persistent pain & pain interventions

Persistent Pain & Persistent Pain & Pain InterventionsPain InterventionsPersistent Pain & Persistent Pain & Pain InterventionsPain Interventions

Dr Heide FeberweeDr Heide FeberweePain SpecialistPain Specialist

Specialist AnaesthetistSpecialist Anaesthetist

Dr Heide FeberweeDr Heide FeberweePain SpecialistPain Specialist

Specialist AnaesthetistSpecialist Anaesthetist

Persistent PainPersistent PainPersistent PainPersistent Pain

Pain present for more than 3 months.Pain present for more than 3 months.

Persistent Pain is a chronic disease.Persistent Pain is a chronic disease.

Associated with anatomical changes in the Associated with anatomical changes in the body.body.

Affects 20% of the population (3.5 M).Affects 20% of the population (3.5 M).

High utilization of healthcare resources.High utilization of healthcare resources.

Labour intensive.Labour intensive.

Persistent PainPersistent PainPersistent PainPersistent Pain

Managing pain is a long term process like all Managing pain is a long term process like all chronic diseases.chronic diseases.

Patients often have flare ups & multiple sites of Patients often have flare ups & multiple sites of pain.pain.

Often associated with complex medical and Often associated with complex medical and psychosocial history.psychosocial history.

Patient and healthcare practitioner distress is Patient and healthcare practitioner distress is common.common.

Managing long term pain and having strategies Managing long term pain and having strategies to deal with flare ups are important.to deal with flare ups are important.

ApproachApproachApproachApproachMultidisciplinary team approach important in Multidisciplinary team approach important in

dealing with all aspects of patient care.dealing with all aspects of patient care.

Pain specialists, Psychiatrists, Neurosurgeons, Pain specialists, Psychiatrists, Neurosurgeons,

Rehabilitation Specialists, Practice Nurse, Rehabilitation Specialists, Practice Nurse,

Psychologists, Physiotherapists, Occupational Psychologists, Physiotherapists, Occupational

therapists worth considering.therapists worth considering.

Palliative Care for terminal patients.Palliative Care for terminal patients.

Group sessions including Pain Management Group sessions including Pain Management

Program, hydrotherapy, mindfulness stress Program, hydrotherapy, mindfulness stress

based reduction.based reduction.

Role of Pain Role of Pain SpecialistSpecialist


Specialist with the Faculty of Pain Medicine Specialist with the Faculty of Pain Medicine ANZCA (FFPMANZCA).ANZCA (FFPMANZCA).

Already a specialist in another field e.g. Already a specialist in another field e.g. Anaesthesia, Psychiatry, Addiction Specialists, Anaesthesia, Psychiatry, Addiction Specialists, Rehabilitation Medicine, General Practitioners etc. Rehabilitation Medicine, General Practitioners etc. who are further trained in Pain Medicine (extra 1-who are further trained in Pain Medicine (extra 1-2 years plus exam at an accredited 2 years plus exam at an accredited multidisciplinary Pain Management unit).multidisciplinary Pain Management unit).

Biopsychosocial approach to pain management.Biopsychosocial approach to pain management.

Consultation looks at full pain history, treatment Consultation looks at full pain history, treatment history, psychological and social issues.history, psychological and social issues.



Physical exam directed specifically at areas of pain Physical exam directed specifically at areas of pain and aspects thereof that may be targeted with and aspects thereof that may be targeted with treatment.treatment.

Screening for ‘Screening for ‘red flagred flag’ conditions – serious conditions ’ conditions – serious conditions that has significant morbidity.that has significant morbidity.

Comprehensive report and possible management Comprehensive report and possible management strategies outlined.strategies outlined.

Further investigations ordered / suggested as needed.Further investigations ordered / suggested as needed.

Pain condition discussed with patient & questions Pain condition discussed with patient & questions answered.answered.



Advice on drug management including complex Advice on drug management including complex opioid related issues (some may be DDU opioid related issues (some may be DDU directed).directed).

Depending on skill set & interest some acquire Depending on skill set & interest some acquire Pain Interventional management skills.Pain Interventional management skills.

Diagnostic & therapeutic Interventional Diagnostic & therapeutic Interventional procedures can be offered. procedures can be offered.

Referrals with adequate information including Referrals with adequate information including previous specialist reviews and results previous specialist reviews and results (laboratory, radiology etc.) useful.(laboratory, radiology etc.) useful.



