Sammi: Good evening everybody and welcome to this evening’s twilight online Managing Chronic Pain in General Practice webinar. My name is Samantha and I am you host for this evening. Before we get started I would just like to make a quick Acknowledgement of Country. We recognise the traditional custodians of the land and sea on which we live and work. So before we jump in, I just want to take you through our learning outcomes for this evening. So by the end of this evening’s webinar, we hope that you will have a better understanding and be able to discuss the epidemiology and neuroscience of chronic pain, be able to list the benefits and harms of prescribing opioids and develop strategies for de-prescribing opioids, discuss multimodal alternatives to pharmacological management of chronic pain and manage common complicating aspects of chronic pain like mental health, sleep difficulties and dependency.
In saying that, I would like to introduce our presenters for tonight. So we are joined tonight by Dr Simon Holliday and Dr Chris Hayes. So, Simon is a rural GP and Staff Specialist addiction physician in Taree New South Wales, and Chris is a specialist pain physician, Director of the Hunter New England Integrated Pain Service and Dean at the Faculty of Pain Medicine. So, welcome Simon and Chris and thank you for joining us tonight.
Simon: Thanks Sammi and g’day everybody.
Sammi: No problem. And that means that now I will hand over to Simon to begin the presentation for this evening.
Simon: Right. G’day. As you all know, we are swamped with chronic pain conversations and pain in general. It might be acute. It might be to do with palliative care. One study in the United States showed that almost half of all consultations included pain, but it was usually not raised as the first topic. It was usually raised as the third or fourth topic. You know just a script after the diabetes or depression or blood pressure were dealt with. But if you do a community study, it is suggested that almost 20% of adult Australians experienced three months of moderate to severe pain in the last six months. But if you ask a general survey, it’s almost two thirds of Australians have had some pain in the last month, so that is why we are dealing with pain all the time. And how you manage pain is a very important clinical culture which we need to be discussing today as there have been some fairly major swings in this area.
Chris: Chris Hayes coming in now. Hello to everyone. So as Simon has pointed out, chronic pain is common. Many GP consultations involve chronic pain and the overall prevalence figure in Australia like the rest of the world sits around that 20% of the population figure. So common, and yet we do not consistently treat pain well across Australia. There is substantial clinical variation and one of the points of change that we need I think to address better spins off the underlying neuroscience. So the next few slides relate to that and when you start to look at the role of the brain and the nervous system as opposed to structural change in the tissues in the body, the noteworthy finding is that the experience of chronic pain relates better with change on functional brain imaging than it does with say a structural scan of the body. And so when you look at a brain scan of someone with chronic pain, you see in the top row there, that some of the expected areas of the brain light up consistently, the sensory cortex and motor cortex related to that. And then in the bottom row below that, that chronic pain also involves activation of the limbic system, the emotional area and some of the cognitive regulating areas such as the medial prefrontal cortex which can have a role in in damping down activity in the lower brain region. So that puts in perspective the next slide, and why we are thinking a little differently than Rene Descartes the French philosopher in the 1600s when he proposed his specificity theory of pain which was really to say that there was a relatively fixed or a hard-wired relationship between stimulus like a fire near the foot and the messages going up to the brain and the experience of pain at the top end. So that is the so-called Cartesian model; that fixed stimulus response idea that is incomplete I would say as a theory and yet widely used as a default position today.
Patrick Wall is one of our pain pioneers, so you may have heard of the Melzack and Wall gate control theory of pain. One of his lines thinking about this was to say that we should not confuse the activity of the nervous system before it gets to the brain, which is essentially nociception, with the actual experience of pain itself. So the experience of pain is very much a brain interpretation. All pain comes from the brain one could say. So he stated that labelling the nociceptors as pain fibres was not an admirable simplification but an unfortunate trivialisation. 6.30 – 6.34 with pain fibres in the nervous system they are nociceptors and it is the nociceptor system conveying neural and chemical messages until those messages arrive at the brain and the brain makes an interpretation of pain. So this is important in terms of treatment planning because it means we are looking at brain interpretation as a key part of target for treatment. Extending this further in the next slide, this looks again at the same idea, the relationship between structural change in the body and the experience of pain. And you can see in this, this is a systematic review from 2014, looking at the increasing prevalence of structural changes in the lumbar spine as we age. So that this addresses various changes from disc degeneration through to disc protrusion and so forth, and the prevalence increasing as we age you can see. And so by the time we are in our latter years of life, most of us have structural changes. But the interesting thing is in this systematic review, that these findings were all in people who were pain-free. So again underlying that it is…
Simon: Yes, I have been really fascinated by this graph. I actually use it as my desk top in my surgery and it is quite helpful during a consult when people say, “Oh I have got this bad back and I just want to know what it is.” And so I say “Well, you know we can tell you what it is because look at this graph.” And that is quite a powerful learning for people and it allows us to divert off the biological pathway early on.
