Persistent (chronic) Pain

1. Persistent (chronic) Pain A joint exploration leading to first steps in improving management AND in teaching these skills. Dr Dave Tomson FRCGP GP, North Shields Network Director and freelance consultant in patient centred care

2. Plan for the day • 9-1 Understanding and improving management of persistent pain • 2-4 Processing the workshop and designing teaching sessions for registrars • Doing some practice of this in small groups • 4pm Finish ( at the latest!)

3. Objectives for the workshop 1 Improving the health outcomes for patients with persistent pain: • more confident to self manage their pain problem • better health, functional outcomes, lives • better knowledge and skills with own access to resources/ tools to support these outcomes + • reduction in ineffective unsafe use of medication • reduction in addiction to opioids or gabapentinoids Outcome Reduction in impact of pain on their lives and some reduction in level of pain Reduction in use of health care/more appropriate use

4. Objectives for the workshop 2 Increase knowledge + skills of front line providers managing patients with persistent pain: • Name emerging persistent pain syndromes <6 months onset • Shift focus from biomedical to biopsychosocial; person centred approach with shared Responsibility • Explain pain and Explore impact • Move from HOW IS PAIN? to HOW IS YOUR LIFE? • Use of tools + guides to help understanding and self management • Less drugs and always framed as a trial • More effective, timely, and successful referral to Living well with pain service ( or alternative pain management service)

5. The basic model Recognise PP and tentatively name it Hear the story, and start exploring broader IMPACT Use the 2 questions if necessary ACTIVITY AND MOOD Start trying to SHIFT the conversation - from search and fix towards – acceptance/ understanding/ and living well with Explanation of pain Exploration of impact Self management Toolkits/ HNA/ Exercise/ etc and referral - Less meds/ more patient responsibility

6. Demonstration of how it sometimes goes

7. Where are you now? • Knowledge and confidence in managing Persistent pain? • Ever given the patient a diagnosis? • Ever coded persistent /chronic pain?

8. Challenges in PP • For patients – both living with PP and working with the health care system • For you - as clinicians working with patients with these difficulties – the clinical issues AND the personal/ professional issues

9. Why is PP so difficult to live with for patients? Difficult to get diagnosis, prognosis and validation Impacts on every aspect of life Cause can be someone else’s fault Misconceptions about pain Accepting there is often no cure or complete relief Co-morbidity

10. What is PP so difficult for practitioners? • Medical model does not work well • Drugs don’t work well • We worry we still might miss something ‘treatable’ • Patients can feel hard work • We are not sure what else we can do • We are often ‘invited’ and often actively take on responsibility for fixing…

11. Understanding (persistent) pain Mostly to help clinicians but also to help some patients who need this understanding to accept the ‘shift’ Basically - Pain turns out not to be simple!

12. Exercise – explain pain • try and explain what you think is happening when someone experiences acute pain • And then persistent (chronic) pain • Share this

13. Explaining pain Common explanations for acute pain include: • Damaged tissues • Chemical release • Pain nerves • Pain centres • Pain is way of avoiding danger This model holds up OK on first glance

14. Acute and chronic illness models

15. Choosing a model If you had a choice of how to think about a health condition; which would you choose? You’d choose the acute pain version as fits with the themes + represents the acute biomedical model – the basis most of us use to think about health and illness

16. Applying the acute model to all health problems leads to the mythology of House = There is always a scruffy doctor somewhere who will have the ‘answer’... ...You just have to find him/her This does not lead us towards understanding persistent pain and better Self-management

17. Biomedical model does not fit in persistent pain managementBiopsychosocial model fits better with modern understanding of what persistent pain is - “a multiple level complex dysfunction of neural networks”

18. Back to Jo and his/her persistent pain (consultation 1) Naming the problem Setting up for a wider biopsychosocial conversation Demonstration

19. Two questions • During the past month has it often been too painful for you to do your day to day activities? • During the past month has your pain been bad enough, or often enough, to make you feel worried or low in mood?

20. I think your pain may not be as simple as we first thought…. • Could we move forward … as this pain is tricky ... And can we look at it in a different way? • We would hope this type of pain in this situation would be getting less/ better controlled with the meds/ starting to fade….so it is not straightforward . We need to change tack • I think you have something called a persistent pain problem.... • We know that at this stage that there is no longer any tissue damage and yet you are still experiencing lots of pain – I think your pain problem is changing… We need to work together and differently... Are you up for that?

21. Rehearsal ONE JO Presents as in demonstration Clinician has a go at : • Standing back • Asking the 2 questions • Suggesting the diagnosis of persistent pain

22. Back to Jo • “OK so you’re saying this is different but what about my pain – why do I still have the pain if the scans are all OK??”

23. Demonstration (also consultation 1) Finding explanatory models Pitching at patient level

24. Pain is not simple!

25. Pain Puzzles • Pain without peripheral stimulus • Pain when you visualise someone else in pain • The pain in foot story • Finishing the 100m with broken leg • Cold hand with blue and red lights • Pain when you are depressed • Mismatch degree of pathology and pain level • Allodynia and other pain syndromes

26. Lee Moran NEW YORK DAILY NEWSWednesday, August 13, 2014, 10:55 AM • A Chinese man is lucky to be alive after a knife dropped from a high-rise building spiked into his head - and he didn't even notice. • Xiao Yunzhi was reportedly walking in Guangyuan, Sichuan province, last Thursday when the blade fell from an eighth floor balcony, then penetrated and lodged inside his skull. • Blissfully unaware, the 57-year-old continued going about his daily chores. But he later felt his head start to feel "oddly heavy" - and he was stunned to find out the cause after walking into a tobacconist, where a worker pointed at his scalp.

