(06!02!11) -Living With Disability

COMMONWEALTH OF AUSTRALIA

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      Author of Lecture: Nicholas, Michael (Prof.)

Title of Lecture: Living With Disability (Problem 6.02, PPD, 2013)

Pain Management Research Institute, Sydney Medical School-Northern, University of Sydney, Royal North Shore Hospital,

Professor Michael Nicholas

“Living with chronic pain” is easy to say, but how?”

› Pain is primarily a warning signal and useful › But pain can also cause major suffering and disability › Especially when it persists (and becomes chronic) › As there is no cure for chronic pain, the only realistic option is to manage it

› Just as required for other chronic diseases (eg. diabetes, asthma)

› The question is: How? › A challenge for all chronic pain sufferers and health professionals

Summary

Useful reference for this talk

4

Persistent pain by age and sex NSW 1997 Health Survey (Blyth et al., 2001)

11.613.8

11.913

16.815.9

23.927.3

29.128.329.3

27.826.4

30.5

17.1

8.2

11.6

10.914.1

16.9

18.5

19.7

19.3

25.8

23.1

26.420.3

21.3

18.6

20.1

0 5 10 15 20 25 30 35

All

20-24

30-34

40-45

50-54

60-64

70-74

80+

malesfemales

What does this mean?

6

Ø Almost 1 in 5 Australians have some form of chronic pain Ø Multiple possible causes Ø Disability due to pain reported by about 60% Ø Many with chronic pain also have other health

problems = extra load to cope with Ø Especially depression Ø Chronic pain + depression = worse quality of life

“Traditional” Bio-medical model of pain, shared by most people in community

Pain

Injury/disease (Nociception or neuropathy)

Impact on activity, mood

Treatment implications?

Pain-free

Nociception or neuropathy

Normal activity & mood restored

e.g. Bogduk N. Management of chronic low back pain. Med J Aust 2004; 180 (2): 79-83

No Pain

This model works…

› (Usually) in acute pain › For example: Headache? Paracetamol › (Often) in some chronic pain conditions with orthopaedic procedures (eg. hip replacements)

› But for most who develop chronic pain? › On average about 30% reduction in pain, at best Turk DC. Clinical effectiveness and cost-effectiveness of treatments for patients with chronic pain. Clin J Pain 2002; 18: 355-65).

Despite all the advances in medical technology….

Ø  For people with chronic pain, curative treatment is very unlikely and its very pursuit may not be risk-free.

Deyo et al. Overtreating chronic back pain: Time to back off? J Am Bd Fam Med 2009; 22: 62-68

Goucke CR. The management of persistent pain. Med J Aust 2003; 178(9): 444-447. Loeser JD. Mitigating the dangers of pursuing cure. In: Cohen MJM, Campbell JN, eds. Pain Treatment Centers at a Crossroads: A Practical and Conceptual Reappraisal. Seattle, IASP Press, 1996:101-108.

Concerns rising about management of persisting pain

Sydney Morning Herald June 8, 2009 Rise in addiction prompts call for painkiller policy (Julie Robotham Medical Editor)

› Unfortunately, the focus was on addiction, it should have been on pain management

›  If pain management was better understood and practised in the community then drug problems would be much less of a problem

›  It seems addiction is more interesting than pain management to the media and politicians

“DOCTORS groups are urging a radical rethink of how opioid drugs are supplied and controlled, amid evidence of a surge in the number of people addicted to prescription painkillers.”

Concerns about treatment of chronic pain elsewhere too

Deyo et al. noted…since the mid-1990’s..

› A 629% increase in (US) Medicare expenditures for epidural steroid injections;

› A 423% increase in expenditures for opioids for back pain;

› A 307% increase in the number of lumbar MRIs among Medicare beneficiaries; and

› A 220% increase in spinal fusion surgery rates.

› Yet, no good evidence of general improvements in patient outcomes or disability rates.

› Note: In Australia, Medicare-funded prescriptions of oxycodone has quadrupled Australia-wide since 2000 to 1.6 million in 2007.(RACP, Prescription Opioid Policy, 2009)

More access to opioids?

› Martell et al. Ann Intern Med. 2007;146:116-127: Systematic Review: Opioid Treatment for Chronic Back Pain: Prevalence, Efficacy, and Association with Addiction

Concluded: “Opioids are commonly prescribed for chronic back pain and may be efficacious for short-term pain relief. Long-term efficacy (>16 weeks) is unclear.”

