Taking the Pain Out of Pain Management
Carmen:
Okay. Well, we might get started. So welcome to the latest instalment of our rural health webinar series. My name is Carmen, and I will be your host for this evening. Tonight’s webinar will focus on how to simplify history taking and look at innovative ways to examine, diagnose and provide targeted interventions to patients with chronic pain. The webinar will be presented by Dr Andrew Horwood, a GP working in rural Victoria for the past 25 years. Dr Horwood’s interests include multidisciplinary pain management and safe prescribing in the use of opiates. He has also presented numerous webinars on pain-related topics.
Next slide please Andrew.
Okay.
We would like to begin tonight’s webinar by acknowledging the traditional owners of the land that we are all together coming from tonight and the lands on which this event has been broadcasted. I would like to pay our respects to the elders past and present and would like to acknowledge any Aboriginal or Torres Strait Islander people who are with us this evening.
Okay. Next slide Andrew.
RACGP Rural would also like to thank our sponsor, Medical Insurance Protection Society (MIPS). MIPS memberships includes comprehensive indemnity cover for the provision of healthcare to individuals. MIPS exists to promote honourable practice and protects the interests of its members. MIPS provides a range of benefits in addition to insurance covers such as our 24-hour medicolegal support and accredited risk education workshops. We do greatly appreciate their support for the webinar series.
Next slide. Thank you, Andrew.
Okay and just before we start just a few housekeeping things.
So, as I said before to those of you who were already with us. So, all the participants microphones are set to mute. That just ensures that there are no disruptions with background noise or anything like that, but we encourage you all to use the chat function, the Q&A box to ask any questions you may have. So, when using the chat function, we do ask that you address your questions and comments to all panellists and attendees, rather than just to the panel and that will ensure that everyone can see your comments and questions, and finally the webinar has been accredited for 1-hour educational activities CPD. To be eligible for this you must be present for the duration of the webinar. We also kindly ask that you complete the short evaluation at the end of the webinar. So, when it closes that will pop up. This should only take a few minutes and it will help us improve the format and the content for our future webinars and out Q&A session will be at the end.
So, next slide please Andrew.
So, learning outcomes. By the end of the webinar participants will be able to:
- Identify a simpler way to approach patients with chronic noncancer pain.
- Recognise pain patterns and how that opens up treatment options.
- Describe a simple pain management algorithm.
- The safe use of opiates and who to contact if any problems arise.
But for now, I will hand over to our facilitator for the evening, Dr Andrew Horwood. Thank you.
Dr Andrew Horwood:
Thank you, Carmen.
I would like to add my acknowledgement of the First Nations people of the various lands of which we are meeting around Australia. So, why me sharing with you tonight? Well, I have been a rural GP in Horsham in Western Victoria for 25 years. I thought I had retired but got talked out of retirement, so for the last five years I have been working in pain management solely as part of the Grampians Health Pain Service, and I think I have stumbled across a more user-friendly approach to chronic pain that I had not seen before. So, I want to share that with you tonight.
Just some brief context. Chronic pain is common. 20% of the population are said to be living with chronic pain and for many of us as GPs and certainly this was my experience when I was a GP these are “heart sink” patients, who think “What on earth am I going to do here”. Common pathologies are traumatic or degenerative. That is common. Yes, there are other Neurological diseases and so on, but they are not actually that common in general practice, but the thing that stands out to me now is the underutilisation of effective passive therapies, those are things that GPS can do while the gold standard is active self-management. I find that if when I make sure that the effective passive therapies are in place that all people are more likely to actually engage with active self-management.
So, for many GPs it feels like trying to piece together a thousand-piece jigsaw puzzle, dealing with chronic noncancer pain and I ask myself why is this. Well, I think it is a range of factors that is often [audio buffering cannot make out 15:14] charge surrounding the patient’s experience of pain, a lot of distress, frustration, then there are these various flags that we are told about, yellow flags and black flags. I think there are challenges in the system itself. We have all been bombarded with drug company promotions. I would wager it is the same where you are, the certainly lack of specialist pain services where I am in Western Victoria that specialists’ doctors, allied health staff and pain programs.
