treating postoperative pain
TRANSCRIPT
“ThisUnbearablePain”ThePost-operativeDilemma
DrBrendanMoorePainMedicineSpecialist
PhysicianAdjunctAssociateProfessor
UniversityofQueensland
Topicsfortoday
• PostoperativepainDilemma
Workshop• Interventionsformechanicalbackpain• Opioidissues• PsychologyinpainPatients
3Messages
• EarlyIdentificationandtreatmentofneuropathicpain
• Managementofpostopopioids
• Exampleofmedicationregimes
•“Anunpleasant sensoryandemotionalexperience associatedwithactualorpotential tissuedamage,ordescribed intermsofsuchdamage.”
Definingpain
InternationalAssociationfortheStudyofPainWebsite.Availableat:http://www.iasp-pain.org/terms-p.html.Accessed30June,2006.
InternationalAssociation fortheStudyofPain(IASP)
Thecontinuumofpain1
<1month
Timetoresolution
≥3-6months
AcutePain
ChronicPain
• Usuallyobvioustissuedamage
• Increasednervoussystemactivity
• Painresolvesuponhealing
• Servesaprotectivefunction
• Painfor3-6monthsormore2
• Painbeyondexpectedperiodofhealing2
• Usuallyhasnoprotectivefunction3
• Degradeshealthandfunction31. ColeBE.Hosp Physician2002;38:23-30.2. TurkDCandOkifuji A.Bonica’sManagementofPain2001.3. ChapmanCRandStillmanM.PainandTouch1996.
Insult
Classificationsofpain
Acute
Chronic
Duration
Nociceptive
Neuropathic
Pathophysiology
Biomedical Aspects of Pain1,2
• Nociceptive pain è noxious stimuli, e.g. ongoing tissue damage
• Neuropathic pain è neurological injury or dysfunction
• Clinical features suggesting neuropathic pain: – Absence of obvious tissue damage or inflammation– Characteristic descriptors:
• Burning, shooting, sharp pain– Sensory findings both
• Positive e.g. allodynia/hyperalgesia• Negative e.g. sensory loss
1. Analgesic Expert Group Therapeutic Guidelines: Analgesic. 20072. Jensen TS, et al. Eur J Pharmacol 2001;429:1-11.
Nociceptive Neuropathic
Nociceptivevs neuropathicpainstates
• Arisesfromstimulusoutsideofnervoussystem
• Proportionatetoreceptorstimulation
• Whenacute,servesprotectivefunction
• Arisesfromprimarylesionordysfunctioninnervoussystem
• Nonociceptivestimulationrequired
• Disproportionatetoreceptorstimulation
• Otherevidenceofnervedamage
vs
SerraJ.ActaNeurolScand1999;173(Suppl):7-11.
Nociceptiveandneuropathicpain
• Arthritis• Sports/exerciseinjuries
• Postoperativepain
NeuropathicpainNociceptivepain Mixed
• PainfulDPN• PHN• Neuropathiclowbackpain• Trigeminalneuralgia• Centralpoststrokepain• Complexregionalpainsyndrome• DistalHIVpolyneuropathy
Causedbylesionordysfunctioninthenervoussystem
Causedbytissuedamage
Causedbycombinationofprimaryinjuryandsecondaryeffects
• Lowbackpain• Fibromyalgia• Neckpain• Cancerpain
InternationalAssociationfortheStudyofPain.IASPPainTerminology.RajaSN,etal.inWallPD,MelzackR(Eds).Textbookofpain.4thEd.1999;11-57.
“Sciatica”:mixedpainstate
BaronR,BinderA.Orthopade 2004;33:568-75.
DiscCfibre
CfibreAfibre
Nociceptivecomponent:SproutingfromC-fibresintothedisc
NeuropathiccomponentI:DamagetoabranchoftheCfibreduetocompressionandinflammatorymediators
NeuropathiccomponentII:Compressionofnerveroot
NeuropathiccomponentIII:Damagetonerverootbyinflammatorymediators
Centralsensitisation
Neuropathic Pain
• Bad post operative prognostic indicator
• Early effective treatment planrequired
1. Analgesic Expert Group Therapeutic Guidelines: Analgesic. 20072. Jensen TS, et al. Eur J Pharmacol 2001;429:1-11.
Managementof pain
BelgradeMJ.PostgradMed 1999;106:101-40.AshburnMA,Staats PS.Lancet1999;353:1865-69.Abuaisha BB,etal.DiabetesResClin Pract1998;39:115-21.
