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Australian Story.Dr Penny Briscoe.Pain Management Unit RAH.

Origin of Pain Clinics• WW II John Bonica interested management highvelocity injuries.• 1 st multidisciplinary clinic Tacoma Washington stateUSA 1946.• 1954 talked at Royal Society of Medicine in London reMultidisciplinary Pain Clinics.• 1960 – Multidisciplinary Clinic University ofWashington, Seattle.• Psychologists, surgeons, physicians, and others.• 1962 - St Vincents Sydney multidisciplinary clinic.• RT’s, Neurosurgeon, neurologist, psychiatrist,anaesthetist

Brian Dwyer and theSt Vincent's Pain Clinic 1962 to 1989D B GIBB.A&IC: 2006: 34: SUP 1: 16-21

Origin of Pain Clinics• During 1 st half 20 th century considerable interestrelieving pain by use neural blocks.• 1930’s Nerve Block clinic first appeared.• Because skills – anaesthetists became involved.• Brian Dwyer St Vincent's 1955 – relief cancer pain:• Neurolytic pancreatic block.• Intrathecal neurolytic block.

Origin of Pain Clinics• By 1950’s inadequacies of “nerve block” clinics hadbecome apparent.• Papper recognised chronic pain was a disease.• Initially anaesthetists acted simply as technicians.CARRON H: HISTORY OF PAIN CLINICS AND PAIN CENTRES:2 ND SYMPOSIUM ON REGIONAL ANAESTHESIA: 1988: 38-40

The Pain Clinic:A clinic for the management ofintractable pain:McEwen B, de Wilde F, Dwyer B:MJA : 8 th May 1965: 1: 676-682

Report MJA May 8 th 1965Authors:• McEwen, deWilde: Radiotherapy.• Dwyer:Anaesthesia.• Woodforde: Psychiatry• Bleasel, Connelley: Neurosurgery.• August 1962 – April 1964 – 107 patients.• Established to allow combined opinions.• Group management should not replace GP.• For these patients need sympathy & understanding

Report MJA May 8 th 1965“Finally it is axiomatic that pain can be safely treatedas a symptom only when the underlying cause isknown and when all treatment directed towardsthis has been completed.”

MJA 8 th May 1965• 107 patients over 2 years.• 68% malignant disease.• 15% neuralgias.• 57% “cured” or good pain relief.• 34% no better or worse.• 9% no results available

MJA 8 th May 1965• 107 patients over 2 years.• Attempts to restrict to pts who would benefit.• No acceptance unless appropriate treatment tried.• Pain clinic not diagnostic – Panel of Review.• Initially treatments physically based – but results variable.• By 1980’s – treatments psychologically based.• John Woodforde / Brian Dwyer served 27 years.

Dealing patients intractable pain isdifficult work, frequently frustratingand financially unrewarding.It needs a leader of exceptionalabilities to guarantee viability andcontinuity of such a service.

Pain Clinics in Sydney• St Vincents – Brian Dywer 1962-1989• The Sydney Hospital – Fred Berry mid 1960’s• Royal North Shore 1970’s – Ted Morgan• Westmead Peter Cox - 1978• Prince Alfred John Ditton - 1970’s

Pain Clinics in Adelaide• Queen Elizabeth Hospital 1961-1985• Royal Adelaide Hospital 1972- current• Flinders Medical Centre 1976- current• Memorial Hospital 1979-• Ashford Hospital 1984-

Origin of Pain Clinics• QUEEN ELIZABETH HOSPITAL ADELAIDE.• 1961 MULTIDISCIPLINARY CLINIC• Simpson – Neurosurgeon• Saunders – Anaesthetist.• Rischbieth - Neurologist• Cramond - Psychiatrist• Burnell – Rehab Medicine• Rees – Anaesthetist.

Report MJA May 8 th 1965• “pain remains an exquisitely lonely phenomenon,which …purely subjective experience”• Pt assessed by 3 members team• GP invited Team meeting.• Advantages Pain Clinic:• Direct - ↑ pts referred• Indirect – improve staff attitudes to pts.• Increased referral to psychiatry.• Allow specialists to make meaningful contact.