I found when I started in pain medicine that there wasn’t really GP-friendly assessment resources, and radiology reports can actually be helpful as well and then the new pain approach is yet to have much of an impact and then there are factors related to us. Pain is often taught as complex and complicated by our psychosocial factors all have to be considered. There is dangers, is like walking through minefield, red flags, the challenge of getting authority scripts where you can get interrogated by someone who is nonclinician about have you done the right thing and harm minimisation things have to be considered. I found there was not an easy through process for me to use as a doctor and I had to retrain myself in how to examine for the things that are actually important.
So, when I started in pain medicine five years ago, I wasn’t very confident. I challenged myself to make this work but really for most GPs this is just like a perfect storm, and it is too hard to handle in a 10-15 minute consultation. Well, I had my like “eureka”, so many years ago, my “aha” moment which was to recognise that chronic pain is complex. Yes, there are all these various factors, the biomedical factors, the mind-body connection, the social connections, how active people are and what they eat. All that is true, but I found that there is a simpler way to think of chronic pain which means it does not have to be complicated.
So, the questions I ask myself is not primarily about what type of pain is this person experiencing. What I want to know is “Can I reduce this person’s pain burden quickly” and the effective passive therapies often steroid injections or nonopiate medication. Secondly is their current opiate dose a concern. Do I need to think about harm minimisation, Naloxone or limited supply and “Does this person trust my judgment” because if they don’t, I am not going to get very far. If not, who do I need to get help from.
So, chronic noncancer pain is really like chest pain. So, when someone comes in with chest pain we want to know, where is the pain? Does it spread anywhere else? And What does it fee like? So, it is the same questions with chronic noncancer pain.
One of the traps I see that my GP colleagues around the Wimmera do, is that they often rely on scans rather than making a clinical diagnosis. They will send someone for a scan, and I will get a referral saying, “Please see so and so with back pain, they have got such and such showing up on their scan”. The problem is that scans are frequently misleading because the same findings could be equally found in people with no pain at all. Just look at this diagram and everywhere around the body there is just as many people with pain-free who show various abnormalities as those with pain.
Worse than that though is this is a study that took two groups of 100 people with nonspecific low back pain and scanned them. A CT scan of their lumbar spine, there was very little difference in benefit but there was a lot more difference in harm. So, the people who were scanned, worried more about what their scan showed.
So, I do not order scans until I have made a clinical diagnosis and then I will say on the scan request, the radiology request. “This is what I think is happening clinically” because I want the scan to answer a question for me. It’s very unhelpful to rely on scans to make a diagnosis. They frequently don’t and they more often lead people into a rabbit hole.
So, as I said the principles, I use reduce the pain burden quickly. I rarely have to use opiates. When a person feels their pain reducing, they start to feel hope again. Frequently people feel hopeless and then they are more motivated to engage with self-management. So, this overall leads to a better quality of life and usually that translates into less reliance on medication. So, we can taper opiates and other medication particularly things like pregabalin.
So, I think this is my “aha” starting point. I think there is only three common pain patterns to consider. One is what I call “pain system sensitisation being prominent”, these are people with generalised pains all over the place. The typical one would be fibromyalgia, but also another group where there is a lot of drama in their presentation. So, if there is anyone who is presenting in this dramatic fashion that is a sign that the pain system is sensitised and they are just feeling “dialled up”, “wound up”. Then there are people who have another pattern is localised radicular pain. So, it is in their back and spreading down their leg or in their neck and going down their arm or it is localised an nonradicular. So, the guidelines for localised pains indicate that physiotherapy and exercise therapy are first-line treatments, but my experience is that while it is all very well, they often don’t produce the desired results and yet many of those people respond really well to targeted steroid injections.
So, I like to keep everything simple. So, I want to simplify history taking, simplify examination, target the investigations based on which of these pain patterns I think I am dealing with and plan my treatment to reduce the pain burden, refer for physical therapy and keep education simple.
