2019-12-12

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The Efficient Ax &

Effective Mx of the Chronic Non Cancer Pain (CNCP) Patient

“That’s a Wrap”

Dr John F. Flannery, FRCP(C)

Faculty/Presenter Disclosure

Dr John F. Flannery

• Medical Director of the MSK and Multisystem Rehab Program

• Operation’s Lead of Project ECHO Chronic Pain and Opioid Stewardship

• Co-Director of Project ECHO Ontario Training

Relationships with commercial interests:

• None

The Final ECHO Presentation of the cycle

All the learning will lead to….GREAT Outcomes in your

travels

The potentially overwhelming sense of managing Chronic Disease Patients

The 20% of the practice that take 80% of the TIME!

Chronic Disease Principles Ed Wagner – Feb 2000 BMJ

People• Interprofessional Team

• Nursing, Pharmacy, PT, OT, SW, Psychology, Chirop, Trainers/PSW, Admin support

• Interspecialty Team and Consultants

• In clinical and educational roles (outside of conventional role)

Process• Critical elements:

• Population Mgt

• Protocol based regulations (e.g. guidelines)

• Self Mgt support

• Intense follow-up

CNCP = The Prototype for Chronic Disease mgt!

Goals:1. Primum Non Nocere – First do no harm!2. Help the Pt 3. Avoiding the Bad experience4. Try to stay at the “META” Level

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Today’s Journey

• Pain Context– Overview/Definition

• Assessment - Pearls and Approach

• Diagnosis

• Management Strategies

• Putting it All Together • Motivational Interviewing to get commitment of goals

• Collaboration – Patient and Team

• Communication Skills

Learning Objectives

Elicit at least 5 principles of Chronic Disease mgt

Recall the 5 key Pillars for a comprehensive pain assessment

Describe at least 5 management strategies

Recall the 5 common communication strategies

Recall the most important person in this equation

By the end of this session, participants will be able to:

Pain and Chronic Pain

“The friend that warns you or the enemy that destroys you”Dr. John Marshall (NeuroSx Queen’s Med School 1984)

“Friend” - Withdrawal response / avoid the use of the injured body part – FUNCTIONAL

“Enemy” - Pain that becomes counter-productive or debilitating – DYSFUNCTIONAL

The Context of Pain

• Confusing and complex field with multiple factors at play

• Not a static field : “Hit the moving target!”

• pain reports may change as a result of time or in response to Tx

• research is changing our ideas and concepts

• Many opinions - not all are based on understanding of the pain process

Definitions

“Neuropathic Pain”:

• A type of chronic pain mediated through nerve injury

• 3 cardinal symptoms present to variable degrees:

• Allodynia

• Radiation of pain

• Paroxysmal pain

“ADDOP” The 5 Pillars of Pain Mgt (Smith/Gordon)

• Assess: Symptoms and Risk

• Define the problem: where and what is it?

• Diagnose the kind of pain and treat it

• Other issues: mood, anxiety, sleep, addiction, sex

• Personal management, self management

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Pillar 1: Assessment “Horses are Common - Zebras Aren't!”

• General history –• for LBP -> “Core Back Tool” • NOTE: only about 2 - 3% of LBP in neurologic

• Neurological history

• Pain history• Identify the individuals with the greatest risk of aberrant behaviour NOT

to stigmatize, but to improve care• NB: Chronic pain and addiction can co-exist in a patient

Pillar 2: Define the Underlying Problem

• General and Neuro/MSK exam • Simon Carette – 3 min Back Exam

https://uhn.echoontario.ca/knowledge-base/the-3-minute-primary-care-low-back-examination/

• Dr. Don Miettinen – “ Don’t forget the Sensory Exam”

• Investigations “not fishing expeditions” • Recall - Caution Re MRI’s

• WHERE AND WHAT is the lesion?