Chris: So you can see from those slides that the structural MRI change correlates poorly with the experience of pain, whereas in contrast, the functional brain MRI findings correlate much more closely. Although that it is for better or worse as it is not fallible as a clinical tool.
And then the next slide goes from somatic review to a patient 9.01 – 9.06 possibly in Newcastle where I work as patient’s information slide bank and tell us the story of a lady with rheumatoid arthritis who pre-amputation experienced pain and swelling in her left ankle and if you had asked her the question of where those symptoms arose from, 9.26 - 9.28 questioned and pointed at her left ankle. What happened unfortunately was an ulcer which became infected and led to an amputation and it surprised her that her symptoms stayed exactly the same post removal of the said ankle and it was not until she underwent some brain retraining exercises with guided motor imagery laterality recognition and mirror therapy her symptoms resolved. So again, emphasising the closer correlation of brain activity with the experience of pain than structural change in the body.
And then the next slide is re-enforcing this a little further in the words of the International Association for the Study of Pain who have come up with a new word, nociplastic, representing plasticity in the nociceptive path of the nervous system. And if you look in the pain text books, those lower two types illustrated there, nociceptive pain referring to tissue injury based pain and neuropathic pain referring to nerve injury based pain, are all well and good but many of the people we see in the tertiary pain clinic where I work cannot be neatly categorised into either of those two types of pain. And so the need for a third descriptor arose and hence this term nociceptive pain which is another way of saying pain associated with sensitisation in the nervous system.
And in the next slide we begin to look at how this might be incorporated into a whole person approach and this again is a model we have used, or are using consistently in Newcastle by way a lay-friendly language set rather than saying a biopsychosocial approach which is perhaps a little longwinded. With patients we talk about a whole person approach and break that down into these five points or five fingers as illustrated here. And the gist of all of these is that treatment in any of these five areas can be angled towards retraining the brain and nervous system with a view to reducing pain over time. So Simon and I between us in our turn are going to just go through each of those five fingers in turn now and talk a little bit about the evidence that arises from each one of them.
The biomedical first is interesting I think because in the main our medical treatments, medications included largely worked well for acute pain, short term pain, but the longer pain goes on and once it becomes chronic the less likely we are to see consistent analgesic benefit and so this title was captivating, “Expect Analgesic Failure; Pursue Analgesic Success.” One of the ideas from that review article was that all drugs for all chronic pain conditions, fewer than half of patients have achieved at least a 50% reduction in pain intensity and that is only in the short term. So yes, it is true that a drug like an opioid can perhaps achieve at times some pain reduction not usually 30%, but that gets less over time so most of our analgesic agents at the thumb of our five fingered plan are not particularly effective.
I am going to make one comment about cannabis and then hand over to Simon to talk about opioids.
Simon: Chris, on that topic, just on the Moore slide there, it is interesting that when you look at numbers needed to treat, they are quite high and a lot of the time when we are treating people about general indications in our general practices, we tend to kind of give something expected to work, but I think we need to understand in chronic pain when we use pharmaceuticals, the numbers needed to treat it very best are about six and they go far worse for many other therapies and they go far worse for many other therapies. So when we do introduce a pharmaceutical for chronic non-cancer pain, we need to point out that it is a trial, the chances are that they will not have a very high success rate or that we might need to try a number of different medications. But there is a role for medications but we need to point out to people that we need to have a balanced approach using a biomedical approach as well as the all or holistic approach.