So, I want to show you how I do that. I am going to be focussing really on these two areas of procedures and pharmacotherapy, just remembering that in this multidisciplinary pain management model there is also psychology and physiotherapy. I am not going to be talking about those and in people I see in our pain service, they’re certainly important elements for some people. Most of the people I see probably 10 times as many people in our pain service as our physiotherapy and psychologists see. So, that is why I am more confident to talk to you about the passive therapies.
Well, I use a questionnaire, and by the way at the end if you want access to these resources that I am going to be talking about I will give you my email address. You can email me, and I can send you a google drive link where I have put together a package of resources including this. This was a questionnaire developed by the West Vic Primary Health Network in combination with the Transport Accident Commission and WorkSafe as a cut down version of a much more detailed pain questionnaire called “EPOC”, the Electronic Persistent Pain Outcome Collaborative”. This is very user friendly in general practice. It takes a few minutes for patients to fill out. I scanned the results into the history because some often I want to refer back to what someone said, how they reported their pain, a few months ago and compare their reporting it now. People often forget how much worse they were in the past and I combine it with a body chart. So, people have these three pages to fill out.
The body chart in particular tells me is this localised. Is it radicular or not? And is generalised? Generalised people will have shading everywhere on this chart. So, I also want to ask what it feels like because the feeling, the language they use to describe the feeling helps me identify other elements of the pain pattern and I just find it quite common for people when I ask, “What does it feel like?”. They just say, “It is really bad doc”.
They often confuse intensity with feeling. So, I frequently have to say “yes, I get that it’s bad, I want you to tell me what it feels like, here is some words. Is it burning? Is it aching? Is it tingling? Hot or cold?” Give them some option so they get the idea. So, burning, shooting, numb, tingling sort of pain, I am thinking neuropathic pain much more likely to be radiuclar. Aching or dull, even sharp pain can either neuropathic or nociceptive pain and widespread pain of any type as I say often laced with drama. I am thinking pain system sensitisation.
So, then from that history I want to examine with a view to confirming what I might find on examination. So, if it is radicular pattern of pain, I am looking for sensory or motor function. It is very rare, I find, to find motor impairment but sensory changes not uncommon. So, I use a little brush to test for light touch and hat pin to test for pain. So, they’re the two I test for and are there any other movements that really produce the pain. Localised nonradicular, they will often be some sort of localised tenderness and I think of a bursa on the trochanteric bursa. There is this pinpoint “Ouch, that is the spot doc”, that is the sort of thing I am looking for.
Generalised pain: They have often got tender spots all over the place. Those people with fibromyalgia it often a good way to demonstrate to them their pain system sensitised by pressing them just a little firmly and they will usually say “Ouch” and so I can say to them “Here is an example of your pain system being sensitised that is just pressure, but your pain system is so dialled up that you are experiencing that as pain. So, it is a useful thing to, I find that it is a useful thing to point out to people.
Okay, so we get to that point then what do we do about it? So, what I find is that there are different treatments for sensitisation, local and localised pain. Sometimes these can occur together and so if they are occurring together a localised pain plus pain high sensitised pain system: I will treat the sensitised pain system first. I think of systemic issues. So, I will often do blood tests for people with highly sensitised pain system. I want to make sure their iron levels, B12, thyroid function, kidneys, liver, CRP, make sure I am not missing some systemic illness or systemic process let’s say rather than illness. Then the sort of things I will treat them with is amitriptyline is probably the most common and I find that wonderful, 10-50 mg, often 10 mg take it at 7 o’clock at night. I want the sleepy side effect to kick in overnight, so they get a good sleep, but I want it to have worn off by the following morning.
Duloxetine seems to be a more favoured currently amongst pain specialists. I just don’t find it as useful. I use high doses of magnesium, and these are the people who I would use CBD oil for. Doses up to 50 mg twice a day, if they can afford it.
