Summer 2010 - The British Pain Society

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Timing How long have you had the pain? The answer ‘many years’ will inevitably lead to a chronology of the pain with lists of previous procedures and interventions. Don’t get too blown off tack. “What has changed?” or “What has led to you coming here after all this time?” may elicit useful information. How did it start? Out of the blue, gradually or after something happened? A precipitating cause may be obvious, the road traffic accident, the operation or damage due to a fall, or it may not. The distinction between an obvious precipitant and not is the rationale for the question. Constancy - is it there all the time or does it come and go? How many good (bad) days do you have each week? Is it better, worse or the same as it was e.g. last Christmas? If it’s worse is that more severe or more frequent (or both?) These questions about constancy are important for treatment. Using heavy duty analgesic prophylaxis is just a huge burden for the patient on the day(s) with minimal pain. Identifying and distinguishing background pain and flare pain is really important if prescribing is to be tailored effectively. The issue of whether or not the pain is deteriorating (worse on the better/worse/same question may colour attitudes and expectations. If it hasn’t got worse in five years then it’s unlikely to be fatal. That should be reassuring. The necessity, the urgency and the quest for further investigations may all be coloured by this answer. Pattern Does time of day have an influence or is it truly constant? Does it only hurt when you move? Have you got pain now just sitting there? What things make it better and what things make it worse? Does distraction help? Alcohol? I think there are two obvious patterns which we need to detect a movement-related pain, which takes you into musculoskeletal problems, and neuropathic pain. Distraction and alcohol as alleviating factors are mentioned commonly by patients with neuropathic pain. What have they told you to expect? I often use the question “What does your own doctor think?” You need to know what the patient has been told about the prognosis and treatment approaches. If they have a legal case on the go then the experts may have talked about prognosis and treatment verbally or in writing, and this is true obviously for other hospital doctors involved in the patient’s care. The concern is that expectations are wildly different from the reality. A simple example is when the patient has been referred with the request for a specific procedure, and you believe that is not feasible, won’t work or is otherwise inappropriate. It may take a lot more time to talk this through than it would to do the procedure. It’s important to emphasize the distinction between pain and disability. No matter how good the analgesia it is unlikely to have any effect on the disability - indeed greater activity may accentuate the disability. Somewhere in the consultation you need to gain a view on the patient’s expectations and beliefs about health. It may come in this section, or it may come elsewhere. This may be blisteringly obvious - the patient believes they have insects living in their painful knee, but the more subtle issues, for instance a family background of long periods of time off school and work for dubious medical reasons, may be just as relevant. Often this is the place where the conversation extends to myths about pain, and some of these continue to intrigue me. Many would be answerable if we had a collective prospective database, but we’ve failed to deliver that over thirty years. An example would be nerve damage. The general teaching is that if it’s not better in two years then it won’t get better. That’s perhaps realistic on average, but not true for all, as one might expect for an ‘average’ number. I see some people who continue to improve beyond the two year mark, so I am loath to cut off all hope of further improvement by an ex cathedra statement. Conversely the two years is useful when people are struggling at one year. Don’t be impatient, these things take time. A second example is the general view that amputation won’t help the pain. I've seen people with ankle damage who were undoubtedly better after amputation (but I still give the party line). A third example is our belief that all pains get better if treated early. I've never been sure of the basis for this wishful thinking. It may be that we are given to claiming success of our therapy when actually the natural history would have meant that the pain improved anyhow. My most optimistic colleague always used to say “If they don’t come back they’re cured”. The Dutch trial of epidural in shingles did not suggest any alteration of natural history by the intervention [The PINE study of epidural steroids and local anaesthetics to prevent postherpetic neuralgia: a randomised controlled trial. van Wijck AJ, Opstelten W, Moons KG, van Essen GA, Stolker RJ, Kalkman CJ, Verheij TJ. Lancet. 2006 Jan 21;367(9506):219-24.] What are you using to help the pain? The information you need for each drug is the dose and timing, how long at that dose, adverse effects and percentage of relief. If it really isn’t clear which drug (if any) is helping then “Of all your painkillers which do you think works best (which is the one you’d least like me to stop?)?” may work. For previous procedures what you need to know is did a technically effective procedure succeed or fail? the success or failure may be easy to determine but is often difficult to know if the procedure was technically valid - did the relevant area go numb if local anaesthetic was used etc.? The issue is “Is it worth repeating?” What else have you tried which hasn’t worked? Again for each drug you need the dose and timing, duration, adverse effects and percentage of relief (rarely will you get all this). One of the tough questions to yourself is did this patient have an adequate trial of this medicine? If the patient says they had a week of amitriptyline at 25 mg at night, had no adverse effects and gave up because of lack of efficacy then that might argue for a trial of escalating dose. Conversely, repeated trials of strong opioids to dose levels of 500mg per day morphine equivalents with no pain relief and overwhelming adverse effects might suggest a poorly opioid sensitive pain. In between lies the more ambiguous territory. What other things have you tried? There’s a long list of potential candidates here, from simple hot or cold to TENS (or spinal cord stimulation), physiotherapy, chiropractic, acupuncture, and other alternative or complementary manoeuvres. Two I specifically check for are TENS and topical anti-inflammatories or capsaicin. TENS and capsaicin are still part of my initial thinking for neuropathic pain and so one needs to know if they have been tried or not. 4 6 PAI N N E W S S U M M E R 2010
