Summer 2010 - The British Pain Society

More documents

Recommendations

Info

CHANGING PRACTICE A Personal Reflection on the British Pain Management Programme Society (SIG) Conference 2009 Dr Paul Wilkinson Consultant in Pain Management, Newcastle upon Tyne The Pain Management Programme held its 12th National SIG conference at Northumbria University in Newcastle upon Tyne. The title "Clearing the Fog on the Tyne” reflected not only the aims of the conference but also some nostalgia for the famous folk song from Lindisfarne, the band which, for many years, held Christmas concerts in Newcastle. As the Chair of the organising committee, I offer here a personal reflection of the conference. Although this meeting was many months ago the issues discussed continue to be both pertinent and topical. The aim is to provide a summary for the benefit of those who were unable to attend and serve as a reminder for some of those who did. Please note these are personal reflections and may reflect my own bias and memory! As well as focusing on core issues of pain management programmes, the conference attempted to consider issues allied to pain management programmes. In order to facilitate this, specialists in other fields were amongst those who were invited to help our understanding. Early Interventions in the Management for Chronic Pain The conference began with Professor Chris Main of Keele University talking about designing and implementing early psychosocial interventions. What was made clear during his talk is that there is now a high level of consensus about those factors which predict chronicity. High risk groups such as depression, anxiety, high levels of early disability, catastrophisation, fear avoidance and other pain morbidity predicted prognosis and can be screened for early. It is clear that properly tailoring and targeting early interventions within clinical trials is not trivial, especially ensuring that interventions have appropriately been carried out. Despite these problems there is now clear evidence for the benefit of early psychosocial interventions. There is a large, flourishing contemporary field of implementation science. This was probably news to many including myself. NICE Guidelines for Early Management of Persistent Low Back Pain We asked Professor Martin Underwood, Professor for Research at Warwick University to help us understand better the procedural elements of undertaking NICE guidelines. He was Chair of guidance published in 2009. Clearly these guidelines have been highly controversial. The guidelines are very procedurally driven and have to rigorously adhere to these procedures. Those involved expose themselves to considerable media and professional interest. Professor Underwood defined the scope of the guidelines which had initially been between 6 weeks to 6 months and not to 1 year. He outlined that referring to spinal surgeons but not referral to pain clinics was considered as part of the scope. He discussed the procedures and how the workings of the reference group operated. In order to illustrate the link between the conclusions and the evidence, he focused on the most controversial areas namely acupuncture and injection of therapeutic substances into the back. As we now know these issues are still the subject of much controversy and discussion at both NICE and the BPS ( see the joint letter published by NICE and the BPS in this issue). For interventional procedures this had only led to one low powered admissible study and in contrast, according to Professor Underwood, there were several recognised controlled studies for acupuncture. Another area which is the subject of much debate. Further discussions were undertaken about the nature and the validity of all the evidence presented in the document. Complex arguments about the nature of any evidence will no doubt continue. All at the meeting (including many from the BPS) will be proactive in ensuring the best care for all patients. Dr. David Walsh, Associate Professor in Rheumatology at Nottingham and Chair of the SIG highlighted that the NICE guidelines had recognised the benefits of physical and psychological treatment in people who display high disability or significant psychological distress early. This was obviously of great interest to all PMP SIG members. The CPP programme (combined physical and psychological programme) is recommended before the pain becomes permanent and before all treatment options have been exhausted. Successful CPP programmes require specialist multi-disciplinary input helped by CBT within group settings. Healthcare providers have an obligation to put NICE guidelines into practice but there was anxiety as to whether money for these interventions would come from existing funding or otherwise. Update on catastrophisation Professor Michael O'Sullivan from McGill University in Canada updated us on catastrophisation. A tour de force again! One particularly interesting fact out of many is that catastrophisation can carry a considerable amount of the variance in treatment during a trial. It has been shown in some trials that if the castastrophisers are included in the trials then the treatment appears not to work but if they are taken out the treatment does! Treatment resistance of catastrophisers needs to be considered carefully in the planning of care and specific interventions to minimise the consequences of 5 6 PAI N N E W S S U M M E R 2010