• Applies to neurological conditions and non-neurological conditions

• Treating an underlying or coexisting disease often helps treat pain

Pillar 3: Diagnose- Nociceptive vs. Neuropathic

Nicholson BD (2003)

Pain

Nociceptive Normal stimulation of nociceptors

Neuropathic Abnormal nervous system activation

Somatic Visceral Central Peripheral

Pillar 4: Other Symptoms and Conditions

• Depression• Sleep• Anxiety• Fatigue• Sexual Function• Addiction

Pillar 5: Personal Responsibility and Self-Management

• WHO’s working harder ? – Reality check! • hold yourself and the patients accountable

• “TRUST” - Therapeutic alliance is key; it may be any team member

• “Master of Patience with patients” –• Why all the urgency ?

• Always Be respectful!

• Lack of prompt recovery we tend to repeatedly apply “medical model” – more consults, tests, drugs….

• Step wise approach – Gerald Flannery: “John - don’t be too smart by half”

• Other modalities – psychological and otherwise – are left out

Pillar 5: Personal Responsibility and Self-Management ctn’d

• “Interprofessional care model”• Clinicians need to practice it (not just talk about)

• Pt will often consciously or unconsciously try to split the team

• The “Refractory patient” • Lack of buy-in and self management is likely a key component

• “Proactive” management vs “Reactive”

• Establish realistic expectations

• “External Locus of Control” • Need to educate patient and family about pain mgt techniques

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The Clinical Exam*Watch the Video by Dr. Pam Squires on the ECHO Home Sitehttps://uhn.echoontario.ca/knowledge-base/physical-exam-for-dermatologic-pain-dr-squire-video/

Fundamentals:

• Good Eye Contact

• Aware and Acknowledge that the exam may be painful but very important to understanding the pain issues

• Observe prior to touching / examining

• Proper draping to enable efficient exam time

• Tools for the exam present and explain

The Flannery “KISS” MethodKeep it Simple, Stupid

• Determine if Pain is:

• Neuropathic Pain vs Nociceptive

• Determine if Pain is:

• Anatomical (Peripheral Nerve or Dermatomal)

Versus

• Non Anatomical (Wide Spread) sensory patterns• Non Dermatomal Sensory Deficits (NDSD)

• + (gain) or – (loss)

• Often “Quadratic” or “hemi body”

Physical Exam - Recall Pam Squires/ Simon Carette videos

Common and Challenging CNCP Diagnosis

• CLBP/Failed Back Syndromes – Core Back tools, min MRIs

• FMS – No opioids…Please!

• OA – Team work important ( Ortho, PT, Chirop, OT…)

• Complex Regional Pain Syndrome (CRPS) and Neuropathic pain Syndromes – Accurate Dx

• Headaches

• Myofascial (often pain superimposed on underlying issue) • Dr Janet Travel book, www.mytriggerpoint.net

• Opioid induced problems

Today’s Journey

• Pain Context– Overview/Definition

• Assessment - Pearls and Approach

• Diagnosis

• Management Strategies

• Putting it All Together • Motivational Interviewing to get commitment of goals

• Collaboration – Patient and Team

• Communication Skills

Management Strategies

All of these are Free! • Education, Education, Education…… Education! (Got it Yet?!)

• Communication of Diagnosis … You must commit to a Dx

• Goals Focused Behaviours – “Its All about YOU”/ SMART Goals

Sorry ….I lied – They do Cost = TIME! Yours and Theirs

Management Strategies (ctn’d)

• Drugs:• Opioid “trials” - after a good goal focused trial if it don’t work then stop!

• Non Opioids(Acetomin, NSAIDS, TCAs, anti-seizures, SSRIs, SNRIs, ….)

• Topicals

• Cannabinoids

• Interventions:• goal focused outcomes not just VAS

• Manage the comorbidities

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Before you make the decision to begin a treatment or intervention ….

… you have already screened and established that the patient is a good or ideal candidate for that treatment or intervention

It’s important for the patient to set goals so that you have an agreed upon objective way to measure functional progress

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What are the steps involved with “Effective Motivated Goals” ?

1.Engaging: The relational foundation

2.Focusing: Clarify directions: What is the horizon?