› But this is a chronic condition, we’re talking years

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In the UK, also recognition of the problem of treating persisting pain

So, we are all in agreement?

Ø Chronic pain is common – however it is caused Ø Treatments that can help acute pain not as helpful Ø But can make matters even worse Ø What are our options?

16

If one or two don’t work, try more?

You gotta be kidding – your back still hurts??

Maybe we need to step back and try to make sense of the problem of chronic pain?

REDUCED ACTIVITY

UNHELPFUL BELIEFS & THOUGHTS

REPEATED TREATMENT FAILURES

LONG-TERM USE OF ANALGESIC, SEDATIVE DRUGS

LOSS OF JOB, FINANCIAL DIFFICULTIES, FAMILY STRESS

PAIN

PHYSICAL DETERIORATION (eg. muscle wasting, put on weight, joint stiffness)

DEPRESSION, HELPLESSNESS, FRUSTRATION ANGER POOR SLEEP

SIDE EFFECTS (eg. stomach problems, lethargy, constipation)

When pain persists: Interacting contributors and effects - a biopsychosocial perspective

Nerve damage; changes in central

nervous system (Neuropathic or

Neuroplastic Mechanisms, eg.

Sensitization)

Injury; Tissue Damage

(Nociceptive Mechanisms)

EXCESSIVE SUFFERING

& DISABILITY

INPUT FROM: FAMILY; HEALTHCARE PROVIDER(S); INSURERS; EMPLOYER

M. Nicholas. 2012

CHRONIC

So, more than a pain problem

› Persisting pain › Pain triggered by normal activities › Disability – affecting many normal activities or roles › Unhelpful beliefs (catastrophising, fears) › Depression, anger, sleep disturbance › Side-effects from medication › Multiple losses (financial, personal, family, social) › Changes for family, employer, friends ›  In short – chronic pain can dominate most aspects of your life

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If this many contributing factors are operating

› Is it likely just tackling one or two will be enough? › Consider targeting the pain – OK to start, but later? › What about exercise? – could help fitness & weight But what about pain, depression, sleep, side-effects of medication, work, family life?

The reality is there is unlikely to be a single ‘quick fix’

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REDUCED ACTIVITY

UNHELPFUL BELIEFS & THOUGHTS

REPEATED TREATMENT FAILURES

LONG-TERM USE OF ANALGESIC, SEDATIVE DRUGS

LOSS OF JOB, FINANCIAL DIFFICULTIES, FAMILY STRESS

CHRONIC PAIN

PHYSICAL DETERIORATION (eg. muscle wasting, wt gain, joint stiffness)

DEPRESSION, HELPLESSNESS, FRUSTRATION ANGER POOR SLEEP

SIDE EFFECTS (eg. stomach problems, lethargy, constipation)

Wouldn’t it be more likely to help if we target as many of these contributors as possible?

NEUROPATHIC or NEUROPLASTIC MECHANISMS

NOCICEPTIVE MECHANISMS

EXCESSIVE SUFFERING

& DISABILITY

INPUT FROM: FAMILY; HEALTHCARE PROVIDER(S); INSURERS; EMPLOYER

M. Nicholas. 2012

Targeted medication,

Desensitising, Relaxation, Distraction

Set realistic goals & pace up activities,

exercises – despite pain; diet

plan Education about

pain & treatments + identify & challenge

unhelpful beliefs

Schedule pleasant activities (not just

work), improve sleep habits, anger

management

Rationalise & cease

unhelpful drugs

Review transferable skills,

retraining, job applications, modify

work, negotiate roles with family

Negotiate with employer , agree

on work & management

plan with HCPs

Maintenance plan – chronic

pain will fluctuate, need to

plan for these, and for dealing

with other stressors

Achieving these changes not easy – strong community belief that pain relief should come first

0%

5%

10%

15%

20%

25%

30%

35%

40%

TotallyAgree - 0

1 2 3 4 TotallyDisagree -

5

“A reduction in pain is necessary before a person can start resuming normal functioning”

Survey of insurance company staff

But the health care providers have obstacles too

› Consider their beliefs about pain

› Houben et al. European J. Pain 9 (2005) 173–183. Differentiated between physical therapists on their biomedical vs biopsychosocial orientations towards non-specific back pain. Those with biomedical orientation viewed daily activities as more harmful for the back of a lbp patient ('be careful', 'let pain be your guide')

If these views are transmitted to their patients what might we see? Activity avoidance Disability ?

