Hunter Integrated Pain Service (HIPS)

1. Understanding Pain Hunter Integrated Pain Service (HIPS) Welcome to RNC www.hnehealth.nsw.gov.au/pain

2. Outline What is pain? 1 The new science 2 Whole person management 3 Introducing HIPS & what next? 4

3. What is pain? • Indication of threat • Actual or potential damage • Emotional experience

4. What is acute pain? • Short term • Often linked to body structures • under threat • damaged Egloff N, Hirschi A, von Känel R. J Pain Research 2013;6:765–70 threat ... damage ...

5. What is chronic pain? • Lasts 3 months or more • Often persisting after body structures heal • Wind up of nervous system Egloff N, Hirschi A, von Känel R. J Pain Research 2013;6:765–70 hyper-alert ... flea bite feels like the eagles claws

6. Role of nervous system • Wind up or sensitisation increases pain • Winding down reduces pain 2 The new science

7. Structural changes and ongoing pain

8. Symptoms without the structure • Painful, swollen, stiff left ankle • Imagined exercise of the phantom limb relieved symptoms Haigh et al 2003 Rheumatology

9. Chronic stress changes neurons Davidson, McEwen. Social influences on neuroplasticity. Nat Neurosci. 2012;15(5):689-95

10. Brain changes predict persisting pain • Ongoing pain linked to emotional response to initial injury • “Traumatic” memory imprints the brain in a different way Baliki, Apkarian et al. Corticostriatal functional connectivity predicts transition to CBP. Nature Neurosci. 2012 Back pain recovering Back pain persisting

11. Brain habits Sheep tracks Winding up or down

12. A need to restore balance • Nervous system • Active treatments For many people the balance is not right • Body structures • Medical treatments

13. 3 Whole person management Adapted from Hayes & Hodson. A whole person approach to persistent pain. Pain Medicine 2011;12(12):1738-49

14. Think well • Move well • Eat well Brainman’s choices

15. What is the evidence for medical treatments? “I think the dose needs adjusting. I’m not nearly as happy as the people in the ads.”

16. Morphine in chronic pain 0 2 4 6 8 time (weeks) Moulin et al. Lancet 1996

17. Well known Constipation Drowsy, clouded thinking Tolerance Addiction Did you know about ? Worsening pain (opioid induced hyperalgesia) Sexual dysfunction Driving impairment, risk of death (especially with sleeping tablets) Opioid side effects

18. Biomedical STEP 1: Rule out danger • Harmful structural problems? • Red flags – cancer, fracture, infection, nerve pressure STEP 2: Medical treatment as part of broad approach • Medications / procedures • Time limited • Pain recovery plan

19. Opioid strategy Time limited HIPS support you & GP for as long as needed to wean off opioids

20. Mindbody • This is normal • Mind & body interweave • Awareness of thoughts • Peace of mind Eccleston C. A normal psychology of chronic pain. 2011;24(6):422-425

21. Timeline

22. Connection • People, purpose, place • Isolation & disconnection are common • Reconnecting - part of recovery & wellbeing

23. Activity • Finding the right balance • Body awareness • Awareness of thoughts behind the movement • Ease of movement, ease of mind

24. Nutrition Nutrition Inflammatory diet worsening pain • Fruit & vegetables (2 & 5) • Less sugary drinks • Time limited supplements • Address smoking, alcohol, other drugs

25. Brian’s story • 6 months of low back pain after an injury at work • Scan - disc bulge & tear

26. Brian’s assessment • No red flags - spinal structure less relevant • More about changes in brain & spinal cord • Oxycontin not working • ‘Men should get on with it’ • Pushing through, ‘boom & bust’ cycle

27. Brian’s pain recovery plan • Opioid wean over 4 months • Goal setting – travel & grandchildren • Awareness of thoughts • Pacing activity • Improve flare up management

28. Brian’s recovery • Background pain from 8/10 to 6/10 • Positive changes in thinking, mood & activity • Less interference with life • Flare ups • fewer • managing differently

29. Anna’s story • 30 yrs married • Not working due to poor health • Chronic widespread pain & fatigue

30. Anna after Understanding Pain • Nutrition • less processed food • more vegetables • omega 3 fish oil • weight loss 5 kg • Psychological aspects • local counsellor

31. Anna’s assessment • Onset pain & fatigue age 15 years; ‘fibromyalgia’ • Widespread pain in muscles & joints 6-8/10 • Long term Norspan – no ongoing benefit • Low mood • Avoidance of activity

32. Anna’s timeline • Large family, Anna eldest child • Father’s business failed when Anna was 15 yrs; he moved away • “my childhood ended” • “weight of responsibility settled on my shoulders”

33. Anna’s pain recovery plan • Biomedical - wean Norspan over 3 months • Mindbody workbook / local counsellor • Return to work & future education options • Walking program - “pacing” • Continue “anti-inflammatory” eating

34. Anna’s recovery • Phone call at 1 month • Continuing with pain recovery plan • Phone call at 8 months • 80% less pain & fatigue • Further 5 kg weight loss • Work as part-time cleaner • TAFE course • Mindbody Workbook – forgiveness

35. Public system • Types of pain • Chronic non-cancer • Acute • Cancer • General practice links 4 Hunter Integrated Pain Service

36. Key messages • Use active treatments • Get support • Wean pain medication

37. HIPS websitewww.hnehealth.nsw.gov.au/pain Google: Hunter Integrated Pain Service

38. Assessment and Planning • Small group • Supported self-assessment • Pain assessment & recovery plan • biomedical • mindbody • connection • activity • nutrition

39. Where next?