Treating postoperative pain

“ThisUnbearablePain”ThePost-operativeDilemma

DrBrendanMoorePainMedicineSpecialist

PhysicianAdjunctAssociateProfessor

UniversityofQueensland

Topicsfortoday

• PostoperativepainDilemma

Workshop• Interventionsformechanicalbackpain• Opioidissues• PsychologyinpainPatients

3Messages

• EarlyIdentificationandtreatmentofneuropathicpain

• Managementofpostopopioids

• Exampleofmedicationregimes

•“Anunpleasant sensoryandemotionalexperience associatedwithactualorpotential tissuedamage,ordescribed intermsofsuchdamage.”

Definingpain

InternationalAssociationfortheStudyofPainWebsite.Availableat:http://www.iasp-pain.org/terms-p.html.Accessed30June,2006.

InternationalAssociation fortheStudyofPain(IASP)

Thecontinuumofpain1

<1month

Timetoresolution

≥3-6months

AcutePain

ChronicPain

• Usuallyobvioustissuedamage

• Increasednervoussystemactivity

• Painresolvesuponhealing

• Servesaprotectivefunction

• Painfor3-6monthsormore2

• Painbeyondexpectedperiodofhealing2

• Usuallyhasnoprotectivefunction3

• Degradeshealthandfunction31. ColeBE.Hosp Physician2002;38:23-30.2. TurkDCandOkifuji A.Bonica’sManagementofPain2001.3. ChapmanCRandStillmanM.PainandTouch1996.

Insult

Classificationsofpain

Acute

Chronic

Duration

Nociceptive

Neuropathic

Pathophysiology

Biomedical Aspects of Pain1,2

• Nociceptive pain è noxious stimuli, e.g. ongoing tissue damage

• Neuropathic pain è neurological injury or dysfunction

• Clinical features suggesting neuropathic pain: – Absence of obvious tissue damage or inflammation– Characteristic descriptors:

• Burning, shooting, sharp pain– Sensory findings both

• Positive e.g. allodynia/hyperalgesia• Negative e.g. sensory loss

1. Analgesic Expert Group Therapeutic Guidelines: Analgesic. 20072. Jensen TS, et al. Eur J Pharmacol 2001;429:1-11.

Nociceptive Neuropathic

Nociceptivevs neuropathicpainstates

• Arisesfromstimulusoutsideofnervoussystem

• Proportionatetoreceptorstimulation

• Whenacute,servesprotectivefunction

• Arisesfromprimarylesionordysfunctioninnervoussystem

• Nonociceptivestimulationrequired

• Disproportionatetoreceptorstimulation

• Otherevidenceofnervedamage

vs

SerraJ.ActaNeurolScand1999;173(Suppl):7-11.

Nociceptiveandneuropathicpain

• Arthritis• Sports/exerciseinjuries

• Postoperativepain

NeuropathicpainNociceptivepain Mixed

• PainfulDPN• PHN• Neuropathiclowbackpain• Trigeminalneuralgia• Centralpoststrokepain• Complexregionalpainsyndrome• DistalHIVpolyneuropathy

Causedbylesionordysfunctioninthenervoussystem

Causedbytissuedamage

Causedbycombinationofprimaryinjuryandsecondaryeffects

• Lowbackpain• Fibromyalgia• Neckpain• Cancerpain

InternationalAssociationfortheStudyofPain.IASPPainTerminology.RajaSN,etal.inWallPD,MelzackR(Eds).Textbookofpain.4thEd.1999;11-57.

“Sciatica”:mixedpainstate

BaronR,BinderA.Orthopade 2004;33:568-75.

DiscCfibre

CfibreAfibre

Nociceptivecomponent:SproutingfromC-fibresintothedisc

NeuropathiccomponentI:DamagetoabranchoftheCfibreduetocompressionandinflammatorymediators

NeuropathiccomponentII:Compressionofnerveroot

NeuropathiccomponentIII:Damagetonerverootbyinflammatorymediators

Centralsensitisation

Neuropathic Pain

• Bad post operative prognostic indicator

• Early effective treatment planrequired

1. Analgesic Expert Group Therapeutic Guidelines: Analgesic. 20072. Jensen TS, et al. Eur J Pharmacol 2001;429:1-11.

Managementof pain

BelgradeMJ.PostgradMed 1999;106:101-40.AshburnMA,Staats PS.Lancet1999;353:1865-69.Abuaisha BB,etal.DiabetesResClin Pract1998;39:115-21.