the catastrophisation. Another interesting element is the consequences of physicians who are catastrophisers on the assessment of pain. On the second day of the conference we focused on areas allied to pain management programmes titled "Never on a Pain Management Programme"… Sexual problems and impotence This was commenced by consideration of psychosocial aspects of pain by Dr. Ian Eardley discussing male impotence and erectile dysfunction while Professor Kevan Wylie considered sexual dysfunction more broadly. Dr. Eardley discussed communication issues and the confusion which occurred in clients differentiating orgasm, desire, erection and ejaculation. Problems with ejaculation can be treated medically with high levels of success. Intra-penile devices and prosthesis are much more rarely required. Men who have psychological contributory factors to erectile function may have suggestive features. These may include situational erection failure, the retention of early morning or masturbatory erections. Of relevance to us, selective serotonin reuptake inhibitors, tricyclic antidepressants and some anticonvulsants may lead to impotence as well as alcohol abuse and opioid abuse. Impotence is more common in obesity and it is also relevant that exercise is a protector. For me, the main messages were to be more proactive The British Pain Society’s Pain Management Programme Special Interest Group Clearing the fog… on the Tyne 12 th National Conference on Pain Management Programme 10 th & 11 th September 2009 Northumbria University - Newcastle upon Tyne in screening for impotence and to realise that appropriate treatments are often very effective. Professor Wylie focused on female psychosexual issues and pain. He discussed the organic, psychogenic, relational and social factors which may impact on sexual function. We realise that psycho-sexual problems are common in patients attending pain management programmes. We should all be mindful of the problem, ask more frequently about sex and facilitate patients to talk and deal with the boundaries. Pain management programme teams will have to decide how far along the ladder of care they wish to go. This care pathway may involve basic counselling, specific psycho-sexual work (body work including pelvic floor training and body awareness training), as well as behaviour and couple therapy. Because of the nature of some of these treatments, liaison with local psycho-sexual services will be important. At the end of these sessions I was left with a lingering memory that satisfaction with sex is highest in Nigeria and lowest in Japan (and perhaps surprisingly) France! Why? Unexplained pain, Chronic Fatigue syndrome, Irritable Bowel syndrome, Dorsal column stimulation Prevailing themes in Chronic Fatigue were explained by Mrs Sue Pemberton highlighting the considerable overlap and similarity between these conditions and chronic pain. In fact, the word pain could have replaced the word fatigue on some slides, since many aspects of assessment and management appeared similar. Vincent Dreary highlighted that patients with unexplained symptoms and pain are frequently labelled with prejudicial terms. A variety of other longstanding and allied psychological issues may coexist. Patients must be helped to make sense of the symptoms and assess their impact. CBT approaches were discussed including acceptance, commitment therapy and mindfulness. An excellent talk by Professor Peter Whorwell on irritable bowel syndrome (IBS) helped us understand this condition. Again there were many themes which made us feel we could be talking about patients with chronic pain. Most of the treatments used for IBS are focused on bowel management but one stood out, namely the evidence base for hypnosis in difficult cases. Peter Murphy talked about dorsal column stimulation and emphasised that the variability in outcome may result from various psychological factors. Historically patients waiting for major intervention such as dorsal column stimulation did not get onto a pain management