So, then the localised pain patterns; if it is radicular, I will be thinking of either a nerve root or epidural injection. MRIs are the best investigation for these people, if it is possible, but CTs are pretty good really. I will often talk to the radiologist who work out based on the CT or MRI result what is the best approach. I can’t read these radiology images and I want to know where are the nerves being compressed such that we target either the epidural or the nerve root or occasionally both.
The nonradiuclar pains I am thinking of arthropathies or bursas in particular. So usually, the investigations are quite straight forward, local ultrasound, but one of the things; that has been a gamechanger for me has been to recognise the value of SPECT-CT. I will show you an image of that shortly. So, based on those investigations it is usually fairly obvious where to inject. Sometimes you need repeated injections. So, if someone says, “Look I had my injections and I was really good for four or five days but then it has come back”, that is not a failure of injection.
It is an indication that a repeat is needed and sometimes we need opiate medications to produce some sort of stability whilst working on the reversible elements of this pain passage.
So, here is a SPECT-CT image in you were near a public hospital that has nuclear medicine that’s bulk-billed certainly in Victoria. Here is the image of the lumbar spine where active pain generating lumbar facet. So, these are really good to get a cortisone injection in. If they get good response from that which I would in this image, I would highly anticipate a good response. That person could do well with radiofrequency ablation as a longer-term treatment.
Keeping education simple, this is a great handout from Pain Australia on the one page it emphasises that medications can be useful, but the research shows an on average contribute only 30% reduction of pain and the rest is managing chronic pain without pain killers, stretching, pacing, relaxation, mindfulness, this goes on over two pages. It is a great handout. I highly recommend it and then there are numerous websites with great resources that are easy for people to access and cost-free.
So, how can this work? Well, I think actually a busy GP could make this work over two or three 10-15 minute consults. I think the key thing is to get the patient to accept that “I as the GP take you seriously, I want to get to the bottom of this. I want to understand why you have got pain and what we can do about it”. So first off, I get the patient to fill out the mini EPOC. Have them sit in the waiting room or send them away and ask them to come back following week with the questionnaire filled out.
Understand red flags. They are rare. I have had in five years of pain medicine I have seen two people with cauda equina lesions, they are not common but weight loss, fever, cauda equina things, changes with bowels and bladder, they’re things to keep in the back of your mind but they are not as I say they are not common. Then identify the likely pain pattern. If you achieve that in the first consult you would be ahead. May be the second consult examine the patient and do that examination before ordering investigations. So, you make up your mind about what you think is happening. Which of these pain patterns are you dealing with. So, then you know which investigations to order and then get the results of the investigations and follow the algorithm.
Well, what about opiates? Big question for many of us. Well, I was thinking that really, we use mediation in two ways. Either to prolong life hopefully or to improve quality of life. So, if we are prolonging life that is the rationale for treating hypertension and ischaemic heart disease and diabetes and cancer and so on but if we’re looking for quality of life that is really such things as treating depression or reflux or treating with NSAIDs for osteoarthritis or opiates are in this category. So, then the question is well are they working? They may be working. So, if they are working, they will enable greater mobility, improve mood, enable greater socialising and there won’t be any signs of aberrance. So, such things as people going asking for escalating doses. Going to the pharmacist earlier than is indicated on your treatment plan.
Well then, the question is if they are working is it safe to continue the current treatment? Well, I think the answer is yes if the Oral Morphine-Equivalent Dose is < 50 mg or if there is no reasonable alternative and it is < 100 mg. Ideally, we don’t want people regularly taking more than 100 mg of oral morphine a day. The research shows the risk of death is increased eleven-fold in the cohort of people taking > 100 mg of oral morphine a day but what if they are not working? How do we know they’re not working? So, there is no greater mobility despite the fact they’re taking opiates. Their mood is still poor. They’re isolated socially and there are signs of aberrance. In Victoria we had real time prescription monitoring system called SafeScript.
I am not sure what you might have in other parts of Australia but the data from the real time prescription monitoring is really important to look for signs of aberrance. You can at a glance see what has the dosage been like over time and how often has the patient presented to have more dose dispensed.