Chris: Cannabinoids are topical at the moment as you all know, much in the media and as referenced on the slide there, the Therapeutic Goods Administration Guidance for the use of Medicinal Cannabis in the treatment of chronic non-cancer pain from December just gone. And one might gain the perspective from listening to the media and perhaps listening to community advocacy that cannabinoids in there various forms are highly effective treatments for chronic non-cancer pain. However, when you look at the actual science, that is definitely not the case. The impact from the National Drug and Alcohol Research Centre team, its analysis of the recent systematic reviews, and this is part of what is published in that TGA document, they found in terms of numbers needed to treat that the magic figure was 22 for a 30% pain reduction. So needing to treat 22 patients with chronic pain before one of them gains a 30% pain reduction. Or a figure of 26 for a 50% pain reduction. So generally speaking, we might think that the opioids or 15.26 – 15.36 and cannabinoids are much less than that. So at this point in time, my belief is that we should not be advocating cannabis as a treatment for chronic non-cancer pain pending further research which might define subgroups that may be more likely to gain more benefit. Over to you Simon to talk about opioids in the next slide.
Sammi: I just want to jump in quickly before we move on to the opioids slide. I have just posted a link to the RACGP’s position statement on the medicinal use of cannabis and I just also want to note that we will actually be running a two part webinar series in May with New South Wales Health specifically on this topic. So if you are interested in that, keep an eye on the website for the details and the registration link. So sorry, over to you now, Simon.
Chris: Thanks, Sammi.
Simon: Opioids are very important medications which we have been using for many of thousands of years, but the way we have been using them has changed dramatically over time. During much of the 20th Century, they were relatively unavailable but there was some very powerful advocacy in the 1960s to allow the liberal use of opioids for people with terminal cancer and the hospice movement really did change our medical culture in that area. Then it was the indication of opioids became a lot of other terminal illnesses, people with end-stage respiratory failure, cardiac failure, renal failure. And about 30 years ago there was a switch where people started to use opioids for chronic non-cancer pain, recognising that the perceived success that we saw with terminal illness could perhaps be replicated with non-terminal illnesses. However, this was done more on the basis of advocacy than evidence and it has really taken until recently to get evidence about this area and we will be coming to that later. So, opioids are really important medications. It is very important that we use them appropriately. We need to defend appropriate use of them in anaesthesia, in acute pain and trauma. We need to use them in cancer treatments and palliative care, dyspnoea, when people are near death. And also, opiates are very powerful therapy in opiate-dependency treatment where they have a massive harm minimisation effect in terms of reducing death, mortality and incarceration. And if we use opioids outside the evidence basis there is a risk, and this has happened historically, that regulators might clamp down and reduce our ability to provide opioids for evidence-based indications.
Next slide. So, this study Portenoy and Foley dated in 1986, was one of the pivotal papers. It was actually a letter to a journal reporting, sorry it was a report of 38 cases where they found that people with chronic lung cancer pain did improve in their pain during inpatient treatments and not one of them had any addiction problems. And this followed on from a letter to the editor involving a retrospective hospital study which showed that when people with chronic lung cancer pain were provided opiates only one or two of a very large number seemed to become addicts while they were in hospital. And on the basis of this very small publication basis, this whole movement swung. And now it is to the point where the United States with less than 5% of the world’s population consumes the vast majority of global opioids. But in terms of per capita consumption of opioids, Australia is right up there.
Next slide. Russell Portenoy incidentally has really changed his tune and in recent years he has acknowledged that he did overstate the benefit and minimise the harm. This is a picture of Australian opioid consumption showing rapid escalation, in fact a 15 fold increase has been estimated in dispensing of opioids between 1992 and 2012, and that does not include over the counters.
Next slide. Associated with this increase - oh sorry, this is the United States – and you can see a beautiful parallel between increasing opioid prescriptions and increased prescription opioid deaths. There is something like 65,000 prescription opioid deaths per year, poisoning deaths, and of those two thirds are from prescription opioids. This rate of death from overdose and poisonings has been increasing steadily and the percentage relating to the prescription opioids has been increasing in that time. Quite often it is associated with co-prescription of benzodiazepines, which is a particularly important red flag.
Next slide please. So, Bianca Blanch and colleagues looked at some Australian data where they showed that 15-fold increase in prescribing and like the United States, we have seen a similar increase in opiate-related hospitalisations and you can see that up the top graph. And you can see in about 2001 the red line goes above the green line, and that is when pharmaceutical opiates overtook heroin as the main cause of hospitalisations, of poisonings. And you can see down the bottom slide there poisoning deaths and they have been increasing especially for males.