Past Medical History This pain problem - just in case anything has been missed so far. Other operations Other illnesses Are you seeing any other hospital doctors at the moment? This I find helpful, particularly with the elderly who often have multiple appointments each month. You may get diagnostic clues, and you may be able to bow out if the pain end is already being dealt with. This redundancy sometimes happens if there is an unacknowledged ‘spray’ of referrals to different departments in response to a particular crisis. Previous mental health problems or previous substance abuse are highly relevant, and particularly so if long-term opioid analgesia is envisaged. Social This is where the impact, the burden, of the pain (and disability) should become apparent if not already so. Questions like who else lives with you? How do you spend your time? What can’t you do that you’d like to do? Exercise, or lack of, and how are you managing financially? needs to be asked. If still working then how does work fit with the pain, or is the work required always going to make the pain worse? What is the way forward? Has all that can been done to improve or maintain mobility been done? (House adaptations, rollator etc?). I was trying to avoid that abused word outcomes, but this part of the consultation is asking which bits of your life are or are not affected by the pain, and in follow-up any improvement can be assessed on these aspects. This is an informal version of what Danny Rutter did many years ago [Ruta DA, Garratt AM, Leng M, Russell IT, MacDonald LM. A new approach to the measurement of quality of life. The Patient- Generated Index. Med Care. 1994;32 - Nov(11):1109-26.] and tested in low back pain. How are you sleeping? We were taught that patients with postherpetic neuralgia slept surprisingly well, given their bad day-time pain, and by and large that eyes-and-ears (as opposed to evidence-based) observation holds up. I have no idea how generalisable this is across neuropathic pain as a whole. If true it would be another clear distinction from nociceptive pain which commonly disturbs sleep as you turn. Of course you’d need to know that it wasn’t just the tricyclic antidepressants doing their job. Conclusion Is there anything about this pain that I've missed out? I'm acutely aware there are glaring omissions here, not the least of which is the ‘special’ questions you may need to ask for a headache. Last but not least two things I've come to late in life which I think are helpful are to dictate the clinic letter with the patient present and to copy the clinic letter to the patient. Both things would have caused eyebrows to go through the ceiling thirty years ago, but both (particularly the letter) are important as continuity of care becomes fragmented and intervals between appointments expand. So I finish in the hope that some of these clinical pearls that I have picked up over many years experience in the harsh and rewarding world of a pain clinic may indeed help you consult better as they have indeed done for me. Codipar® Co-codamol 15/500 Codeine Phosphate 15mg/Paracetamol 500mg 8/500 15/500 30/500 PLUGS THE PAIN GAP PRESCRIBING INFORMATION FOR CODIPAR (PARACETAMOL & CODEINE PHOSPHATE) COMPOSITION: Each Codipar caplet contains Paracetamol 500mg and Codeine phosphate 15mg. INDICATIONS: For the relief of moderate pain. DOSAGE & ADMINISTRATION: For Oral administration. In adults one or two caplets every four hours as required should be given, do not exceed 4g of paracetamol (8 caplets in a day). In elderly a reduced dosage may be necessary. Children: Not recommended below the age of 12 years. CONTRAINDICATIONS: Hypersensitivity to either Paracetamol or codeine, or any of the excipients, severe renal or hepatic impairment; acute asthma, obstructive airway disease, respiratory depression, acute alcoholism, head injuries, raised intracranial pressure, after biliary surgery, and patients who have taken MAO inhibitors within 14 days. Codipar is contraindicated in patients for whom opiate medications are contraindicated. WARNING & PRECAUTIONS: Use with caution in patients with acute abdominal conditions, increased intracranial pressure, elderly, debilitated, hypothyroidism, Addison’s disease, impaired hepatic or renal function, prostatic hypertrophy and urethral stricture. The hazard of paracetamol overdose is greater in those with alcoholic liver disease. Patients should be advised not to exceed the dose and not to take other products containing paracetamol or opiate derivatives while on Codipar and consult their doctor if symptoms persist. Tolerance to codeine can develop with continued use and the incidence of unwanted effects is dose related. Patients should be advised not to drive or operate machinery if Codipar causes dizziness or sedation. INTERACTIONS: Use of antihypertensive agents, diuretics, quinine, quinidine, CNS depressants, MAOI’s or tricyclic antidepressant, anticholinergics, antidiarrhoeal agents, antimuscarine drugs, metoclopramide, domperidone, cholestyramine, mexilitine, cimetidine, warfarin and other coumarins may interact with Codipar. Opiods may interfere with results of some laboratory tests and codeine may interfere with tests for gastrointestinal function. PREGNANCY & LACTATION: Not recommended. UNDESIRABLE EFFECTS: Most common are nausea, vomiting, light headedness, dizziness, sedation, shortness of breath, constipation. In addition, miosis, visual disturbances, headache, bradycardia, respiratory depression, difficult micturition, urinary retention and allergic skin rashes can occur. Codeine at high doses can cause respiratory depression. Codipar caplets may cause euphoria, dysphoria, abdominal pain or pruritus. Paracetamol may cause liver damage, more common in patients with chronic alcohol use. Rarely blood dyscrasias have been reported. Please refer Summary of Product Characteristics for detailed information. LEGAL CATEGORY: POM Basic NHS price: £8.25 for 100 caplets Marketing Authorisation number: PL 12762/0056 Product Authorization Holder: Goldshield Pharmaceuticals Ltd., NLA Tower, 12-16 Addiscombe Road, Croydon, Surrey, CRO OXT, UK. Date of preparation or last review: April 2010 Adverse events should be reported. Reporting forms and information can be found at www.yellowcard.gov.uk. Adverse events should also be reported to Goldshield Medical information on 08700 70 30 33 or send a email to medicalinformation@goldshieldgroup.com Codipar/Pain News/0410 Codipar-GIP-O PAI N N E W S S P R I N G 2010 47
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Summer 2010 - The British Pain Society

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