So, if they’re not working, I ask myself two questions. I would review the history and examination and look again for the pain patterns and look for nonopiate treatment options. Has that been optimised? If the answer is yes, I will discuss my concerns with the patient and say look my first responsibility is to keep you safe and this is not safe. It could be a way to start instituting some control, might be to limit pickups, so weekly or fortnightly pickups of medication, but if you are really concerned then I think referring to a pain or AOD specialist is the way to go.
In Western Victoria we have got a public AOD service, the physician there runs what he calls an “Opiate Management Clinic” so we can refer people to him. He will initiate the conversations about swapping, migrating people from prescribed opiates onto opiate agonist treatment and get that ball rolling which is appropriate for some people. I have actually found that in the people I have seen in the last five years that hasn’t been common, despite the fears about it. Most often I found that when opiates aren’t working it is because I haven’t fully understood what the pain challenge is they’re dealing with, and I haven’t ordered the right steroid injection.
So, who do you call if you want some help? Well, again I am talking to you from Victoria, so I am more confident talking about Victorian resources but there in Victoria the Flying Doctors Service has a Telehealth service that Dr Ray Chan is an addiction medicine and pain medicine physician. So, he is an excellent person that I would refer to if I was in a more isolated setting than I am. So, the Flying Doctor Services are by Telehealth, and he gives really good advice. If I want advice in hurry, again in Victoria and Tasmania there and I see that the Northern Territory there is the Drug and Alcohol Clinic or advisory service. They are excellent people. The yare primarily addiction medicine specialists, but as there is a profound overlap between addiction medicine and pain medicine, they are often quite capable of providing advice about medication management for pain medicine.
So, as I mentioned earlier I have put together a package of resources including some on medicinal cannabis. If you are interested email me at my private personal email and I will send you a google link and I think that we will leave that there and open the line for any questions.
Carmen:
Okay. We have already got one in the chat there Andrew.
Dr Andrew Horwood:
Okay.
Carmen:
From [unsure 47:43].
Dr Andrew Horwood:
Let me see. Hold on. Can you read it out, I don’t seem to be?
Carmen:
So, I am not sure about the abbreviations, forgive me, but it’s “SPECT-CT do you just put that on the form?”
Dr Andrew Horwood:
Oh, the SPECT CT. So, it’s a nuclear medicine procedure so it takes four hours. The person is injected with a radioactive isotope. They take one lot of scans, send them away for three hours and come back and do another lot. So, it is a bone scan technology which has CT somehow embedded in the process as well. So, yes you probably tick the box, nuclear medicine but I write “Bone scan and SPECT-CT” as the test that I order.
Carmen:
Okay. We have another attendee asking, “What do you mean by reduce pain burden also what do you think of acupuncture?”
Dr Andrew Horwood:
I love acupuncture. Reducing pain burden is really any step you can take to reduce the patient’s experience of pain hence I prefer doing that without opiates. So, if acupuncture works for people, great. Talking to patients you can g et a sense of whether they are open to so called alternative therapies and if they are I wholeheartedly support them to go for acupuncture. I have now found the questions.
“How can I convince a patient with chronic pain too see a psychologist for psychotherapy?” Let me show you another slide then. I thought this might crop up. I use this. I have got copies of this that I hand to people and I say “Look your pain system is sensitised and it is an absolutely nuisance, it happens to everyone who has been in pain for more than three months to a greater or lesser degree and it is like this overactive car alarm and those things that go off in your pocket and this is a different way to explain it that professor Lorimer Moseley who is one of Australia’s leading pain scientists.
He describes that this way that on the left this mountain that is how much of an activity you could be before the pain started and if you have been in pain for a long time the single biggest impact on your biology and therefore your entire life is the increase in the size of the buffer and the buffer increases because your immune system and nervous system have learnt how to be very good at producing pain. So, you can do very little without crossing that threshold where you start to feel pain.