Next slide please. One of the most important studies that have come out in this field and Sammi is going to provide you with a link so you can have a look at this study afterwards. This came out last month in the JAMA. This was Erin Krebs and co. It was a very courageous study. What they did, was they got ethics approval and funding and then ran a study looking at people with moderate to severe chronic non-cancer pain osteoarthritis and either initiated opioids with comprehensive pain care, or did not initiate opioids with comprehensive pain care. A lot of people would have baulked at this study and said that this is unethical, but it was undertaken and we got some very important study results. First of all, we are going to look at function and we are going to look at pain intensity. Both arms of the study, which was 240 people, both had a similar pain rating at the beginning, 5.4/10. We are going to look at function and we are going to look at pain, but the only other figure is medication side effects which were significantly worse in the group that got the opioids.
Next slide please Sammi. In terms of function, at no point through the 12 months after the initiation of opioids, did the opioid group have better function than the non-opioid treatment group.
Next slide please. Similarly for pain, the opioid group, the authors did expect to see opioids getting an improved pain initially at any rate, but at no point at the three months, six months, nine months or 12 months point did the opioid arm of the study get improved pain. In fact, the non-opioid arm had a statistically significant improved pain outcome at the 12 months level. But it was only 0.5 and this did not reach their clinically significant level. So we would say it is no worse, even though it was a tiny bit better.
Next slide please. So, another very important point is safety for prescribers as well we are going to talk about safety for patients shortly. But it is important that you keep yourself safe with patients. Regulators have got a very important role in looking at public health and the way they do it is a fairly blunt and brutal instrument and you need to know what the rules are in your State and Territory because after having after sex with our patients, mis-prescribing of benzos and opiates in the most important and common reason that doctors get sanctioned by regulators. Every State and Territory says, if you are drug dependent, if a patient is drug dependent, you need to notify the State Department of Health before you provide the first script. Now, what drug dependence means varies from State to State and I believe that Victoria has until recently anyway, did not have a definition of what drug dependency is. None of the State and Territory dependency definitions are the same as any clinical definition that you would be familiar with such as DSM or ICD. When you are looking at the laws for patients that are deemed to be non-drug dependent, they are quite varied for each State and we are not going to be able to go through it today, but the Australian Prescriber article by Walid Jammal and Grace Gown about a year ago, went through it really nicely and this slide is a quick summary of it.
Next slide please. The reason that opioids do not work is because opioids are actually as well as to do with pain control, have actually got a very powerful role in our body. If some actual scientists have been running most of the neuroscience research, they would have perhaps found the endogenous opioid system as a fantastic way that people bond to each other. People work together, people become community minded. People with dysregulation of their endogenous opioid system are more likely to have autism or sociopathy. So, when we have good experiences socially we get release of opioids in our endogenous opioid system. They determine things to do with our mood and depression, to do with our sleep, lactation. And then we also have very powerful effects peripherally such as to do with reproduction, that is why people on opioids often have suppression of their gonadotrophin releasing hormones. They affect carbohydrate metabolism, perhaps one reason why people with say dysfunctional endogenous opioid system from childhood abuse might be more likely to get metabolic syndrome and there does seem to be a relationship between opiates and hypoglycaemia and the immune system whereby use of opiates does seem to affect or make the immune system work less well. So when we add pharmaceutical opiates into this system, they really swamp that whole system and it has been described as hijacking the system. Endogenous opioid systems have a very important role in that if we think that there is something important we have got to do, in terms of something we have got to do for our family, for our nation, or you know, for our cricket team, we will do something that might be painful because our endogenous opioids allow us to have a relatively painful experience for some greater altruistic good.
Next slide please. I think it is very important we talk to people about the side effects of their opiates and why it is important because most people with chronic pain you will be seeing will already be on opiates. You need to talk to them about the toxic effects of the opiates. And I think one of the most important things you have to talk to them about is increased pain. And we have had a look at that endogenous opiate and you can imagine how in the balance of the brain that is one change there that could cause increased pain. But we know that very quickly we get tolerance. Even during a long anaesthetic case, if they are using very fast-acting short half-life opiates, anaesthetists can see tolerance developing on the table. And same for hyperalgesia. This is another phenomena where people get increasing pain from lower threshold. We also find other toxic effects of opiates. We know that people using opiates tend to be slower to return to work and if they have higher doses it will take longer to get back to work. Opiates have an effect on depression and you can imagine how that works with looking at understanding the endogenous opioid system. It is said that the numbers needed to harm are one in 12 will get depression after 90 days. These are association studies. We know that the longer you are on opiates, and the higher dose you are on opiates, the more related to depression. Sleep apnoea, sleep disruption, disruption of sleep architecture, central sleep obstruction are all related to opiates. And then of course, we all know about problematic opiate use. So there have been many studies looking at what are the problems of looking at these sort of harms and because people use very different definitions because we all know it is a bad thing but we do not all quite agree what it is, it is said to be something like one in four people who are on chronic opiates will misuse them in some way and that might be just a matter of doubling up or taking a few extra if they cannot sleep or giving some to their next door neighbour because they have got a bad back, and one in 10 would reach the criteria for addiction. That is in large better analysis by Vowels et al.