Pharmacotherapy
Physicalrehabilitation
Interventionalregional
anesthesia
Complementary/alternative
Lifestyle
Neurostimulatory
Psychological
Treatmentapproaches
ObservationsandAdvicefromtheclinical“coalface”
PostoperativePain
• Stronganalgesiaceasedat2to4weeks• Importanttoplantoceasestronganalgesia• Surgeondoesn’tintendlongtermcontinuationofpostopanalgesia
• Proportionofpatientsfailtheplan!!
NeedaNewPlan!!
• ChangeinthePain• Mixedpaincondition
– NociceptiveandNeuropathic• ComprehensiveManagementplan
– Notmedicationsalone– Aimatrestorationofphysiotherapyandfunction
MedicationPlan
• Paracetamol/NSAIDs• AdjuvantAnalgesics• Gabapentin/Pregabalin• Tricyclicantidepressants(orothers)• StrongAnalgesia
StrongAnalgesia
Asetbacknotasentence!!• Cleardefinitiveplan• Shorttermincrease,thenreduceandcease• Sustainedreleaseonly• BythemouthandbytheClock• Noshortterm,nobreakthrough• Pre-determineddosereduction
FavouredCocktailsandRecipes
FavouredCocktailsandRecipes
1. Paracetamol1gm,qid2. NSAIDs
– Ibuprofen400mgtds– Celecoxib200mgbdè 100mgbd
3. TricyclicAntidepressant– Amitriptyline10è50mgnocte– Sedationandsleepacceptable(oftendesirable)
FavouredCocktailsandRecipes
4.Gabapentinoids• Gabapentin300mg,300mg,600mg• Pregabalin150mg,300mg
StagedincreaseindoseHigherdoseatnightOpioidsparingeffect
FavouredCocktailsandRecipes
• StrongAnalgesiaOxycontin 10or20mgx20tabs
2tabsx5daysthen,1tabx10days
Hydromorphone4mgx20tabs8mgdailyx5daysthen,4mgdailyx10days
FavouredCocktailsandRecipes
• StrongAnalgesiaOxycontin 10or20mgx20tabs
2tabsx5daysthen,1tabx10days
Hydromorphone4mgx20tabs8mgdailyx5daysthen,4mgdailyx10days
TramadolTapentadol
PaintheFifthVitalSign™
Needtoregularlyaskaboutthepresenceofpain.
AmericanPainSocietyMashfordMLetal,TherapeuticGuidelines:AnalgesicsEd4,2002
3Messages
• Managementofpostopopioids
• EarlyIdentificationandtreatmentofneuropathicpain
• Medicationregimes
END
How persistent pain can become a problem
Adapted from: Nicholas, 2008.
IsthePainMechanicalorNot?
Mechanical Non-Mechanical (red flags)
PainPoorly localisedWorse later in the dayUsually worst when sitting, worsens with movement
Usually localisedNo diurnal variationsUninfluenced by posture or movement
Spinal movementPainful limited movement usually of several segments
Normal or hypomobility limited to one or two segments
TendernessDiffuse Localised
Other featuresPatient is essentially well Of underlying disease
Neurological signsMay be present May be present
AdaptedfromMashford.TherapeuticGuidelinesAnalgesic;2002.
Acute and Persistent Pain: Different Clinical Entities1
• Acute pain: – Recent onset– Expected to last a short
time– Expectation is complete
recovery
• Persistent pain:– Persists for > 3 months– Expectation is not one
of cure
Recurrent acute pain, feature elements of both acute and
persistent pain
1. Analgesic Expert Group Therapeutic Guidelines: Analgesic. 2007
Red Flags1
• Most clues are in the history
1. Australian Acute Musculoskeletal Pain Guidelines Group. Evidence-based management of acute musculoskeletal pain. A guide for clinicians. 2004.
FeatureorRiskFactor Condition
Symptomsorsignsofinfection(e.g.fever)Riskofinfection(e.g.penetrating wound)
Infection
Historyoftraumaorminortrauma(if>50 years,osteoporosis+corticosteroiduse)
Fracture
PrevioushistoryofcancerUnexplainedweightlossAge>50yearsPainatrestPain atmultiplesitesFailuretoimprovewithtreatment
Tumour
Absenceofaggravatingfactors Aorticaneurysm
Pain and Impact on Quality of Life1
Physical well-being Psychological well-beingStamina/strengthAppetiteSleepFunctional capacityComfort/pain
CopingControlEnjoyment/happinessSense of usefulnessAnxiety/depression/fear
Social well-being Spiritual well-beingSocial support/familySexuality/affectionEmploymentFinancesRoles and relationshipsIsolation/dependence/burden
ReligionSense of purpose/meaning/worthHopefulnessUncertaintySuffering
1. Lynch TJ, Jr. Pain the fifth vital sign. J Intravenous Nursing 2001;24(2):85-94
Factors Associated with Persistent Back Pain1
• Structural changes on spinal imaging
• Disc degeneration• Disc tears / prolapse• Facet joint degeneration• Central & lateral canal stenosis
1. Waris E, et al. Spine 2007 15;32(6):681-4. 2. Jarvik JG, et al. Spine 2005;30(13):1541-8.3. Schenk P, et al. Spine 2006;31(23):2701-6. 4. Videman T, et al. Spine 2003;28(6):582-8.