programme. Patients can now attend pain management programmes either before dorsal column stimulation insertion or afterwards. Defining the priority of treatments cannot be grounded in strong evidence based medicine, but multi-disciplinary assessment and management plans remain pivotal. Medico legal cases An intriguing talk by Dr. Ian Yellowlees on medico-legal cases highlighted the current caution about placing patients on pain management programmes that had coexisting medico-legal cases. The central concern appeared to be that of financial disincentives to improve from a pain management programme. This view is currently not grounded on evidence. Wider studies in other interventions in patients with chronic pain provide mixed evidence that interventions are less effective with a medico-legal case ongoing. In charismatic style, Dr. Yellowlees made this a brief part of the talk because, though much was affirmed, little which was grounded in evidence. Dr. Yellowlees then switched to put the audience through the complexities of the legal process presenting a powerful view that rather than focusing on the issue of financial disincentives for improvement, the personal toll of legal cases on the individual should be the main consideration (e.g. pain behaviour, body vigilance and self worth to mention a few). He also made a few interesting observations about those businesses involved in the processing of medico legal complaints. Pain and addiction Dr. Freedman led a session on addiction and pain medication. Reducing and managing pain medicines are frequently a theme of pain management programmes and the time beyond. People with addiction problems have more pain problems statistically. In addition, many with pain can misuse medication and alcohol. Red flags for addiction such as prescription forgery, using non-prescribed medicines and even obtaining medicines from non medical sources represent extreme cases. While dependency can be defined as craving, continued and compulsive use (3c's), people can experience subtle problems with medicines and substances. Dr. Freedman recommended thinking very carefully about what the function of individual drugs were for patients. In summary, I hope some of these brief, highly selected, personal reflections are helpful to those that did not attend the conference or whose specialist interest lie in other areas and give an accurate flavour of the conference to those that did. Others may have taken away completely different key points of course! I would like to thank the University for hosting the conference, the members of the organisation committee and all the work which was done in the secretariat especially Ken Obbard. Finally, a lingering memory, for many was the Gateshead Millennium Bridge, the “winking eye bridge” which opened almost by a twist fate as we stood in front of it drinking wine at the Baltic Museum balcony. For those who like to plan well in advance, the next conference is in Bath in 2011. PAI PAI N N NNE E WS S S US PM RMI NE G R 2010 57
Page 1 and 2:
s u m m e r 2 0 1 0 pain news a pub
Page 3 and 4:
12 5 8 PAI N N E W S S U M M E R 20
Page 5 and 6: ecame squalid and violent. Opium wa
Page 7 and 8: is the National Pain Audit (http://
Page 9 and 10: The first licenced intranasal Fenta
Page 11 and 12: Breakthrough Cancer Pain (BTcP)* Fa
Page 13 and 14: PAI N N E W S S U M M E R 2010 13
Page 15 and 16: NEWS - ASM 2010 Citation for Profes
Page 17 and 18: NEWS - ASM 2010 NEWS - ASM 2010 A p
Page 19 and 20: Internationally the SIG is active w
Page 21 and 22: PAI N N E W S S U M M E R 2010 21
Page 23 and 24: Pain controlled Constipation restra
Page 25 and 26: will also be expected to produce an
Page 27 and 28: NEWS Napp Awards for Chronic Pain M
Page 29 and 30: i SAFE USE OF PAINKILLERS • When
Page 31 and 32: MultiGen RF Nerve Ablation Save Tim
Page 33 and 34: ® (tramadol) ONCE DAILY AT BEDTIME
Page 35 and 36: PRO-Diary® by A new electronic wri
Page 37 and 38: that is completely counter intuitiv
Page 39 and 40: advice in uncertain or complex case
Page 41 and 42: to carry out any treatment that a p
Page 43 and 44: I have to say that I can see no 'go
Page 45 and 46: PROFESSIONAL PERSPECTIVES Teaching
Page 47 and 48: Past Medical History This pain prob
Page 49 and 50: and “like having a blow torch on
Page 51 and 52: world, apart from someone who is ca
Page 53 and 54: the possession of narcotics. She pl
Page 55: was employed as this may have had a
Page 59 and 60: BOOK REVIEW Oral feeding difficulti
Page 61 and 62: 3 studies ( n=25,34,56) looked at t
Page 63 and 64: R E S E A R C H & D E V E L O P M E
show all

Summer 2010 - The British Pain Society

Create successful ePaper yourself

Delete template?

Save as template?