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REDUCING REFERRALS TO THE CHRONIC PAIN CLINIC

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REDUCING REFERRALS TO THE CHRONIC PAIN CLINIC Dr Damien Smith FRCA, FFPMRCA Consultant Anaesthesia & Pain Management Hillingdon NHS Trust OTHER GUIDELINES RCGP uses ... – PowerPoint PPT presentation

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Title: REDUCING REFERRALS TO THE CHRONIC PAIN CLINIC


1
REDUCING REFERRALS TO THE CHRONIC PAIN CLINIC
  • Dr Damien Smith FRCA, FFPMRCA
  • Consultant Anaesthesia Pain Management
  • Hillingdon NHS Trust

2
RECENT NATIONAL PAPERS REPORTS
  • Report by Chief Medical Officer 2009
  • Nice guidelines for management of lower back pain
  • Review of chronic pain services (Wales)

3
HEALTH SECRETARY AND CMO
4
CMO REPORT 2009PAIN BREAKING THROUGH THE
BARRIER
  • United Kingdom Pain in numbers
  • 7.8 million people live with chronic pain
  • NHS spent 584 million on 67 million
    prescriptions for analgesia
  • 1 million women suffer with chronic pelvic pain
  • 1.6 million adults suffer with chronic LBP
  • 49 adults with CP experience depression
  • 25 of sufferers lose their jobs
  • 500 pain specialists in the UK
  • Roughly 1 specialist per 250,000 people
  • (1 specialist per 32,000 sufferers????)

5
CMO REPORT
  • When pain becomes chronic, normal damping
    mechanisms stop working
  • Biological, psychological and social factors
    combine to exacerbate symptoms
  • Modern pain management should address all these
    elements with an Integrated Approach
  • Treatments involve activity, rehab, drug therapy,
    psychological therapy, TENS, acupuncture and
    interventions
  • Key is to ensure all aspects are INTEGRATED and
    joined up rather than instigated in isolation

6
IDEAL MODEL
7
CMO REPORT IDEAL MODEL?
8
WAYS TO REDUCE REFERRALS
  • More level 3 services in the community?
  • Educational programme for GPs
  • Prescribing guidelines
  • Pharmacy teaching of community pharmacists

9
WAYS TO REDUCE REFERRALS
  • More level 2 care
  • Community screening teams
  • Interdisciplinary CBT based programmes
  • Patient support groups
  • Physio
  • ? TENS clinics
  • ? Acupuncture clinics
  • ? Consultant sessions in the community

10
NICE GUIDELINES MAY 2009
  • Early Management of Persistant Lower Back Pain
  • Patients must have back pain for LESS than a YEAR
  • Does NOT cover SUSPECTED
  • Malignancy
  • Infection
  • Fracture
  • Radiculopathy
  • Inflammatory disorder

11
NICE GUIDELINES
  • Care should be patient centred
  • Give patients advice and information to promote
    self management
  • Exercise
  • Manipulation
  • Acupuncture
  • Psychology

12
EXERCISE PROGRAMMES
13
EXERCISE PROGRAMMES
  • 8 sessions over 12 weeks
  • Groups of 10
  • Aerobic activity
  • Muscle Strengthening
  • Posture Control
  • Stretching

14
MANUAL THERAPY
15
MANUAL THERAPY
16
SPINAL MANIPULATION!!
17
MANUAL THERAPY
  • Spinal manipulation
  • Spinal mobilisation
  • Massage
  • MAY be performed by osteopaths and chiropractors
  • 9 sessions over 12 weeks

18
ACUPUNCTURE
19
ACUPUNCTURE
  • Advises 10 sessions over 12 weeks
  • Does not advise injection of therapeutic
    substances into the back

20
COMBINED WITH PSYCHOLOGY
21
PROBLEMS WITH THE GUIDELINES
  • NICE summary we recommend acupuncture and
    manipulation because they work every bit as good
    as placebo but we don't recommend injections as
    they only work as well as placebo.
  • Advise patients to have osteopathy and
    chiropractor services?????
  • Lack of regulation concerns!!!
  • Concerns from medical profession about potential
    damage from poorly practiced spinal manipulation.

22
PROBLEMS WITH GUIDELINES
  • No discussion with The British Pain Society
  • Multidisciplinary body
  • Conflict of interest with BPS chairman
  • Chairman had to resign
  • NEXT MONTH BPS NICE will meet to look at
    reformulating the guidelines.

23
WAYS OF REDUCING REFERRALS
  • Do not refer patients with NON specific back pain
  • Do not refer patients with less than 1 year
    history
  • Offer patients exercise, manual therapy,
    acupuncture and psychology
  • DO REFER patients with known specific back pain
  • DO REFER patients with potential mailignancy,
    infection, fracture, radiculopathy or
    inflammatory disorder

24
RECENT SURVEY OF GPS ABOUT SERVICES
  • Questionnaire about local chronic pain services
    and questions exploring ways to improve pain
    services.
  • 48 satisfied with service
  • 15 dissatisfied
  • 37 neither

25
WAYS TO IMPROVE THE SERVICE
  • GPs wanted-
  • More pain education in GP surgeries
  • More advise through the internet
  • More hospital based study days

26
WAYS TO REDUCE NEW REFERRALS
  • GPs requested a telephone helpline
  • Different triage system
  • Email helpline
  • More psychological training for community staff
  • Stricter criteria to accept patients to pain
    clinic

27
PRESCRIBING GUIDELINES FOR PREGABALIN
  • Based on a guideline produced by the European
    Federation of Neurological Studies
  • Algorithm for treatment of neuropathic pain

28
Neuropathic pain
Localised
Lignocaine patch
Satisfactory
TCA
Gabapentinoid
Pain Clinic
Lignocaine patch
TCA
Gabapentinoid
29
TRICYCLIC ANTIDEPRESSANTS
  • Amitriptyline starting dose 10-25 mg nocte
  • Dose may be increased to 50 mg nocte
  • Not an antidepressant dose and will not interact
    with concurrent antidepressants
  • Convert to Nortriptyline if problems with
    drowsiness (not licensed for pain / /equivalent
    dose)
  • Contraindications include glaucoma, hypertension
    and may lower seizure threshold in epileptics

30
GABAPENTIN
  • Starting dose 300 mg od
  • Gradual increase over days up to 900 mg tds
  • Requires a lot of patient compliance
  • Usually safe to take with other medications
  • Effects may be seen in WEEKS
  • Dosage needs to be adjusted in patients with
    renal dysfunction
  • Do not stop abruptly, needs to be done over weeks

31
PREGABALIN
  • Starting dose 75 mg bd
  • Increase to 150 mg bd if tolerated
  • Can work up to 300 mg bd in some cases
  • Effects may be seen in DAYS
  • Safe in patients with renal dysfunction

32
LEICESTERSHIRE MEDICINES STRATEGY GROUP
33
Neuropathic pain
Localised
Lignocaine patch
Satisfactory
TCA
Gabapentinoid
Pain Clinic
Lignocaine patch
TCA
Gabapentinoid
34
OTHER GUIDELINES
  • RCGP uses CREST guidelines (2006)
  • www.rcgp.org.uk
  • NICE guidelines (March 2010)
  • www.nice.org.uk

35
ANY QUESTIONS?
  • Damian.smith_at_thh.nhs.uk
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