Dr Cathy Price

Solent NHS Trust

Southampton

UK

Where we were….

Where we are now…..

2002

Pain Service challenges SCOTLAND GUANDONG PROVINCE

Timeline – the ups and downs

2009 2010 2011 2012 2013 2014 2015

CMO report Pain: breaking through the barrier

MAKING PAIN COUNT

ask2Q’s

APPS

Pregabalin

POLICIES

CLINICAL PRACTICE

2015

Science: Development of Persistent Pain

When sex- and age- matched found 27% decrease in DLPFC and 11% loss in contralateral thalamus =

neurodegeneration?

Where chronic pain is managed in UK

0

10

20

30

40

50

60

70

Where chronic pain is

managed

Bedside

Pain clinic

Consulting room

Community

White KL et al, NEJM 1961

Green LA et al, NEJM, 2001

Smith BH, Thin air, 2009

Patients who are referred to a pain clinic have extremely poor quality of life scores (average EQ5D-3L of 0.4), high reliance on emergency care both of which are improved after attending specialist pain services (Price: National Pain Audit 2013)

Top 10 pain-related inpatient admissions over 1 year

44024

33027

24018

19932 19412

14828 14776

11674

8531 6440

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

50000

Chest pain,unspecified

Other andunspecifiedabdominal

pain

Painlocalized toother parts

of lowerabdomen

Other chestpain

Low backpain

Pain in joint Painlocalized to

upperabdomen

Precordialpain

Pain inLimb

Unspecified

Dorsalgia,unspecified

South East South Central South West Total South England

Dr Foster Data on Pain-related Inpatient Admissions (September 2011 to August 2012)

Those at high risk of admission Southampton using the adjusted clinical groups tool (RUB 3-5)

MSK disorders have significant co-morbidities – CVS/depression most

common; require careful meds management and multiple needs

Research

Effective Treatments for pain Neuropathic pain medication Medication Yoga/Tai Chi CBT for disability/distress Patient education Acupuncture, TNS Interventional pain

Steroid nerve injection Radiofrequency Spinal cord stimulation

Patient Centred Co-creation Support

Wagner’s chronic disease model 1998

Specialist support,

MOM /ACG

education./group

dynamics/peers

Skills/worklo

ad credit

registries/

“top 5%” Kaiser Model of

chronic disease

management 1999

Triage

Co-management with patients

Co-management with primary care

Co-management with hospital, community matrons Mental health teams

Patient characteristics Pain Single issue

High psychosocial risk factors:

TACKLE TO IMPROVE

Pain part of multi-morbidity presentation :KEEP SAFE

Use Startback or other risk assessment tools

Focus on increasing confidence to self manage -social barriers -brief psychological interventions - Good access to information

Focus on reducing tablet load Support Patient safety - eg reablement services

Resources and Policies

Procedures of Limited Clinical Value

• Facet injections • Acupuncture

PRESCRIBING GUIDANCE

LOCAL RESOURCE FOLDERS

Staff Training Shared decision making

Training of staff in relational empathy and AHP/nurse in independent practice

Development of decision support aids

Specialist Educator Role

Opioid audits

Tutorials

Virtual clinics

GP educational needs survey

http://www.gptutorials.org.uk/

Self management support

http://www.healthtalk.org/peoples-experiences/chronic-health-issues/chronic-pain/nhs-pain-management-programmes Co-creation of health

Secondary Prevention and Identification of Risk of poor outcome from pan persistence

StarTBack

ASK2Questions: Faculty of Pain Medicine Over the past two weeks has pain been bad enough to interfere with your day to day

activities?

Over the past two weeks have you felt worried or low in mood because of this pain?

Cf Orebro Yellow Flag questionnaire

Trained Physiotherapists Videos/Leaflets for low risk patients CBT for higehr

Applying the chronic care model – Clinical Information systems

An integrated system Care plans

Joined to primary and secondary care

Advice /Signposting

33%

CBT self management

19%

Medical/rehab/support

48%

Outcomes from Referrals

ALL OFFERED PATIENT EDUCATION

Health Outcomes – Southampton Model of Care Specialist pain Qualitative Research

“Chaos into Order” Consistent messages

Opportunity to try treatments

Quantitative Research

Brief Pain Inventory: 66% small NS change

Pain Self efficacy significantly increased

44% increased self efficacy

A Case of OXYCODONE waste

April 2014 3 years worth

PRIMARY CARE PRESCRIBING Regular paracetamol (1g qds) taken as baseline analgesic before

dihydrocodeine initiation 48% achieved

Dihydrocodeine prescribed as a first-line opioid before tramadol initiation 22% achieved (NB Co-drugs were not included)

Oxycodone prescribed for severe persistent pain only when side effects to morphine are intolerable 31% achieved

Where oxycodone indicated, MR is prescribed 75% achieved

Tapentadol prescribed only after pain specialist recommendation 100% achieved

Hospital and Primary Care AUDITS - Southampton

Discharge plan 15%

Inpatient pain plan

22%

Died 12%

Care plan with

multidisciplinary

meeting 8%

Pain Clinic outpatient

s 15%

Referral to liaison

psychiatry team 25%

Social worker referral

3%

Inpatient Audit Outcomes

OXYCODONE

Variation per practice

UK- Outcomes of Care delivery – 3 key Patient Reported Outcomes

Key processes of care are not accessible to a significant number

0% 20% 40% 60% 80% 100%

Quality of Advice Offerred

Involvement in planning care

Help to understand condition Y N

Excellent/good

Excellent/good

Satisfactory

Satisfactory

Poor

Poor

Measures of empathy SURE

Most have multimorbidity

KEY MESSAGES Use the evidence base for

Systems management

Treatments

Understand the population needs

pain issues

Conditions seen (>1)

Train staff to understand these

Design systems to manage

Relentless Audit!

THANKS! – It’s a team effort…

Bibliography Blyth FM, March LM, Benabic AJM, Cousins MJ. (2004). Chronic pain and

frequent use of health care. Pain 11: 51-8 Tracey I, Bushnell CM. How Neuroimaging Studies Have Challenged Us to

Rethink: Is Chronic Pain a Disease? The Journal of Pain. 2009;10: 1113-1120 Torrance N et al. Severe chronic pain is associated with increased 10 year

mortality. A cohort record linkage study. European Journal of Pain Valet M, Gundel H, Sprenger T, et al. (2009). Patients with pain disorder show

gray matter loss in pain processing structures: a voxel based morphometric study. Psychosomatic Medicine 71: 49-56

Chief Medical Officer’s report: Pain breaking through the barrier: 150th annual report of the Chief Medical Officer. Department of Health 2009.

Elliott AM, Smith BH, Hannaford PC, et al. The course of chronic pain in the community: results of a 4-year follow-up study. Pain 2002;99:299–307.

Wong WS, Fielding R. J Pain 2011;12(2):236-245 Wang, H. H., Wang, J. J., Wong, S. Y.S., Wong, M. C.S., Li, F. J., Wang, P. X.,

Zhou, Z. H., Zhu, C. Y., Griffiths, S. M., and Mercer, S. W. (2014) Epidemiology of multimorbidity in China and implications for the healthcare system: crosssectional survey among 162,464 community household residents in southern China. BMC Medicine, 12 (188). ISSN 1741-7015

Wallace E, Salisbury C, Guthrie B, Lewis C, Fahey T, Smith SM. BMJ. 2015 Jan 20;350:h176. doi: 10.1136/bmj.h176.