Transcript Does Primary Care need a Pain Clinic?

Does Primary Care need
a Pain Clinic?
Selina Dunn
CCG Clinical lead
Chronic Pain
”Pain that persists beyond the point at which
healing would be expected to be complete (3
mths) or that which occurs in disease processes in
which healing does not take place”. International
Association for the Study of Pain 1994
Does Primary Care need a Pain Clinic?
Mrs. Smith is here again, Monday morning you are
on call. Complaining of pain in her back …she has
been investigated and you know she has chronic
back pain. She has physio etc with no
improvement.
What do you do???
Chronic Pain
• Common dilemma, accounts for at least 22% of GP consultations
• 2nd most common complaint for benefits claimants
• A major clinical, social and economic problem however under
recognised and under treated
• For many it is a prominent feature of their lives and has a profound
impact on their QOL
• JSNA Kirklees PCT, pain had the greatest impact on health and
function
• How much education have doctors received?
Pain pathways
1. Pain primary assessment and management
2. Spinal Pain
3. Musculoskeletal pain (non spinal, non-
inflammatory)
4. Neuropathic Pain
5. Pelvic Pain/Visceral (Male and female)
Chronic Pain
• Changes in structure and function of the nervous
system (brain, spinal cord and periphery),
peripheral receptors fire independently of
stimulus
• Central Nervous Sensitivity – “plasticity”
• Many believe it is a disease in its own right as
opposed to those who believe it is a simple sign
of disease process
What is Pain?
A complex multidimensional experience with
sensory,
cognitive,
emotional,
behavioural +
motivational components
All of which need addressing not just physical dimensions, a
simple pain history is therefore not enough…..
Biopsychosocial model
• Gold standard to understand and explain pain
(Gatchel 2007,Weiner 2008)
• Bio - the role of nociception neuropathy
interacting with psychosocial factors. These are
not mutually exclusive and are invariably
interwoven in an individual case
• Helps to explain the divergence in symptoms
and signs
Biopsychosocial model
• Biological – to arrive at a diagnosis, red flag
exclusion, pain history, nature, intensity
• Psychosocial – may or may nor be pain
related, emotional aspects, beliefs and
functional and dysfunctional aspects
Earlier identification of patients at risks
of chronicity
• Earlier identification and treatment proven to
reduce risk of chronic pain
• 60 - 80% pts with LBP consulting in primary care
still report problems one year later. (Croft1998)
85% of those consulting have NSLBP. (Deyo
2001)
Pain primary assessment and
management
Bio
• Pain history: sensory nature, qualities of pain, many
types of pain have features of neuropathic and
nociceptive pain mechanisms
• Verbal Rating Scale: 0= no pain,10=worst pain ever
• Exclusion of red flags
• PMH e.g DM
• Medication
Condition specific pathways
1. Spinal Pain
2. Musculoskeletal pain (non spinal, noninflammatory)
3. Neuropathic Pain
4. Pelvic Pain/Visceral (Male and female)
LBP – Initial Consult
1. ICE, reassurance, advice to keep active and
continue working if possible
2. Analgesia, may need neuropathic pain
medications as per NICE
3. Signposting to self care/management (leaflets,
book, video, 3rd sector peer support)
Self care and management
• Underpins all activities within ALL pain pathways, at
each care point.
• Pain management is most effective when it engages the
patient in self-management / care
• Provision of reliable information about their condition and self-care
options and how to access these appropriately
• Promotion of an individual’s understanding of his or her own health
and its maintenance
• Development of self-management or ‘coping’ skills.
Self care and management
www.selfcareconnect.co.uk includes EPP
www.paintoolkit.org/
www.sheffieldbackpain.com
www.nhsinform.co.uk/health-zones/scottish-backs.aspx
www.backcare.org.uk/
www.arthritisresearchuk.org/
'Non-specific Lower Back Pain in Adults' (PDF) from Patient UK at
http://www.patient.co.uk
Back and neck pain' (PDF) from the British Brain & Spine Foundation
http://brainandspine.org.uk
'Back pain' (URL) from Bupa at http://www.bupa.co.uk
Self care and management
'Back pain: patient perspective articles' (URL) from the British Brain & Spine Foundation
at http://brainandspine.org.uk
'Injections for chronic back pain' (URL) from Bupa at http://www.bupa.co.uk
'Low back pain: understanding NICE guidance' (PDF) from the National Institute for
Health and Clinical Excellence at http:// www.nice.org.uk
Book: Roland, M.O et al. (2002) The back book. London: The Stationary Office.
DVD: Get Back Active www.youtube.com/watch?v=7ao9Y19TZJQ
Review 2 weeks
No improvement /deterioration:
1. Severe radicular pain/neurological defecit: refer spinal centre
2. Biopsychosocial assessment
a. 4D’s risk assessment tool to support review
• Depression
• Disability
• Drug use problematic
• Diagnostic uncertainty, red flags
b. Keele STarT Back Tool
The Keele STarT Back Tool
Hill 2001
• Diagnosis and management of BP is often difficult in primary care, but
prognostic indicators offer assistance in management of the patient
• Often treatment modifiable prognostic indicators are identified too late
therefore problems are entrenched, STarT - early targeted intervention
• 9 item tool to identify subgroups (high, medium or low risk) by screening
for prognostic indicators that can be targeted with evidence based
treatment options
STarT Back tool improves back pain
management
• Preventing low risk patients from being over-treated
• Reducing medium risk patient secondary care referrals
• Improving high risk patient access to targeted treatment
aimed at preventing long-term disability
The Keele STarT Back – 9 item tool
Thinking about the last 2 weeks, tick yes/no as your response
(yes = 1, no =0)
1.My back pain has spread down my leg(s) at some time in the last 2 weeks
2.I have had pain in the shoulder or neck at some time in the last 2 weeks
3.I have only walked short distances because of my back pain
4.I have dressed more slowly than usual because of back pain
5.It’s not really safe for a person with a condition like mine to be physically active
6. Worrying thoughts have been going through my mind a lot of the time
7.I feel that my back pain is terrible and it’s never going to get any better
8.In general I have not enjoyed all the things I used to enjoy
9.Overall, how bothersome has your back pain been in the last 2 weeks?