So, the question is how can you reduce the size of the buffer? Well, a good deal about that is about learning to be less fearful of experiencing some pain. So, avoidance is a common phenomenon in people who have had chronic pain. What we know is that in a sense it is a desensitisation that is needed so it is a bout confronting the fear of that If I start to push myself or start to exercise a bit more I am going to feel pain and if I feel pain that means I must be damaging myself again. So, there are these faulty beliefs and fears about pushing back the size of the buffer. Sio that is a reason to get a psychologist involved because it is a lot about understanding correcting misinformation that is common in the collective mind of out humankind. “Isn’t it obvious that if I am feeling pain I should rest?” Well, yes that is true, if you have got acute pain, but in chronic pain that is not true. So, it is about challenging those beliefs that apply in one part of their life but get carried over into chronic pain state where they are actually working against us. So, I am hoping that that might have gone partway to answering that question.
Let’s see. “Do you do a GP MP? That would be a great thing, a GP management plan and refer to physio and psychology. I work in a pain service now, so that is part of the public hospital system. So, I don’t do those, but I think that is a great way to do it.
“Do you have resources, how to deal with drug-seeking behaviour?” Drug-seeking behaviour if it’s as I say, if I have my first approach is how can I help reduce the pain without the use of opiates, someone who comes in and is a drug-seeking I would say “Look Mo, I hear you are distressed, my first step is I want to understand why you’ve got the pain you’ve got. Please fill out this questionnaire. This is my approach; I want to work with you to understand it and see how we can reduce this”. If they’re genuinely drug-seeking I think it is they’re most likely to be new patients to you and requesting opiates, I would suggest you don’t accede to that. You may give them one or two days supply and say look I want you to fill out this questionnaire, come back and see me with this questionnaire in two days’ time. You can always write “5 Endone” on the prescription and if they are genuinely drug-seeking you won’t see them again.
“In your experience does medicinal cannabis help in all types of pain?” No. The people who do best are those with generalised pain system sensitisation. Those who need cortisone injections I would rather do the cortisone injection rather than give them medicinal cannabis and as I work in Western Victoria nearly everyone wants to drive, so probably 55 of people I would use TCH containing cannabis and only for people who are not driving. Most people I treat with CBD oil and when that works it is dramatic. I say to people it is worth a try and within one month you should experience a 30-50% reduction in pain. If you are not experiencing that then it is not worth your while going on. So, I have been surprised how often it has been helpful even when I have not through it would be, but it doesn’t help all types of pain. No.
“Can I send to pain management?” Yes. Hapy to do so, if you email, I will send you the… [speaker trailed off]
One of the questions has gone away. You mentioned repeat health and is it reasonable to repeat injections? I would get advice from the radiologist, but certainly four time a year it would probably be the maximum if you are doing epidurals. I would want to see significant improvement to do that many. So, often I would order an epidural or nerve root injections and if the person gets a partial response or as I said they feel much better for five or six days I would repeat that in 8-12 weeks’ time give it that long to see does it reach, did they get any further benefit down the track? And it would be happy to do those three times, and I would expect they should get an increasing benefit with each injection. If they are not asking myself, am I doing the right things here or do they need an epidural injection rather than nerve root injections or vice versa.
So, what high dose of magnesium do I give? I have got a handout about that but 300-500 mg or elemental magnesium three times a day for two weeks and then 300-500 mg every second day. I usually use 300 mg for women, 500 mg for men. The main side effect of magnesium in loose bowel motions. I saw if you are getting that, back off the dose a bit.
“How much is CBD?” I have just stuck with one company. Their CBD works at about $6 a day. I find even pensioners are willing to pay that if they are getting this 30-50% reduction in pain.
“Can patients drive?” Yes.
“Have I found an association between pain sensitisation and trauma?” Very often. So, my operating assumption is t hat anyone under 40 who presents with a generalised pain pattern has got some childhood trauma or often complex PTSD, so I have got, and I have got this in my resource kit for you. When I find someone presenting like that once I can see the pain pattern I will ask them to fill out an adverse childhood experience questionnaire and I say “Look this is a bit out of left field but could you just fill this out for me?”, they are just yes or no circles,
“Have these various things happened to you?” and then I will look for the yes answers and say can I ask you a bit more about that.