Overdose is also a very important problem and only about one in seven are fatal. But if you are looking at people on over 120 morphine milliequivalents, it is something like 1.8% per annum will have hospitalisation or hospital presentation for overdose. And that rate is increased quite dramatically if people are using benzodiazepines or Z-drugs at the same time.
Next slide please. The way, while many people think pain is defined by something that needs opiates, we need to change the way we have been thinking about opiates, and first of all, we need to not start them in chronic non-cancer pain. But given that when we meet a new patient, or we look at our patients that we have been looking after, they have already been on them and probably been on them for a long period of time, sometimes many decades. We need to start having conversations about weaning. What is the rate that we need to come down off the opiates with these patients? Well, there is no evidence base for that. So you can have a chat to you patient and say we need to do this and we can do it maybe 10% per month or whatever it is. I have got a chap who I have been looking after for 20 years, and he was on a very large amount of opiates and he still uses a little bit, but we have been having this discussion for that long, and I do not expect you to have 20 years for all your patients, but some patients might find that over a matter of a couple of months that they can come down from quite a reasonably high dose. But do talk to your patient about it and it is important to be moving in the right direction and having some safety strategies incorporated. One thing we know you can do to help wean people off opioids is by bringing in excellent pain care, and that is the holistic model, the multimodal model of care that we are going to be talking about, and this has been shown in a randomised study by Mark Sullivan et al last year where they found that tapering was easier to do and there was no increase in pain intensity when they introduced multimodal care.
Next slide please.
Chris: Thank you Simon. This brings us to that multimodal care you have been talking about as we come back to consider the remaining four fingers, mindbody, connection, activity and nutrition. Can we look at that next slide please, Sammi. We have got into a little trouble I think putting the cart before the horse so to speak or the treatment ahead of the scientific evidence base, particularly in the opioid zone and potentially we are at risk of doing the same thing I think with the cannabinoid zone. So normally in the course of events, the cart should follow the horse. The treatment rolled out into clinical practice should follow scientific evidence and I think that is where the active self-management approaches as we might call them, rank more highly from an evidence perspective than the medical treatments. We do need to think, the next slides shows how this can be rolled out across our nation and think about the different tiers of the system. You can see in this pyramid that really the hospital-based pain clinics can only see a small number of patients considering the overall prevalence of the problem across Australia. This pyramid should be even steeper I think with a smaller pinnacle given the limited resources of hospital-based clinics. So the bulk of our approach needs to be around the base of the pyramid. We need to think about population health approaches and we need to think about what is possible in primary care and certainly the active self-management approaches and those four fingers of the whole person approach are very achievable in a primary care approach and a preventative care approach. So over to you Simon with the next slide as we begin to think a bit further about this.
Simon: Just on that slide, Chris you said that it has got to be a fairly tight pyramid at the top, there was a large study of outpatient consultations to do with chronic pain in the United States by Rousseau and Nell and it was several hundred million consults, and of these consults, pain specialists only prescribed 0.12% of the opiates involved in the consults, so the vast majority of pain consults in this large American study were done outside specialist pain physician practices, and that is why we need to make sure that primary health care providers who do the hard work of a lot of health care, are well equipped to give excellent health care and not harmful pain care.