3.Evoking: The person’s own arguments for change

4.Planning: Developing commitment to change + formulating a plan of action

Miller and Rollnick, 2013

Engaging

Focusing

Evoking

Planning

The Technique to “Engagement”

Paddling your way through “Murky Waters” with “OARS”

• Open ended questions

• Affirmation

• Reflection

• Summarize

The Underlying Intention of

“Effective Goal Setting”

•Trust

•Rapport

•Collaboration

Collaboration with Patients and FamilyCollaboration with Team

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What is Self-Management?

“The individual’s ability to manage the symptoms, treatment, physical and social consequences and lifestyle changes inherent in living with a chronic condition”(Barlow et al, 2002)

“Let’s work on your internal medicine cabinet”

You’ve suggested to your patient that the Self-Mgt or the Mindfulness might help

and THEY Say:• “I don’t like groups”

• “It won’t work for me”

• “I don’t have time”

• “I’ve tried everything, nothing works”

• “Doc, just give me my pills, that’s all I want”

• …..

1 more Reason “WHY WE NEED A TEAM”!

Patrice/Paul/Amy/Mandy/Lucy/Carlo/Pearl

HELP!!!!!!!!“What can you offer the Patient”

OT/PT/SW/Nursing /Psych …Roles Breaking down barriers

• Talk about their previous experiences with self management. • What education have they received/pursued?

• What strategies have they tried, and for how long?

• How did it go? What was the reaction? Was there something that really spoke to them?

• What informal strategies / approaches do they apply?

Today’s Journey

• Pain Context– Overview/Definition

• Assessment - Pearls and Approach

• Diagnosis

• Management Strategies

• Putting it All Together • Motivational Interviewing to get commitment of goals

• Collaboration – Patient and Team

• Communication Skills

The Goals of an Effective Hx and PxEncourage Open Dialogue

• Build Trust that you care Start with open ended questions

• The Px – we touch the patient Shows you care

• Have Clear Picture of Sx Direct closed ended questions

• Train your patient about what you are looking for

• Is the feeling - Present or Absent ?

• If present - Normal or Abnormal ?

• If abnormal - Increased or Decreased ?

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A patient-centered approach to a good interview with CNCPs

A patient centered approach

does not mean

a patient controlled interview

Crucial Conversation - SUMMARY

•Encourage Open Dialogue – “Heart and Head”1. From the heart

2. Watch and listen

3. Control emotions and thoughts

4. State your path listen to theirs

5. Action plan

Putting it ALL Together

• Education, Education, Education…… Education! (Got it Yet?!)

• Communication of Diagnosis … You must commit to a Dx

• Goals Focused Behaviours – “Its All about YOU”/ SMART Goals

• Therapy • Self mgt to Physical to Psych to Cognitive to Life Mgt/ Stress mgt/ CBT….

• Drugs• Opioid “trials” - after a good goal focused trial if it don’t work then stop! • Non Opioids(Acetomin, NSAIDS, TCAs, anti-seizures, SSRIs, SNRIs, ….) • Topicals• Cannabinoids

• Interventions

• Manage the Co-morbidities

AND ….Follow – Up!

Learning Objectives

Elicit at least 5 principles of Chronic Disease mgt People: Interprof’l and Interspec’y Teams; Process: Pop’n mgt; Guidelines; Self Mgt; Intense Follow-up

Recall the 5 key Pillars for a comprehensive pain assessment

(ADDOP)

Describe at least 5 management strategies

(Dx, Educ’n, Goals, Drugs, Interv’ns, Co-morb’y)

Recall the 5 common communication strategies

(“Heart and Head”)

By the end of this session, participants will be able to:

Flannery Principles in CNCP

People

• Create a GREAT Interprofessional Team

• Trust yourself

• Build Trust with your patient BUT never forget “Humans are Humans”!

• “Master of Patience with patients”

Process• Start with SMART Goals

• Your are in it for the “Long Haul”/ the “Horizon is far off” = Start Small

• Keep pts accountable (Goals/ Behaviours) for their actions and then “Reset more Goals”

• The “Refractory patient” • Lack of buy-in and self management is likely a key

component

• Pt. Proactive management vs Reactive

• Realistic expectations

Discussion