It is surprising how often people have been quite profoundly traumatised but that is quite tender. If you are going to ask those questions you need to have time to hear the answers and that is not something to try and rush in a 10-minute appointment because when people divulge that sort of information you can retraumatise them unless you are willing to sit with them while they describe that let them express it and let them feel your appreciation of what they have experienced.
“For bursitis, how often can steroid injections be given?” Again, three or four times a year. Bursas, I would probably inject more quickly so six or eight weeks apart if need be but again I would want after a second or third one I would want to be seen longer benefit. If I am not seeing that I wouldn’t continue.
Well, that looks like the end of the questions that I am looking at.
Carmen:
Well, if that is all the questions. I think two have just come through a final there Andrew.
Dr Andrew Horwood:
Okay.
Let me just scroll down here.
Carmen:
So, then we have just got another one “CBD oil and magnesium” are the last two ones I have got.
Dr Andrew Horwood”
Okay. “If CBD oil used is driving safe?” Yes.
“Magnesium at 300 mg of elemental magnesium three times a day for two weeks only?” That is a loading dose. Then 300 mg elemental magnesium every second day.
“Patient on CBD when they are driving how are they legally bound on drug testing?” CBD is not tested for on roadside drug testing. It is THC that is tested for. So pure CBD has almost undetectable amounts of THC in it. So, the companies are reluctant to say there is not THC in this product because it is made from the cannabis leaf, but they are wanting to cover their backside in case they are taken to court, but I am satisfied there is no THC in it.
“Amitriptyline daytime?”. No. Nighttime. I always say we are using amitriptyline because it has got an action on the pain system, and it has got sedation as a side effect. So, I always use it in the evening, usually suggest start at 7 o’clock kin the evening hoping that the sleepy side effects worn off by the following morning. If it hasn’t take it at 6 o’clock and you can play with the timing of the dose depending on how the sleepiness is.
“Two weeks 300 mg every second day for how long?” As long as they have significant pain.
“Do you use ….[speaker trailed off]?”No. I haven’t used Epidiolex. I stuck with Little Green Farmers products, so I am not sure what the composition of that is. So, regarding magnesium every second day 1 tablet or it depends what magnesium product they get because you are after the elemental magnesium dose. So, they can buy any magnesium product from the supermarket, just turn it around and see each tablet will be equivalent to so much of elemental magnesium then the question is work out how many of those tablets do you need to get 300 mg of elemental magnesium.
“Can you combine amitriptyline and duloxetine?” Yes, but you need to warn people around serotonin syndrome. In my little resource kit, I have got a handout on serotonin syndrome. It is very rare, but I always explain that to people that there is a potential for interaction.
Carmen:
That is very good. I think that is our last question. I think I have answered everyone who has asked your email Andrew.
Dr Andrew Horwood:
Excellent.
Carmen:
But did you want to just bring that slide back up while I [
can’t make out 01:09:21] a little?
Dr Andrew Horwood:
Sure.
Carmen:
So excellent. So, again for anyone needs access to those resources, please email Andrew. So, I just want to say thank you so much Dr Horwood. That has been a really incredibly informative webinar for us all. RACGP rural would also like to thank our seminar sponsor again which is Medical Insurance Protection Society. And also Thank you everyone for joining us this evening. It has been a really great evening with you all and just a reminder so when we close the webinar you will have an evaluation come up so, please do take a moment to fill that out and it honestly only should take you a minute to complete.
So certificates of attendance will be available on you CPD statements within the next few days but for any nonRACGP members on the webinar tonight, if you would like a certificate of attendance please email us at
rurual@racgp.org.au and don’t forget to tune in for our other free monthly webinars and they are held in the first Thursday of every month and on that note I will end the webinar and everyone have a wonderful evening. Thanks everyone. Goodnight.
Dr Andrew Horwood:
Thank you, Carmen.
Carmen:
Thank you.