Pharmacotherapy

Physicalrehabilitation

Interventionalregional

anesthesia

Complementary/alternative

Lifestyle

Neurostimulatory

Psychological

Treatmentapproaches

ObservationsandAdvicefromtheclinical“coalface”

PostoperativePain

• Stronganalgesiaceasedat2to4weeks• Importanttoplantoceasestronganalgesia• Surgeondoesn’tintendlongtermcontinuationofpostopanalgesia

• Proportionofpatientsfailtheplan!!

NeedaNewPlan!!

• ChangeinthePain• Mixedpaincondition

– NociceptiveandNeuropathic• ComprehensiveManagementplan

– Notmedicationsalone– Aimatrestorationofphysiotherapyandfunction

MedicationPlan

• Paracetamol/NSAIDs• AdjuvantAnalgesics• Gabapentin/Pregabalin• Tricyclicantidepressants(orothers)• StrongAnalgesia

StrongAnalgesia

Asetbacknotasentence!!• Cleardefinitiveplan• Shorttermincrease,thenreduceandcease• Sustainedreleaseonly• BythemouthandbytheClock• Noshortterm,nobreakthrough• Pre-determineddosereduction

FavouredCocktailsandRecipes

FavouredCocktailsandRecipes

1. Paracetamol1gm,qid2. NSAIDs

– Ibuprofen400mgtds– Celecoxib200mgbdè 100mgbd

3. TricyclicAntidepressant– Amitriptyline10è50mgnocte– Sedationandsleepacceptable(oftendesirable)

FavouredCocktailsandRecipes

4.Gabapentinoids• Gabapentin300mg,300mg,600mg• Pregabalin150mg,300mg

StagedincreaseindoseHigherdoseatnightOpioidsparingeffect

FavouredCocktailsandRecipes

• StrongAnalgesiaOxycontin 10or20mgx20tabs

2tabsx5daysthen,1tabx10days

Hydromorphone4mgx20tabs8mgdailyx5daysthen,4mgdailyx10days

FavouredCocktailsandRecipes

• StrongAnalgesiaOxycontin 10or20mgx20tabs

2tabsx5daysthen,1tabx10days

Hydromorphone4mgx20tabs8mgdailyx5daysthen,4mgdailyx10days

TramadolTapentadol

PaintheFifthVitalSign™

Needtoregularlyaskaboutthepresenceofpain.

AmericanPainSocietyMashfordMLetal,TherapeuticGuidelines:AnalgesicsEd4,2002

3Messages

• Managementofpostopopioids

• EarlyIdentificationandtreatmentofneuropathicpain

• Medicationregimes

END

How persistent pain can become a problem

Adapted from: Nicholas, 2008.

IsthePainMechanicalorNot?

Mechanical Non-Mechanical (red flags)

PainPoorly localisedWorse later in the dayUsually worst when sitting, worsens with movement

Usually localisedNo diurnal variationsUninfluenced by posture or movement

Spinal movementPainful limited movement usually of several segments

Normal or hypomobility limited to one or two segments

TendernessDiffuse Localised

Other featuresPatient is essentially well Of underlying disease

Neurological signsMay be present May be present

AdaptedfromMashford.TherapeuticGuidelinesAnalgesic;2002.

Acute and Persistent Pain: Different Clinical Entities1

• Acute pain: – Recent onset– Expected to last a short

time– Expectation is complete

recovery

• Persistent pain:– Persists for > 3 months– Expectation is not one

of cure

Recurrent acute pain, feature elements of both acute and

persistent pain

1. Analgesic Expert Group Therapeutic Guidelines: Analgesic. 2007

Red Flags1

• Most clues are in the history

1. Australian Acute Musculoskeletal Pain Guidelines Group. Evidence-based management of acute musculoskeletal pain. A guide for clinicians. 2004.

FeatureorRiskFactor Condition

Symptomsorsignsofinfection(e.g.fever)Riskofinfection(e.g.penetrating wound)

Infection

Historyoftraumaorminortrauma(if>50 years,osteoporosis+corticosteroiduse)

Fracture

PrevioushistoryofcancerUnexplainedweightlossAge>50yearsPainatrestPain atmultiplesitesFailuretoimprovewithtreatment

Tumour

Absenceofaggravatingfactors Aorticaneurysm

Pain and Impact on Quality of Life1

Physical well-being Psychological well-beingStamina/strengthAppetiteSleepFunctional capacityComfort/pain

CopingControlEnjoyment/happinessSense of usefulnessAnxiety/depression/fear

Social well-being Spiritual well-beingSocial support/familySexuality/affectionEmploymentFinancesRoles and relationshipsIsolation/dependence/burden

ReligionSense of purpose/meaning/worthHopefulnessUncertaintySuffering

1. Lynch TJ, Jr. Pain the fifth vital sign. J Intravenous Nursing 2001;24(2):85-94

Factors Associated with Persistent Back Pain1

• Structural changes on spinal imaging

• Disc degeneration• Disc tears / prolapse• Facet joint degeneration• Central & lateral canal stenosis

1. Waris E, et al. Spine 2007 15;32(6):681-4. 2. Jarvik JG, et al. Spine 2005;30(13):1541-8.3. Schenk P, et al. Spine 2006;31(23):2701-6. 4. Videman T, et al. Spine 2003;28(6):582-8.