• Patients with pure addiction problems should Patients with pure addiction problems should see also be referred to ATODS / Addiction see also be referred to ATODS / Addiction Specialist.Specialist.

• Active suicidal patients & psychosis should be Active suicidal patients & psychosis should be treated as per normal guidelines first.treated as per normal guidelines first.

• Workcover can occasionally complicate Workcover can occasionally complicate treatment if ongoing claims / litigation.treatment if ongoing claims / litigation.

• Look at non-pharmacological, pharmacological Look at non-pharmacological, pharmacological and interventional aspects of pain management.and interventional aspects of pain management.

Red flagsRed flagsRed flagsRed flags

High acuity casesHigh acuity casesHigh acuity casesHigh acuity cases

Complex Regional Pain Syndrome (CRPS).Complex Regional Pain Syndrome (CRPS).

CA pain, especially with limited life expectancy.CA pain, especially with limited life expectancy.

Adolescents & parents looking after young Adolescents & parents looking after young

children.children.

Threatened loss of employment.Threatened loss of employment.

Consideration for severe psychological impact Consideration for severe psychological impact

of pain.of pain.

CRPSCRPSCRPSCRPS

• Complex Regional Pain Syndrome.Complex Regional Pain Syndrome.

• Debilitating syndrome with sudden onset, can Debilitating syndrome with sudden onset, can

be after major (type 2) or minor trauma (type 1).be after major (type 2) or minor trauma (type 1).

• Swelling / sweating, colour changes, sensory Swelling / sweating, colour changes, sensory

(pain), motor dysfunction / atrophy.(pain), motor dysfunction / atrophy.

• Need signs and symptoms in all categories.Need signs and symptoms in all categories.

• Timely (early) treatment has best outcome.Timely (early) treatment has best outcome.

CRPS handCRPS handCRPS handCRPS hand

CRPS footCRPS footCRPS footCRPS foot

Thermal imaging Thermal imaging CRPSCRPS

Thermal imaging Thermal imaging CRPSCRPS

Interventions for Interventions for CRPSCRPS

Interventions for Interventions for CRPSCRPS

• Depending limb affected, different types of Depending limb affected, different types of sympathetic blocks can be offered – stellate sympathetic blocks can be offered – stellate ganglion blocks, brachial plexus blocks, lumbar ganglion blocks, brachial plexus blocks, lumbar sympathectomies, ankle blocks.sympathectomies, ankle blocks.

• Normally done as a series of 5 procedures.Normally done as a series of 5 procedures.

• Physiotherapy critical in keeping limb moving.Physiotherapy critical in keeping limb moving.

• Procedure provides window of opportunity for Procedure provides window of opportunity for patient to engage in active therapy. patient to engage in active therapy.

Chronic Back PainChronic Back PainChronic Back PainChronic Back Pain

• Very common.Very common.

• Often multiple causes contributing to pain.Often multiple causes contributing to pain.

• May be recent onset or long standing.May be recent onset or long standing.

• Surgery may not be indicated or pain may Surgery may not be indicated or pain may

be ongoing after surgery.be ongoing after surgery.

• May be associated with radicular pain.May be associated with radicular pain.


• Significant relationship between gender, Significant relationship between gender, age, BMI & structural causes of CLBP.age, BMI & structural causes of CLBP.

• Lumbar internal disc disruption is more Lumbar internal disc disruption is more common in young males while facet joint common in young males while facet joint pain is more common in females with pain is more common in females with increased BMI.increased BMI.

• Female gender and low BMI is associated Female gender and low BMI is associated with sacroiliac joint pain.with sacroiliac joint pain.

Multivariable Analyses of the relationship between age, gender and body mass Multivariable Analyses of the relationship between age, gender and body mass index and the source of chronic low back pain. De Palma et al. Pain Medicine index and the source of chronic low back pain. De Palma et al. Pain Medicine

2012;13:498-506.2012;13:498-506.

Chronic Back PainChronic Back PainChronic Back PainChronic Back Pain• Young adult (20-35) internal disc disruption (IDD) most likely Young adult (20-35) internal disc disruption (IDD) most likely

source of pain (70-98%), regardless age or gender.source of pain (70-98%), regardless age or gender.