Next slide please. One very important way that you can determine whether you are doing excellent pain care or not, is to measure your pain outcomes. Because if you do not measure your pain outcomes, how can you know whether you are doing better or not. Also, patients do move from doctor to doctor, it might be in your same practice, it might be they go to another practice or another town. And if we all consistently evaluate outcome assessments, we can see whether over the days, weeks, years, decades, if people are doing better or not. The chap that I was telling you about who I looked after for 20 years, it was quite a powerful thing to go back and look at a simple pain outcome score I did very early in the piece. It was not the PEG score because it had not been developed at the time. But, and when he was in a truckload of opiates and when he was just down onto a couple Endone, and his pain scores were really a wee little bit better than when he was on the large doses that time ago. And that helped him keep focussed and reassured that we were doing the right thing. This PEG score, we are all time poor in general practice and you know, I am usually running late and you guys probably are too, and often your pain patients have got 16 different problems as I was saying and they just want the script because they have already been talking to you about their blood pressure and their diabetes and their osteoarthritis, their obesity. So, one thing you can do is this PEG score. It is by Erin Krebs who did that SPACE study I just talked to you about earlier. To introduce this outcome measure takes me 45 seconds initially and then to run it subsequently, takes me about 15 seconds. So we can all afford that sort of amount of time in our practice and I imagine if you are doing a GP mental health treatment plan, you do have to do outcome measures and that you could use this as one of your outcome measures. So, you need to say to people, righty-o, we are going to look at your pain last week and we are going to talk about three things. We are going to talk about your pain on average in the last week, where zero is no pain at all, 10 is the worst pain you can imagine and then we are going to talk about your general activity. It is best to go from pain to general activity, it flows better. So, we are going to talk about your general activity. We are going to be talking about your sleep, relationships, doing some housework, work in the backyard, work standing, sitting and just how you are going, where zero pain does not interfere with those sort of functions, and 10 is completely interferes with them. And then we are going to talk about your quality of life and what number best describes during the last week pain has interfered with your contentment, where zero is does not interfere and 10 is completely interferes with your enjoyment of life, and then you run through it. And I can usually get that score in 45 seconds initially and it is a really handy tool. If you do it from time to time and you can see if patients are getting better or not and whether you are on the right track with your approach or not and they can feel more comfortable with how things are going.
Next slide please.
Chris: We are looking now at the next finger, mindbody and making some comments about what be achievable in a time efficient way in a primary care setting. So the mindbody, all one word no hyphen, makes us recognise that thoughts, our beliefs and our emotions do not exist in isolation from our physical state, but they bring immediate changes in function of the nervous system and the neuroendocrine systems. So a simple question in terms of cognitive function or belief that you might ask your patient is this: “In regard to your pain, what are you most afraid of?”, which then sets the scene for the next slide, which is your treatment response of targeted reassurance. So we are really looking at addressing their greatest fear with some healing words that bring a sense of safety and readiness to move. So I do exaggerate slightly, but maybe not so much when I say that I would always interpret an MRI scan of the spine in this way, other than I suppose the exception of if there was cancer evident. But really one needs to think through the way a patient might be terrified by the words “in the MRI report” and they need something different to empower them to move. So I would generally say there are no harmful underlying problems with your spine that require surgery and the scan does show that you have a strong and stable spine and this is a good foundation for movement. So by this we are really trying to steer our words which can be brief. It does not have to be a consultation into their zone of need.
Next slide please.
Simon: Behavioural activation is the next slide and this is very simple psychotherapy which we can do. There has been a study by Richards about looking at non-specialist psychologists providing this treatment. Very briefly, we can do it. What it is, is we say to people we want to stop avoiding things that you are afraid of and we want you to start doing things that you really enjoy. It is as simple as that. Because what that does, it helps with issues to do with depression and anxiety and it is something we can do which will help in the holistic measure of pain as well.
Chris: And a further comment on depression, to note the bicausal relationship with pain. Pain can make depression worse, but also depression can make pain worse and there is in the neuroscience some similarity in the changes in the brain glial cell activation for example, can play a role in the pathophysiology of both conditions. And so treating depression can in fact be a helpful part of treating pain and there are various activities listed there that are achievable and addressable in primary care.
Next slide please. Simple measures like mindfulness, meditation and observation of the breath are again things that are very achievable in a short space of time in primary care for your patients.
And next slide again please. So from the pain science, cognitive behavioural therapy has a fairly large body of evidence that demonstrates a degree of benefit. However one would say looking critically at this literature that the gains in the main are modest as they pertain to improvements in physical and psychological function. And we are looking at ways in which, this is at the specialist end, those results could be improved and some of the aspects that are being looked at now are acceptance in form of acceptance commitment therapy and whether that might bring additional benefits and the mindfulness aspects that I have mentioned before and a greater recognition of neuroplasticity, the idea around retrain the brain to gradually reduce your pain over time. So we are hoping in the specialist end with cognitive behavioural based pain group interventions, that we may get better results from incorporating some of these strategies, not to exclude you from incorporating some of these in a general practice setting.