Commonas we agebut not associatedwith pain

GP’s Role1

• Patient education and motivating change• Biopsychosocial assessment

– Red and yellow flags– Periodical reassessment and whenever new

symptoms are reported• Coordination of care and appropriate referral• Discouraging inappropriate searches for a cure• Discouraging prolonged treatment that is not

leading to improved function

1. Analgesic Expert Group Therapeutic Guidelines: Analgesic. 2007

The Evolution of a Persistent Pain

DrJames O’CallaghanAnaesthetist

and Pain Medicine Specialist

Mater Private Clinic,

Brisbane

Recovery

Chronic Pain Disability Cycle1

1. Analgesic Expert Group Therapeutic Guidelines: Analgesic. 2007

Surgery

Rehabilitationdespite pain

Pain-dependentbehaviour

Behaviour NOT dependent on pain

ACUTE PAIN

CHRONIC PAIN DISABILITY CYCLE Desperation

Hopelessness

Anger

Loss of controlInappropriate management

Social stressesAnxietyActivity avoidance

Unhelpful beliefs

Passive treatments

Demands for treatment

Deconditioning

Drug tolerances

Transition To Persistent Pain1

Emotionally charged

Loss of: • Hope• Confidence• Trust

Stressed relationships• Family• Doctor

Poor communicationDesperation

1. Analgesic Expert Group Therapeutic Guidelines: Analgesic. 2007

Psychosocial Yellow Flags1

Work Behaviours

Believe pain is harmful èfear avoidance behaviourBelieve pain must be abolished before returning to workCompensation issues

Passive attitude to rehab.Use of extended restê activityAvoidance normal activitiesé alcohol consumption

Beliefs AffectiveCatastrophising, thinking of the worstMisinterpreting bodily symptomsBelieve pain is uncontrollable

DepressionFeeling useless, not neededIrritabilityAnxietyLack of supportOverprotective partner

1. Jensen S. Aust Fam Physician 2004;33(6):393-401

Factors Associated with Persistent Back Pain1

• Premorbid factors– Older age– High levels of psychological distress– Below average self rated health– Low levels of physical activity– A history of low back pain– Not being employed, dissatisfaction with current employment

• Episodic factors – The presence of widespread pain– Long duration of symptoms prior to consultation– Radiating leg pain

– Restriction of spinal movement

1. Thomas E, et al. BMJ 1999;318(7199):1662-7.

Influences on Progress and Outcome1

• Negative influences

– Maladaptive ‘treatment’style

– Maladaptive family ‘support’

– Maladaptive work environment

– Conflict– Unrealistic expectations– Maladaptive response to

life stressors

• Positive influences (on early response)– Adequate assessment,

treatment and support– Early pain relief– Appropriate style

• Patient, family, GP– Understanding their

situation– Realistic expectations– Adaptive response to life

stressors

1. As adapted from Analgesic Expert Group Therapeutic Guidelines: Analgesic. 2007

Persistent Postoperative Pain1

• Preoperative factors– Moderate – severe pain lasting more than 1 month– Repeat surgery– Psychological vulnerability– Worker’s compensation

• Intraoperative factors – Nerve damage during surgery

• Postoperative factors– Pain (acute, moderate – severe)– Depression– Psychological vulnerability– Anxiety– Neuroticism

1. Perkins FM, Kehlet H. Anesthesiology 2000;93(4):1123-33.

Persistent Pain Requires a Different Approach1,2

Acute pain Persistent painCure the illness causing the pain Restore physical, psychological, social

function, minimise distressSymptom relief Control pain to tolerable level, ê distress

Focus on the painful part “Whole person” rehabilitationExpectation: return to previous health status

Adjustment is necessary, new skills/lifestyle

Passive dependent patient Active coping, participating patientActive “hands on” practitioner Practitioner who acts as a “coach”Analgesics given according to current level of pain, dose reviewed frequently

Regular, predictable schedule of analgesics

Medication and physical modalities Multidisciplinary approach Short-term focus Long-term focusRest is often appropriate Activity is generally appropriate

1. Analgesic Expert Group Therapeutic Guidelines: Analgesic. 2007. 2. NSW TAG. Prescribing guidelines for primary care clinicians. General principles. 2002.

Thankyou