Commonas we agebut not associatedwith pain
GP’s Role1
• Patient education and motivating change• Biopsychosocial assessment
– Red and yellow flags– Periodical reassessment and whenever new
symptoms are reported• Coordination of care and appropriate referral• Discouraging inappropriate searches for a cure• Discouraging prolonged treatment that is not
leading to improved function
1. Analgesic Expert Group Therapeutic Guidelines: Analgesic. 2007
The Evolution of a Persistent Pain
DrJames O’CallaghanAnaesthetist
and Pain Medicine Specialist
Mater Private Clinic,
Brisbane
Recovery
Chronic Pain Disability Cycle1
1. Analgesic Expert Group Therapeutic Guidelines: Analgesic. 2007
Surgery
Rehabilitationdespite pain
Pain-dependentbehaviour
Behaviour NOT dependent on pain
ACUTE PAIN
CHRONIC PAIN DISABILITY CYCLE Desperation
Hopelessness
Anger
Loss of controlInappropriate management
Social stressesAnxietyActivity avoidance
Unhelpful beliefs
Passive treatments
Demands for treatment
Deconditioning
Drug tolerances
Transition To Persistent Pain1
Emotionally charged
Loss of: • Hope• Confidence• Trust
Stressed relationships• Family• Doctor
Poor communicationDesperation
1. Analgesic Expert Group Therapeutic Guidelines: Analgesic. 2007
Psychosocial Yellow Flags1
Work Behaviours
Believe pain is harmful èfear avoidance behaviourBelieve pain must be abolished before returning to workCompensation issues
Passive attitude to rehab.Use of extended restê activityAvoidance normal activitiesé alcohol consumption
Beliefs AffectiveCatastrophising, thinking of the worstMisinterpreting bodily symptomsBelieve pain is uncontrollable
DepressionFeeling useless, not neededIrritabilityAnxietyLack of supportOverprotective partner
1. Jensen S. Aust Fam Physician 2004;33(6):393-401
Factors Associated with Persistent Back Pain1
• Premorbid factors– Older age– High levels of psychological distress– Below average self rated health– Low levels of physical activity– A history of low back pain– Not being employed, dissatisfaction with current employment
• Episodic factors – The presence of widespread pain– Long duration of symptoms prior to consultation– Radiating leg pain
– Restriction of spinal movement
1. Thomas E, et al. BMJ 1999;318(7199):1662-7.
Influences on Progress and Outcome1
• Negative influences
– Maladaptive ‘treatment’style
– Maladaptive family ‘support’
– Maladaptive work environment
– Conflict– Unrealistic expectations– Maladaptive response to
life stressors
• Positive influences (on early response)– Adequate assessment,
treatment and support– Early pain relief– Appropriate style
• Patient, family, GP– Understanding their
situation– Realistic expectations– Adaptive response to life
stressors
1. As adapted from Analgesic Expert Group Therapeutic Guidelines: Analgesic. 2007
Persistent Postoperative Pain1
• Preoperative factors– Moderate – severe pain lasting more than 1 month– Repeat surgery– Psychological vulnerability– Worker’s compensation
• Intraoperative factors – Nerve damage during surgery
• Postoperative factors– Pain (acute, moderate – severe)– Depression– Psychological vulnerability– Anxiety– Neuroticism
1. Perkins FM, Kehlet H. Anesthesiology 2000;93(4):1123-33.
Persistent Pain Requires a Different Approach1,2
Acute pain Persistent painCure the illness causing the pain Restore physical, psychological, social
function, minimise distressSymptom relief Control pain to tolerable level, ê distress
Focus on the painful part “Whole person” rehabilitationExpectation: return to previous health status
Adjustment is necessary, new skills/lifestyle
Passive dependent patient Active coping, participating patientActive “hands on” practitioner Practitioner who acts as a “coach”Analgesics given according to current level of pain, dose reviewed frequently
Regular, predictable schedule of analgesics
Medication and physical modalities Multidisciplinary approach Short-term focus Long-term focusRest is often appropriate Activity is generally appropriate
1. Analgesic Expert Group Therapeutic Guidelines: Analgesic. 2007. 2. NSW TAG. Prescribing guidelines for primary care clinicians. General principles. 2002.
Thankyou