Next slide please.
Simon: When we were talking about the endogenous opioid system, we did look at mood as one of the areas that it determines, and also social aspects are very important with our endogenous opioid system which has a regulatory aspect to our pain control. And connectivity is really important when we are talking about pain management. And we need to encourage people to re-engage socially and that includes things like returning to work and we need to look at the spouse and make sure that the spouse is also on side with the re-engagement. A spouse can be for example very critical and judgemental and this can be a bit of a problem. On the other hand, the spouse might be running around and making sure that the person has to do nothing more than sit on the chair and use their remote control. And both of these sort of spouse behaviours are associated with worse pain outcomes. Also we need to look at the issue about intimacy and for many people, working on an activity pacing to sexual performance and sexual behaviour and interaction is also very important in their pain management and very meaningful for the couple.
Next slide please.
Chris: In our work in Newcastle, I would add that that connection is the middle finger and if you like, in most human beings the longest of our fingers which we use to emphasise to patients that that is central, you know, connection is a central if understated aspect of pain management program. So I agree very much with all Simon’s good words. And then we move to the fourth finger which is activity and looking at ways in which you might time-efficiently be able to address physical activity in your general practice setting. One of the tests that we found helpful again in hospital practice but with a view to translating to primary care is the five times sit to stand test. So this is asking your patient perhaps in the middle of a long discussion about OxyContin and with a view to changing topic, you ask them to without using the arms of their chair, sit to stand five times. This should take less than 15 seconds or they are at falls risk and that brings in the sense that the strength program could be part of their pain management approach.
Next slide please. Really in considering physical activity we are looking at this balance between active and passive treatments. The passively received approaches have limited power to retrain the brain and nervous system, whereas the passive approaches meaning think differently, eat differently, move differently have considerably more power to retrain the brain. So definitely we want from an evidence-based perspective to be prioritising active treatments including the various forms of physical activity there. We do need to be careful though, as the next slide points out, not to overload people with too much activity too early. So this is the idea of pacing activity, avoiding under or overdoing activity and start with a small amount and build up. So this may mean that the person might need to in the first instance reduce their baseline activity and perhaps do less on their good days and then gradually build up slowly. This next slide that follows illustrates that in a graphic way. You can see the wavy line might have been the patient’s activity levels before treatment which may emphasise the fluctuation, something of a boom and bust cycle, doing a lot on good days and not much at all on bad days. What we are trying to do with a pacing approach is to get them to drop to a lower base line in the first instance and then build slowly and steadily on top of that over time.
Next slide please.
Simon: So with activity pacing we want to try and avoid that boom-bust problem where people cycle between overdoing it and then being flat and on their back and doing nothing except lying on their sofa and eating MS Contin for the next few days. Sleep is also a really important aspect and we did talk about sleep and mood as part of the endogenous opioid system. Sleep, like depression, has a bicausal relationship with pain and sleep is a very common problem. 10%-15% of the population report sleep troubles.
Next slide please. And what we need to be doing as a first line of treatment is cognitive behavioural therapy. Now CBT-i incorporates four elements. There is relaxation therapy and we have already talked about the active breathing care and also the next one is psychoeducation or sleep hygiene and that is things we all know about sleep hygiene, things like watching your clock, sitting up you know, it is now 50 minutes since I have been awake, 60 minutes, and also using substances to help sleep. There is a consistency about substances and sleep in that they are not good. They seem to work well, and I am sure you have all got patients who say yes, I just need a couple of cones to get to sleep, or a couple of drinks, or a couple of benzos, or whatever it is. And whether you use self-reports sleep measures or whether you use polysomnography, we know that most substances that seem to make you sleep a bit better effect sleep architecture and they tend to decrease the REM sleep which is the refreshing sleep where you learn things, you help cope with your life and the emotional aspects of your day. And fairly soon you get a tolerance to most of the substances including opiates that people use to sleep and it takes some time, often weeks and sometimes months to get over that. But people do tend to get a restoration of normal sleep when they come off substances. The next area is stimulus control, and these are things most of us know, that you go to bed when you are sleepy and get out of bed when you are unable to sleep. You use your bed only for sleep or for sexual relations and you get up about the same time every day.
The last therapy is a really important one for you to learn tonight. Most general practitioners the studies show are not familiar about sleep restriction strategies or bedtime restriction strategies.