28. Metaphors • Car alarm • Smoke detectors • Love is real but you cannot scan it • Pain as Rottweiler/ the beast • Thinking of yourself as athlete • Life as a bus – who is driving?

29. Metaphors and pain puzzles • Your own ideas/ favorite explanations?

30. Neuropsychosociobiology of pain • Pain is ultimately about protection – the brain’s attempt to protect the body • ALL pain is a conscious experience created by the brain and designed to protect the person • It is the end result of a highly complex set of peripheral and central neuroendocrine processes Pain is complex and a two way process impacting on health function and impacted by many aspects of persons behaviour

32. A helpful way of talking with patients (and thinking about this yourself) CONCIOUS MIND/ SELF UNCONCIOUS BRAIN PAIN SYSTEM TISSUE DAMAGE

33. Further ideas - to explore later • Sensitisation • Downward regulation • Nociceptive and neuropathic pain • Neurotags Great references: Explain Pain – lorimer Mosely et al and 10 Minute consultation – persistent pain

34. Nociception Nociception • Tissue damage – pain- healing time • Pain beyond natural healing time begins NOT to reflect state of tissues • Failure of the pain SYSTEM – the process that switches off the pain fails

35. Neuropathic • Damaged nerves firing in both directions – neurogenic pain • Firing off more easily • Particular character

36. Differentiating and identifying PP and the transition or development of PP • Remember the 2 question tool • STarT tool for back pain • Leaflet on diagnosing PP • Neuropathic pain tool • Time/ yellow flags What else can we come up with?

37. Yellow flags from BMJ article on back painBMJ2003; 326 doi: http://dx.doi.org/10.1136/bmj.326.7388.535 (Published 08 March 2003) Cite this as: BMJ 2003;326:53 • A negative attitude that back pain is harmful or potentially severely disabling • Fear avoidance behaviour and reduced activity levels • An expectation that passive, rather than active, treatment will be beneficial • A tendency to depression, low morale, and social withdrawal • Social or financial problems

38. How to start ‘moving towards new shared understanding with patients’ Shifting the frame/ narrative/ thinking

39. You have identified persistent pain but patient is stuck on “why?”

40. The basic model Recognise PP and tentatively name it Consult. 1 Hear the story, and start exploring broader IMPACT Use the 2 questions if necessary ACTIVITY AND MOOD Websites Leaflets Utube videos Start trying to SHIFT the conversation - from search and fix towards – acceptance/ understanding/ and living well with Exploration of impact Explanation of pain Self management Toolkits/ HNA/ Exercise/ etc and referral

41. Rehearsal TWO • So using some of the above – start with Jo - “why am I still in pain?”

42. Debrief and learn from eachother

43. The basic model Recognise PP and tentatively name it Consult. 1 Hear the story, and start exploring broader IMPACT Use the 2 questions if necessary ACTIVITY AND MOOD Websites Leaflets Utube videos Start trying to SHIFT the conversation - from search and fix towards – acceptance/ understanding/ and living well with Consult 2 Consult 2 Explanation of pain Exploration of impact Self management Toolkits/ HNA/ Exercise/ etc and referral

44. Demonstration Exploration of the pain and its impact on Jo’s life Five areas Iceberg and pain cycle HNA

45. Introducing the idea of self care more details You are moving from ‘Search and fix’ to ‘ Living well with pain’. How to do this? • Use of five areas and other ways to broaden the lens • Use of pain and self management circles • Use of Health needs assessment

46. Exercise – • what influences a person’s experience of pain? Think of patients you have seen with persistent pain problems. What do you know about their thoughts/ behaviours/ emotions/ body symptoms and their life situation?

47. Five areas model (person centered ) Cognitive Behavioural Model Life Situation/Practical Problem etc. Altered thinking Altered physical Altered body symptoms mood(emotions) Altered behaviour

48. Sally’s Five areas model (person centred model) I can’t cope anymore, nothing helps no money coming in, lost my future now. I worry something worse will go wrong with my neck Worried, low Neck pain, stiff shoulder, I sleeps badly, tired all day Stopped work & my daily dog walks, Just watching daytime tv. And rest whenever I can. Don’t go out much now Life Situation/Practical Problem etc. Memory; boss bullying me, stress with neighbours, gas bill due this week Altered thinking Altered physical sensations Altered mood(emotions) Altered behaviour / actions

49. The pain cycle Understanding the ‘what’ before the ‘how’ persistent pain relationship concerns being less active time off work, money worries loss of fitness, weak muscles, stiffness the pain cycle depression, mood swings sleep problems, tiredness negative thinking, fear of the future stress, fear, anxiety, anger, frustration weight gain side effects of medication

50. Persistent Pain Sleep and tiredness problems Money worries Medication side effects. addiction Feeling low, angry, ashamed, anxious Relationship worries Loss of fitness, job, health, self identity Weight issues Iceberg tool is on the website