REDUCING REFERRALS TO THE CHRONIC PAIN CLINIC

Dr Damien Smith FRCA, FFPMRCAConsultant Anaesthesia & Pain ManagementHillingdon NHS Trust

RECENT NATIONAL PAPERS & REPORTS

Report by Chief Medical Officer 2009

Nice guidelines for management of lower back pain

Review of chronic pain services (Wales)

HEALTH SECRETARY AND CMO

CMO REPORT 2009PAIN : BREAKING THROUGH THE BARRIER

United Kingdom : Pain in numbers 7.8 million people live with chronic pain NHS spent £584 million on 67 million

prescriptions for analgesia 1 million women suffer with chronic pelvic pain 1.6 million adults suffer with chronic LBP 49% adults with CP experience depression 25% of sufferers lose their jobs 500 pain specialists in the UK Roughly 1 specialist per 250,000 people (1 specialist per 32,000 sufferers????)

CMO REPORT

When pain becomes chronic, normal damping mechanisms stop working

Biological, psychological and social factors combine to exacerbate symptoms

Modern pain management should address all these elements with an “Integrated Approach”

Treatments involve activity, rehab, drug therapy, psychological therapy, TENS, acupuncture and interventions

Key is to ensure all aspects are INTEGRATED and joined up rather than instigated in isolation

IDEAL MODEL

CMO REPORT : IDEAL MODEL?

WAYS TO REDUCE REFERRALS

More level 3 services in the community? Educational programme for GP’s Prescribing guidelines Pharmacy teaching of community

pharmacists

WAYS TO REDUCE REFERRALS

More level 2 care Community screening teams Interdisciplinary CBT based programmes Patient support groups Physio ? TENS clinics ? Acupuncture clinics ? Consultant sessions in the community

NICE GUIDELINES MAY 2009

Early Management of Persistant Lower Back Pain

Patients must have back pain for LESS than a YEAR

Does NOT cover SUSPECTED : Malignancy Infection Fracture Radiculopathy Inflammatory disorder

NICE GUIDELINES

EXERCISE PROGRAMMES

EXERCISE PROGRAMMES

8 sessions over 12 weeks Groups of 10 Aerobic activity Muscle Strengthening Posture Control Stretching

MANUAL THERAPY

MANUAL THERAPY

SPINAL MANIPULATION!!

MANUAL THERAPY

Spinal manipulation Spinal mobilisation Massage MAY be performed by osteopaths and

chiropractors 9 sessions over 12 weeks

ACUPUNCTURE

ACUPUNCTURE

Advises 10 sessions over 12 weeks Does not advise injection of therapeutic

substances into the back

COMBINED WITH PSYCHOLOGY

PROBLEMS WITH THE GUIDELINES

NICE summary: we recommend acupuncture and manipulation because they work every bit as good as placebo but we don't recommend injections as they only work as well as placebo.

Advise patients to have osteopathy and chiropractor services?????

Lack of regulation concerns!!! Concerns from medical profession about

potential damage from poorly practiced spinal manipulation.

PROBLEMS WITH GUIDELINES

No discussion with The British Pain Society Multidisciplinary body Conflict of interest with BPS chairman Chairman had to resign NEXT MONTH BPS & NICE will meet to look at

‘reformulating’ the guidelines.

WAYS OF REDUCING REFERRALS

Do not refer patients with NON specific back pain

Do not refer patients with less than 1 year history

Offer patients exercise, manual therapy, acupuncture and psychology

DO REFER patients with known specific back pain

DO REFER patients with potential mailignancy, infection, fracture, radiculopathy or inflammatory disorder

RECENT SURVEY OF GP’S ABOUT SERVICES

Questionnaire about local chronic pain services and questions exploring ways to improve pain services.

48% satisfied with service 15% dissatisfied 37% neither

WAYS TO IMPROVE THE SERVICE

GP’s wanted:- More pain education in GP surgeries More advise through the internet More hospital based study days

WAYS TO REDUCE NEW REFERRALS

GP’s requested a telephone helpline Different triage system Email helpline More psychological training for community

staff Stricter criteria to accept patients to pain

clinic

PRESCRIBING GUIDELINES FOR PREGABALIN

Based on a guideline produced by the European Federation of Neurological Studies

Algorithm for treatment of neuropathic pain

Neuropathic pain

Lignocaine patch

TCA Gabapentinoid

Satisfactory TCA Gabapentinoid

Lignocaine patch

Localised

Pain Clinic

TRICYCLIC ANTIDEPRESSANTS

Amitriptyline starting dose 10-25 mg nocte Dose may be increased to 50 mg nocte Not an antidepressant dose and will not

interact with concurrent antidepressants Convert to Nortriptyline if problems with

drowsiness (not licensed for pain / /equivalent dose)

Contraindications include glaucoma, hypertension and may lower seizure threshold in epileptics

GABAPENTIN

Starting dose 300 mg od Gradual increase over days up to 900 mg tds Requires a lot of patient compliance Usually safe to take with other medications Effects may be seen in WEEKS Dosage needs to be adjusted in patients with

renal dysfunction Do not stop abruptly, needs to be done over

weeks

PREGABALIN

Starting dose 75 mg bd Increase to 150 mg bd if tolerated Can work up to 300 mg bd in some cases Effects may be seen in DAYS Safe in patients with renal dysfunction

LEICESTERSHIRE MEDICINES STRATEGY GROUP

Neuropathic pain

Lignocaine patch

TCA Gabapentinoid

Satisfactory TCA Gabapentinoid

Lignocaine patch

Localised

Pain Clinic

OTHER GUIDELINES

RCGP uses CREST guidelines (2006) www.rcgp.org.uk

NICE guidelines (March 2010) www.nice.org.uk

ANY QUESTIONS?

Damian.smith@thh.nhs.uk