Next slide please. This, oh, we will come to that after this. We will just talk about benzos very quickly. Benzos came in before we started to really look at evidence-based medicine, before we started to look at specific illnesses and specific treatments, before scientific process had to be at a certain level. So a lot of the studies that allowed benzos to be widely released were in the 60s and 70s. They were very often pharmaceutical companies doing short studies on selected populations. But we know, if you look prospectively at people there was a study in nursing homes looking at sleeping quality. Those people in nursing homes who are using benzodiazepines for sleep had worse sleep than people who were not using benzos as at the initial cross section. At one year, their sleep got worse relative to the non-users and also they got lots of other side effects including the issue of overdose we talked about before.
Next slide please. So bedtime restriction therapy is done, you need to do this over several weeks. But when somebody comes to you and they say, “I cannot sleep” or you are talking about their pain and sleep comes up “I cannot sleep because of my pain,” you need to give them a sleep diary and as part of the resources for this webinar you will be given a sleep diary. So you give them a sleep diary and you get them to record what they have been doing during the day before they get to bed before they go to sleep. When they wake up in the morning, they record what their night was like. And it is really important, because what you do, is you work out how many hours they actually sleep and what the minimum number of hours they usually sleep. And then what you do, you say “Well righty-o, well you really only need 6.5 hours sleep, so what time do you want to get up in the morning?” and they say “I want to get up at seven in the morning every day.” So you say, “Righty-o, that means you need to go to bed at 12.30.” “I cannot do that! I would not be able to stay awake!” they say. And you say, “Well that is the right thing.” So, you work out what amount of time they need to sleep and then you restrict their time in bed to that time and then if they are still tired and they are sleeping efficiently, you start to bring the going to bed time a little bit earlier, but you keep the getting up time the same. And if you do this, this will also help you reduce those benzos which are also harmful in the pain practice.
Next slide please.
Chris: To finish tonight, three websites that we would like to mention that you may be interested in. First one is Hunter Integrated Pain Service website there and one of the aspects if you look at the left-hand column is a series of Brainman videos designed for use in general practice.
Next slide please. There are three Brainman videos available on the site that are listed there and these are designed to be short, time-efficient things between 90 seconds and 2.5 minutes of video that you or your practice nurse might perhaps watch with a patient while you are developing a care plan such as this next slide illustrates. Again, this is available on the Hunter Integrated Pain Service website. A template pain recovery plan. You may have some other forms of this, this is just one type of template available along those lines. So this pain recovery plan that will come in a minute is just based around those five fingers that will come up and pass on. And the other two websites that we wanted to mention that may be coming up in due course. There is the Agency for Clinical Innovation New South Wales Health Chronic Pain website. If it does not come up now, I am sure Sammi will be able to give you some details of that in due course. A lot of information there both for consumers and primary health care professionals. And then the final website that we wanted to mention relates to Health Pathways. So there are a number of Health Pathway groups putting together material across Australia and New Zealand. In fact it was designed in Christchurch, New Zealand. We have got up there a slide again, Sammi can give you the details afterwards if it does not come up now, of the Hunter New England Health Pathways. We have a username and a password that you will need to access that, but that does have some useful information about assessment, treatment and referral processes relating to chronic pain and also some of the drug and alcohol aspects as well, and in particular a pathway about opioid de-prescribing. So that brings us I think to the end of our formal presentation. Although Sammi were you wanting to mention the Australian Prescriber article as well?
Simon: Well, I could do that Chris. If you enjoyed the book you can go and see the movie. Or at least you can go and read next month in the Australian Prescriber, an article that Chris and I have put together with some colleagues about the non-pharmaceutical management of non-cancer pain.
Just to look at the learning outcomes from today. Hopefully you should be able to have a bit of understanding about the epidemiology and the neuroscience of chronic pain and opiates and you should have a bit more of an understanding of non-prescribing of opioids in chronic pain and prescribing opioids for evidence-based indications, and also having a bit of some tools which will allow you to de-prescribe opiates. Hopefully you will have a little bit of an understanding and introduction to the holistic management of chronic pain and also a few of the other aspects to do with depression and anxiety, substance use and sleep problems.
Sammi: I just want to say a big thank you to Chris and Simon for their fantastic job presenting tonight. I hope you will all go away with a better understanding of the learning outcomes that are currently on the screen. Thanks again Chris and Simon, and everybody enjoy the rest of your night.