Report MJA May 8 th 1965• “Clinic in operation 18 months• Results first 58 cases:• Pain Free 10• Marked improvement 12• Slight improvement 13• No change 22• Still under treatment 120 cases considered “purely psychiatric”– successful outcome very modest.

Report MJA May 8 th 1965Advantages:• Combination treatments – physical, psychologicaland administration appropriate antidepressant /muscle relaxant drugs – rewarding.• Neurosurgeon who is trained to operate has beenable to resist, with support team.• Neurologist – clinic provided valuable insightsimportance personality factors/ depression, even ifpain appears entirely organic.

Pain clinics in Qld.1967 due to her interest in Cancer pain,Prof Tess Cramondestablished the Multidisciplinary Pain Centreat the Royal Brisbane Hospital.She remained Director of this unit until herretirement in 2009.

Pain Clinics in Queensland• Royal Brisbane 1972 -• Princess Alexandra 1979 -• Axxon 2001 -

Pain Clinics in Melbourne• Graham Burrow• Terry Little• George Mendelson• Russell Cole @ Peter MacCallum• La Trobe - Peck

Pain Clinics in Western Australia• Sir Charles Gairdner – Giles / Vaughan• Royal Perth Hospital

Pain Clinics in NZ• Auckland - Bob Boas – 1972• David Jones contact with him 1973.• Clinic Dunedin (Michael Roberts – 1974).• David started working Dunedin 1979.– Mike Roberts / Steuart Henderson.

Pain: 1982: 12: 365.• Rapid growth in number Pain Clinics since conceptmultidisciplinary approach 1 st introduced.• Early clinics recognised importance psychologicalaspects – focused on physical treatments.• Increasing awareness personality / psychologicalfactors lead inpatient units to modify behaviour.

FMC Pain Management Unit• Professor MJ Cousins 1976-1991• C. Glynn Co-ordinator 1977-80• P. Wilson Director 1980-82• D. Cherry Director 1982- 2008• D. Kapur Director 2008 -• L.Mather Unit Scientist 1976-91• GK Gourlay Unit Scientist 1979 - 2008

Australian and New ZealandPain Meetings.

1 st Australian / New ZealandConference on Pain 1978• 47 abstracts.• 2 Overseas speakers.• Topics basic research through to bedside.• Well known names including Duggan, PeterWilson, Bob Boas, Mendelson, Ditton, Pilowsky,Peck and Bogduk

FPMANZCA.

FPMANZCA• 1994 Working party – Pain Management AdvisoryCommittee ANZCA – chaired John Gibbs.• 1995 Joint Advisory Committee in Pain Medicine –RACS, RACP, RANZCP, AFRM (RACP), ANZCA – developtraining for Certificate in Pain Medicine.• Graham Rice, Ben Marazceky, Terry Little, LeighAtkinson, Richard Chye, Bruce Rounsefell, Roger Goucke• 1998 Council ANZCA – Interim Faculty Board• 02-10-1998 – ANZCA Council - approval RegulationsFaculty Board.• 23-11-1998 – inaugural teleconference

FPMANZCA• 04-02-1999 : Foundation Fellows FPMANZCA (10).• 1 ST face to face Inaugural Board.• Presentation Foundation Fellows (37) May Adelaide1999• 1 st assessment training Dr Eric Parisod (Geneva) 1999.• 1999 Nov - 1 st Examination RNSH.• Feb 2000 – 1 st Faculty Election.• May 2000 – 1 st Elected Faculty Board

FPMANZCASince then:• 6 Deans• 291 Fellows• 129 by Examination.November 2005 Pain Medicine recognised by AMC asMedical Speciality.2 nd country in world to have Pain Medicine recognised

National Pain Strategy.Pain Management for all Australians.www.painsummit.org.au

National Pain Strategy.First comprehensive initiativein Australia (and worldwide)which sets outto improve assessment and treatmentof all forms of pain.

