to pharmacotherapy 9. Medication Mx – one doctor, close monitoring 10.Monitor progress, compliance and symptoms and maintain vigilance for evidence of dependence. 10 Tips for Managing Patients with Chronic Pain cont. (2)

25. Pain Management Strategies for Managing Aberrant Behaviour Re-assess medication, expectations, underlying cause Consider changing drugs /  interval between supply Reinforce discussions / contract Consider urine testing / warn of consequences of continued behaviour Wean or cease opioid use Notify health department / joint management with drug treatment agency Consider very frequent medication supply / MMT.