Not at all (0) / Slightly (0) / Moderately (0) / Very much (1) / Extremely (1)
Which group?
1. Low risk of chronicity
•
Good prognosis
•
Primary care management
•
Advice and support patients to self-manage
•
If persists >6 weeks refer physio
2. Medium risk of chronicity
•
Unfavorable prognosis
•
Advice and support patients to self-manage
•
Physio approach addressing pain & disability: Back to fitness group, no defined
direct pathway yet
Which Group?
3. High risk of chronicity
Very unfavourable prognosis
Require physio approach addressing pain & disability and
additional cognitive behavioural approaches, refer to
someone with those skills.
Pain Management Programme
(PMP)?
10 week programme at a hospital
Long waiting list
Average length of time from onset of CP to PMP is 5 yrs!
Chronicity likely to be entrenched by the time arrive!!
One-size-fits all policy
£10,000 per patient
Tier 2 service
•
GPSI, ESP and health trainers with motivational skills to support patients in
self management and coping
•
Focused on preventing and reducing long term disability and distress in
those with complex problems
•
Patients need to have accepted that there is no further medical investigation
or treatment available and be willing to follow a self management approach
Tier 2 service
• A home based cognitive behavioral approach supporting the
self-management of chronic pain
1. Pain Management Plan book www.npowered.co.uk
• £12 per book (£7 in bulk)
• 9-10 yr old reading level
2. On-line www.pathwaythroughpain.com
• £150
Review no later than 12 weeks
•
RED FLAGS?
•
Alternative diagnosis?
•
Screen risk of persisting pain-related disability and refer
Consider earlier review if :
• if patient not returned to work job is at risk
• there is a suspicion of opioid misuse/chemical coping
Take Home Pain Messages
•
A multidimensional experience therefore in order to understand a persons
pain, all dimensions need to be considered: BPS model
•
A key focus must be to enable patients to effectively manage their own
pain
•
Prognostic Indicators (PI) exist that increase the risk of chronicity/long term
disability
•
Screening for PI with subsequent allocation of patients into subgroups
enables targeted treatment of increasing complexity with the aim of
improving self management and reducing chronicity
References
•
Accident compensation Corporation and the New Zealand Guidelines Group, Wellington, New
Zealand. 1999
•
Buchbinder R, Jolley D, Wyatt M. Population based intervention to change back pain beliefs and
disability: three part evaluation. BMJ. 2001 Jun 23;322(7301):1516-20.
•
Croft PR, Macfarlane GJ, Papageorgiou AC, Thomas E, Silman AJ. The outcome of low back pain
in general practice: a prospective study. BMJ 1998;316:1356 –9.
•
Deyo RA, Weinstein JN. Low back pain. N Engl J Med 2001; 344:363–70.
•
Gatchel RJ, Peng Y, Peters ML, Fuchs PN, Turk DC. The Biopsychosocial Approach to Chronic
Pain: Scientific Advances and Future Directions. Psychological Bulletin. 2007;133:581-624.
•
Hill JC, Dunn KM, Lewis M, Mullis R, Main CJ, Foster NE, et al. A primary care back pain
screening tool: identifying patient subgroups for initial treatment. Arthritis Rheum 2008;59(5):632–
41www.keele.ac.uk
•
Hill J. Comparison of stratified primary care management for low back pain with current best
practice (STarT Back): a randomised controlled trial. The Lancet. 2011;9378(9802):1560-71.
•
Weiner BK. Spine update: the biopsychosocial model and spine care. Spine. 2008;33(2):219-23.
Opioid Guidance
Full guidance for prescribers and patients available at
http://www.britishpainsociety.org/book_opioid_main.pdf
and
http://www.britishpainsociety.org/book_opioid_patient.pdf
Unsuitable for combined physio/cbt
• Patient unwilling/not ready yet for self- management approach
• Primary drug or alcohol problems
• Psychological or psychiatric problems which require urgent
intervention or which preclude the use of cognitive and behavioural
methods
• Severe disability such that the basic requirements of attending
treatment exceed the patient’s current capacity. This depends in part
on the physical characteristics of the treatment setting and access to
it.
Risk of chronicity
yellow flags
•
Beliefs that pain and activity are harmful
•
“Sickness behaviours” – extended rest
•
Low, negative mood, social withdrawal
•
Problems at work (high or low demands), control, support, satisfaction
•
Threat to benefits, issues with claim and compensation
•
Beliefs / attitudes of friends or relatives (solicitousness, punitive responses
in an unhappy relationship)
•
Medication and/or treatment not working
Common problematic beliefs about chronic
pain.
“I may become paralysed if I am physically active”.
“My pain is either real (physical) or all in my head”.
“My suffering is someone else’s fault”.
“Nobody understands what I’m going through”.
“I need an operation”.
“Doctors should be able to cure me”.
“I should not be working”.
“I should rest in bed”.
“I should be on stronger medication”.
“I need to wait for a medical breakthrough”.
“I do not have a correct diagnosis”.
Mechanism Based
Classification
Neuropathic
Inflammatory
Dysfunctional
Nerve Injury
RA
Fibromyalgia
Trigeminal neuralgia
Post Op.
Whiplash
Amputation
Colitis
Low back pain
DM
Tendonopathy
Tension headache
Stroke
Myositis
Irritable Bowel Sy
Finnerup NB 2004