National Pain Strategy.Mission:To improve quality of lifefor people with pain & their families,and to minimisethe burden of pain on individuals & thecommunity

National Pain Strategy.Unacceptable 50% cancer patients and patients followingsurgery and trauma unable to receive effective painrelief.The burden of pain is huge – in humanitarian, health careand financial terms.Pain is Australia's third most costly health problem.MICHAEL COUSINS 2010

National Pain Summit.11.3.2010End result 15 months work involving multidisciplinarySteering Committee, Working Groups and ReferenceGroups, consultations with industry, a Leaders meetingin Sept 2009, fact finding visits O/S.• 150 organizations working together.• Health professionals /consumers / industry / funders• 200 representatives attended the Summit.

MISSIONS / GOALS / PRIORITY NPSGOAL 1:People in pain as national health priority.Establish National BodyDestigmatise the predicamentAchieve federal / state recognition.

MISSIONS / GOALS / PRIORITY NPSGOAL 2:Knowledgeable,empowered /supported consumers.Improve community understanding & best practise.Provide easily accessible information and supportprograms

MISSIONS / GOALS / PRIORITY NPSGOAL 3:Skilled professionals / best practice care.Train & support health practitioners.Establish & promote systems & guidelines to ensureadequate management

MISSIONS / GOALS / PRIORITY NPSGOAL 4:Access to interdisciplinary care at all levels.Develop & evaluate patient centred service deliveryEnsure meaningful communication about painmanagement between practitioners

MISSIONS / GOALS / PRIORITY NPSGOAL 5:Quality improvement and evaluation.Ensure quality use of medication for pain managementImprove standards by developing national benchmarking.

MISSIONS / GOALS / PRIORITY NPSGOAL 6:Research .Enable pain research at a national level.Identify information gaps underpinningall National Pain Strategy objectives.

NATIONAL PAIN STRATEGYEXECUTIVE.13 TH July 2010

National Pain Strategy Executive.• Michael Cousins• Lesley Brydon• Stephen Gibson• Penny Briscoe• Milton Cohen• Stephen Leow• Mark Goodsell• Coralie Wales• John Daye• Dianna AspinallChair.NPS Executive DirectorAPSFPM / ANZCARACPRACGPAIGCPACHFArthritis NSW

National Pain Strategy Executive.• Establish a national advocacy body for pain.• Entity structure and constitution.• Membership.• Funding and Endorsements of NPS.• Board composition.• Name (distinctive) and logo.

National Pain Strategy Executive.Biggest Challenges:• Intellectual property.• Advocacy.• National Fundraising.

PAIN RELIEF –A Basic Human Right!M J COUSINS, F BRENNAN: PAIN: 2004: 112: 1-4

Appropriate Pain Managementshould bea fundamental Human Right,limited onlyby our capacityto provide pain reliefin a safe and effective manner.

PAINAS THE 5 THVITAL SIGN.Already USA & Canada.

↑ access.↓ waiting times.↑ pt, GP & Specialist educ.Research

painaustraliaworking to prevent and manage pain

Patients in pain consult:1. GP’s2. Physiotherapists3. Pharmacists.

Patients in pain :1. Condition not recognised.2. Family / friends / colleagues / employers do notbelieve they are in pain.3. Wait more 12 months for appointment.4. Health professionals not trained / educated.5. Little access to community support.6. ↓ work – unemployment / impoverished

Patients in pain :Increased risk:depressionanxietydeconditioningpoor self esteemsocial isolationrelationship breakdown

OUTCOMES:• Raise awareness - Burden.• De-stigmatise.• Up skill all health professionals.• Widespread education / information forconsumers, public, employers and healthprofessionals.• TV, web, printed materials, billboards etc.

OUTCOMES:• Raise awareness –• Incidence• Impact individual.• Impact families.• Impact community.

OUTCOMES:• Support for patients / carers:• Phone support from consumer groups• Phone support professionals.• Easy access to educational literature.• Community based training programs.• Prepare, plan & train educators.

OUTCOMES:• Better access for patients to psychologists,mental health teams.• Better access to physical therapy.• Improve Medicare funding GP’s for longconsultations.• Reverse inequities of PBS:• opioids available / gababinoids are not!

Steering Committee• Multidisciplinary medical• Allied health professionals.• FPM / APS.• Consumers• Industry• Pharma.