• Over age 50, IDD is the most likely source (40-65%) except Over age 50, IDD is the most likely source (40-65%) except for females with low BMI (<18.5) where SIJ pain is more likely for females with low BMI (<18.5) where SIJ pain is more likely (49%).(49%).

• Males > 65 facet joint pain is most likely (30-54%), regardless Males > 65 facet joint pain is most likely (30-54%), regardless BMI.BMI.

• Females > 65 FJP most likely (46-57%) when BMI 30-35 & SIJ Females > 65 FJP most likely (46-57%) when BMI 30-35 & SIJ pain more likely when BMI <25.pain more likely when BMI <25.

• Males > 80 have other sources of CLBP (47-53%) when BMI Males > 80 have other sources of CLBP (47-53%) when BMI <30 & FJP (49%) when BMI >35.<30 & FJP (49%) when BMI >35.

• Females >80 had SIJP (45-62%) when BMI <25 & FJP (47-Females >80 had SIJP (45-62%) when BMI <25 & FJP (47-58%) when BMI >30.58%) when BMI >30.Multivariable Analyses of the relationship between age, gender and body mass index and the Multivariable Analyses of the relationship between age, gender and body mass index and the

source of chronic low back pain. De Palma et al. Pain Medicine 2012;13:498-source of chronic low back pain. De Palma et al. Pain Medicine 2012;13:498-506.506.


• Need to exclude ‘Need to exclude ‘red flagsred flags’.’.

• Radiological appearance may not coincide Radiological appearance may not coincide with area of pain.with area of pain.

• Need clinical examination to ascertain Need clinical examination to ascertain pain contributors.pain contributors.

• Facet joint & Sacroiliac joint common Facet joint & Sacroiliac joint common causes for pain.causes for pain.

Facet jointsFacet jointsFacet jointsFacet joints


• Other causes include cluneal nerve neuropathy, Other causes include cluneal nerve neuropathy, piriformis syndrome, greater trochanter bursitis.piriformis syndrome, greater trochanter bursitis.

• Diagnostic followed by therapeutic procedures Diagnostic followed by therapeutic procedures possible for these.possible for these.

• Often trial injections followed by radiofrequency Often trial injections followed by radiofrequency neurotomies done.neurotomies done.

• Caudal epidural / lumbar epidural with local Caudal epidural / lumbar epidural with local anaesthetic and steroid may be useful.anaesthetic and steroid may be useful.

RF neurotomy facet RF neurotomy facet joint nervesjoint nerves

RF neurotomy facet RF neurotomy facet joint nervesjoint nerves

Radiofrequency Radiofrequency neurotomies FJsneurotomies FJsRadiofrequency Radiofrequency neurotomies FJsneurotomies FJs

RF FJ & SIJRF FJ & SIJRF FJ & SIJRF FJ & SIJ

Cluneal nerveCluneal nerveCluneal nerveCluneal nerve

Spinal Cord Spinal Cord StimulatorsStimulatorsSpinal Cord Spinal Cord StimulatorsStimulators

• Has a place for especially chronic back Has a place for especially chronic back pain post surgery.pain post surgery.

• Specific guidelines for usage.Specific guidelines for usage.

• Conservative management strategies Conservative management strategies exhausted.exhausted.

• Normally trial done followed by permanent Normally trial done followed by permanent implant.implant.

Spinal Cord Spinal Cord StimulatorsStimulatorsSpinal Cord Spinal Cord StimulatorsStimulators

Head & Neck PainHead & Neck PainHead & Neck PainHead & Neck Pain

• Many causes for headaches.Many causes for headaches.

• Drug management needs optimization.Drug management needs optimization.

• Interventions can be done for Greater Interventions can be done for Greater

Occipital Nerve neuralgia, Cervical facet Occipital Nerve neuralgia, Cervical facet

joint disease.joint disease.

• Trial injections followed by RF.Trial injections followed by RF.

• Advice on drug management.Advice on drug management.

Shoulder PainShoulder PainShoulder PainShoulder Pain

• Very common.Very common.

• Possible to treat most causes of shoulder pain, Possible to treat most causes of shoulder pain,

before & after surgery & where not indicated.before & after surgery & where not indicated.

• Frozen shoulder syndrome common & overuse Frozen shoulder syndrome common & overuse

e.g. wheelchair bound spinal injury patients.e.g. wheelchair bound spinal injury patients.

• Trial suprascapular nerve block followed by RF.Trial suprascapular nerve block followed by RF.