24

Physicians’ recommendations for activities in Chronic low back pain

› Rainville et al. Spine 2000; 25: 2210-2220

Concluded: › Wide variations noted, often restrictive (don’t do..) › Seemed to reflect personal attitudes (of physicians) as well as patients’ clinical symptoms

So, it’s not just the pain sufferer who needs to update their understanding of chronic pain

› Health care providers and the general community too

› Think about it – how often have you had others find it hard to believe your pain is ongoing?

› The good news is that community beliefs can be changed

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What if the community accepted the idea that being active despite pain was OK?

›  Buchbinder et al. Spine 2001;26:2535–2542 ›  Population-based, state-wide public health intervention to alter beliefs

about back pain and its medical management

›  In Victoria in late 1990’s

›  Short ads on TV and signs by roadsides

›  Evaluation: ›  4,730 interviewed 2.5 yrs apart; 2,556 GPs interviewed 2 yrs apart. ›  1 state (Victoria) = intervention, another state (NSW) = control

Buchbinder et al, BMJ, 2003

Outcomes?

› In Victoria: Decline in claims for back pain,

rates of days off, and costs of medical management (~ $65m)

› In NSW: No change

Conclusion: Changing community’s beliefs about back pain led to change in behaviour of patients and the behaviour of their GPs.

The Truth about Chronic Pain Treatment

› When you seek help for your chronic pain, no doctor or physio or chiropractor can do it all by themselves – it must be a collaborative effort

› “Medical care for chronic illness is rarely effective in the absence of adequate self-care (by patient)”.

› Collaborative care = patients + providers : shared goals, sustained working relationship, mutual understanding of roles/responsibilities, requisite skills for carrying them out.

Von Korff et al. (1997) Ann Int Med, 127, 1097-1102

Pain self-management methods: many to choose from, they might include:

› Hot/cold packs › TENS machines › ‘Alternative’ medicines, alcohol, marijuana › Meditation, relaxation, distraction techniques, self-hypnosis › Prayer › Acceptance – mindfulness; challenging unhelpful thoughts › Exercise (fitness, stretch, strength) › Negotiate change of roles with family, workplace › Rest/avoid activities › Hot pools/hot showers › Modulating activities, using pacing, setting priorities/goals

31

Some might ease your pain, briefly, others may not

› But if the pain is chronic, which ones and how many? › How will they fit into the big picture?

32

NSA Pain Study, PAIN 2005;113:285-292

33

2092 adults in NSA 474 with chronic pain

Randomly selected from

community

NSA Pain Study, PAIN 2005;113:285-292

34

NSA Pain Study, PAIN 2005;113:285-292

35

› Divided pain self-management into 2 broad categories: 1.  Passive (rest/avoidance, hot packs, alcohol) 2.  Active (exercise, maintaining/modifying activities) Found: › Passive coping strategies strongly associated with higher pain-related disability (compared to active strategies)

› So, self-management methods not all equally helpful

New study: Nicholas et al. Euro Jnl of Pain, 2012

› Evaluated adherence to active self-management strategies › At end of intensive (3 week) pain management program › Strategies studied: › Compared to those who used these strategies irregularly › Those who used these strategies consistently made greater gains in

› New study – we found the difference was still there at 1-yr 36

Setting goals, activity pacing, exercising, desensitising, thought challenging

Usual pain, disability, depression, less medication, less catastrophising, higher self-efficacy

In summary

› Regular use of active self-management strategies improves quality of life for people with chronic pain

› Many work out their own methods › But, if not, they can be taught › But it is not black or white, or ‘one size fits all’ › Each person needs to work out a balance of methods that suit them

› In the end, it is what helps you to achieve your aims and to maintain a healthy lifestyle despite pain

37

Postcard from chronic pain patient

“We have been treking in the Annapurna region (in Nepal) - proof (if you needed more) that your treatments work!!!”

How did she do it?

A regular (stable) dose of slow release analgesic

and pain self-management strategies, including pacing, relaxation, cognitive strategies

Conclusions – when pain persists

› Chronic pain can cause great suffering and disability › There is no treatment or health professional who can fix it all ›  It is risky to expect the doctor to have all the answers › As with all chronic diseases, the person in pain must play an active role

›  If they do, chronic pain can be managed and a good quality of life is possible, despite ongoing pain

› Working with one's doctor in a collaborative way, often with others (like a physiotherapist or psychologist), offers hope

› But the person in pain must play their role and apply themselves consistently until it becomes a habit

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