Suprascapular nerve Suprascapular nerve blockblock

Suprascapular nerve Suprascapular nerve blockblock

Other PainsOther PainsOther PainsOther Pains

• Can do scar injections post procedures, Can do scar injections post procedures, especially with neuropathic pain post caesarean especially with neuropathic pain post caesarean sections / hysterectomy, mastectomy scar pain sections / hysterectomy, mastectomy scar pain etc.etc.

• Neuroma injection for amputees.Neuroma injection for amputees.

• Intercostal nerve Phenol injections for infiltrating Intercostal nerve Phenol injections for infiltrating chest wall tumours (palliative care).chest wall tumours (palliative care).

• Many others directed at specific conditions Many others directed at specific conditions including knee joint injections.including knee joint injections.

Pharmacological Pharmacological treatmenttreatment

Pharmacological Pharmacological treatmenttreatment

Drug treatmentsDrug treatmentsDrug treatmentsDrug treatments

ParacetamolNSAIDsTramadolOpioids / Mor-NRIAntidepressantsAnticonvulsants – Pregabalin / GabapentinNMDA antagonists

OpioidsOpioidsOpioidsOpioids

• Schedule 8 drugs.Schedule 8 drugs.

• Regulatory requirements as drugs of abuse / Regulatory requirements as drugs of abuse /

addiction.addiction.

• DDU oversees prescribing in QLD.DDU oversees prescribing in QLD.

• Need to have a single opioid prescriber (GP).Need to have a single opioid prescriber (GP).

• Consider opioid contract even for trial.Consider opioid contract even for trial.

• Universal precautions & opioid risk screening tool.Universal precautions & opioid risk screening tool.

Opioid potency - Opioid potency - OMEDOMED

Opioid potency - Opioid potency - OMEDOMED

• OMED = Oral Morphine Equivalent DoseOMED = Oral Morphine Equivalent Dose

• 10mg Oxycodone = 20mg Morphine10mg Oxycodone = 20mg Morphine

• 10mg Methadone = 70-140mg Morphine10mg Methadone = 70-140mg Morphine

• 8mg Hydromorphone = 40mg Morphine8mg Hydromorphone = 40mg Morphine

• 12mcg/hr Fentanyl patch = 40mg Morphine12mcg/hr Fentanyl patch = 40mg Morphine

• 5-20mcg/hr Buprenorphine patch = 10-50mg Morphine (up to 5-20mcg/hr Buprenorphine patch = 10-50mg Morphine (up to 90mg)90mg)

• 100mg Tapentadol = 40mg Morphine100mg Tapentadol = 40mg Morphine

• Dose above OMED 90 - 120mg per day considered high dose.Dose above OMED 90 - 120mg per day considered high dose.

Universal Universal precautionsprecautionsUniversal Universal

precautionsprecautions1.1. Diagnosis with appropriate DDx.Diagnosis with appropriate DDx.

2.2. Psychological assessment incl. addiction Psychological assessment incl. addiction

risk.risk.

3.3. Informed consent.Informed consent.

4.4. Treatment agreement.Treatment agreement.

5.5. Pre & post interventional assessment of Pre & post interventional assessment of

pain & level of Fx.pain & level of Fx.

Universal Universal precautionsprecautionsUniversal Universal

precautionsprecautions6.6. Appropriate trial of Rx & adjuncts.Appropriate trial of Rx & adjuncts.

7.7. Reassessment pain score & Fx.Reassessment pain score & Fx.

8.8. Regularly assess the 4 A’s.Regularly assess the 4 A’s.

9.9. Periodically review Pain Dx & Periodically review Pain Dx &

comorbidities incl. addiction disorders.comorbidities incl. addiction disorders.

10.10. Documentation.Documentation.

ConclusionConclusionConclusionConclusion

• Multiple sites of pain can be targeted.Multiple sites of pain can be targeted.

• Need to address other aspects of patient Need to address other aspects of patient

care, including drug management, care, including drug management,

psychological stressors and social issues.psychological stressors and social issues.

• Team of healthcare practitioners useful to Team of healthcare practitioners useful to

reduce burden of care.reduce burden of care.

Questions ? Questions ? Questions ? Questions ?

persistent pain & pain interventions

Documents

pain history

sensory pain

areas of pain

pain condition

pain management program

role of pain specialistadvice

persistent painmanaging

long term pain