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A comprehensive two-day meeting on pain management in primary care was held at the Gibson Hotel in Dublin recently.
Mr Tom Coogan, General Manager of Grunenthal Pharma Ireland, which organised the meeting, opened proceedings by extending a warm welcome to attendees. Mr Coogan also provided a brief overview of Grunenthal, which is a pain specialist company.
“We are striving to generate a pain portfolio; a portfolio of products that offer benefit to you and for your patients, for a wide spectrum of pain conditions,” outlined Mr Coogan.
“Specifically from our side we are delighted to be able to provide that portfolio of products for you. We are really striving to be perceived by you as a significant company in Ireland with a significant portfolio, offering solutions for your patients.”
Mr Tom Coogan
Mr Coogan said the company is grateful to GPs for their interest in its products. “We have a strong heritage in primary care,” he said.
Chair of the opening session was Drogheda GP Dr Alan Moran. He introduced the first speaker, Mr Enda Murphy, a leading cognitive behavioural therapist. Mr Murphy spoke on stress management and introduced strategies to help GPs reduce their own stress and to assist patients, including those experiencing pain.
As Mr Murphy outlined, feelings are not caused by circumstances, but the interpretation of those circumstances. “In its simplest form, our interpretation and what attachment we make to that interpretation, we call that a belief,” he said.
People possess a logical brain in the prefrontal cortex, and an emotional brain located in the limbic system. “When they are in sync with one another and we are in good mental health, you reach a point that I would call your wise mind,” he outlined.
The emotional mind has nearly twice the number of neurological cables and connections as the logical brain, “so our life tends to be dictated more by emotion than logic”.
The CBT expert also distinguished fear from anxiety. “Fear is generally about something that has already happened, and we are afraid it will happen again. Similarly, anxiety is about something that hasn’t happened yet. And because it hasn’t happened yet, we over-think it.”
In fact, nothing that one became anxious about ever came true. “It is the curveball that arrives on a wet Tuesday afternoon that gets you — the thing you never saw coming.”
Similarly, one could be afraid of making mistakes and may make mistakes. However, the consequences would never be as bad as one had imagined.
People who were chronically depressed for years had abnormalised normal, distressing emotions and insisted that they must not be anxious, said Mr Murphy.
Mental health is about learning to accept the uncertainty and insecurity of life without getting anxious.
“What you gradually do is start striving for what we call ‘mental health’ — changing whenever possible but adapting when necessary, because the skill of living is accepting the uncertainty of life without getting anxious,” he said.
Anxiety could be dismantled in the same way it had grown — by practice. “You have developed the problem over time by practice and you can only dismantle it over time by practice,” he said. “The less control you try to exert, the more control you will feel you are in.”
Dr Hugh Gallagher, Director of the Acute Pain Service, St Vincent’s University Hospital, Dublin, was the second and final speaker on the first day of the meeting. Interventional pain treatment and management of pain issues in the aging population are among Dr Gallagher’s clinical interests.
Dr Hugh Gallagher, St Vincent’s Hospital
During his presentation on ‘Pain: Pathways and Diagnosis’, Dr Gallagher outlined how pain is a highly challenging issue for both patients and doctors. It is an understandable source of frustration for patients, he said.
A description of pain, often used in the nursing literature, is that it is whatever the person said it is, existing whenever the experiencing person said it does. However, Dr Gallagher noted that this definition is not particularly scientific. In the scientific community, pain is described in terms of sensation and emotion.
There are various approaches for classifying pain, said Dr Gallagher. Pain could be described as acute or chronic. If pain persists for longer than an arbitrary period of three to six months, one is looking at an intractable, persistent or chronic pain state.
Pain could also be classified according to its underlying pathophysiology — that is, nociceptive versus neuropathic pain. The latter involves the body’s response to an external insult or injury, or internal injury due to an autoimmune condition, for example. Neuropathic pain involves damage, injury or disease within the somatosensory nervous system.
“Now, to our patients, they have got pain. You don’t ask them, ‘do you have acute pain today or do you have chronic pain’ — they have got pain,” he said.
In terms of the focus of the meeting — chronic pain — Dr Gallagher said this type of pain is the echo of whatever caused it in the first instance. “It is the residual long-term neurological after-effect of some insult — whether it is chemotherapy causing peripheral neuropathy, years of diabetes and bad living, or some condition which has resulted in pain. Generally, it is taken to be somewhere between three and six months from the initiating event, and the sad thing is that it can be lifelong.”
Dr Gallagher clarified that chronic pain does not mean daily, severe, relentless pain. Rather, it can be associated with a condition that relapses. Patients with Crohn’s disease, for example, can be relatively well controlled on anti-TNF drugs, but occasionally they may have flares and experience severe pain. This is psychologically challenging for patients, who live in fear of the pain recurring, he said.
“It is just the unknown-ness of it, that it might come back again,” remarked Dr Gallagher. “‘I won’t do ‘X’ because I might get pain.’ A lot of people put their lives on hold and it has a traumatic effect in terms of their quality of life, their enjoyment of life, their spontaneity and indeed their employability. It results in lots of social problems as well.”
Mental health is about learning to accept the uncertainty and insecurity of life without getting anxious
Pain is something that transcends culture, age and other variables. “We all know what it is and how bad it is, and there is a lot of it about,” he added.
Dr Gallagher pointed to a survey of chronic pain in Europe (Breivik et al, 2006), which put prevalence of chronic pain in Ireland at 13 per cent, lower than the European average of 19 per cent. Furthermore, the PRIME study (Raftery et al, 2011) found that chronic pain affected up to one-in-three people, and estimated the total cost of pain in Ireland as €4.76 billion per year, or 2.55 per cent of Irish GDP in 2008.
“We are talking about a significant social as well as a medical cost,” said Dr Gallagher. “The prevalent conditions are what you would expect — headaches, migraine, lower back pain, arthritis in general and knee pain — they are the top-line reasons for someone seeing a GP with pain, overall throughout the world. And all of those I just mentioned, they are all commoner in women.”
In respect of treatment, Dr Gallagher said Ireland is not performing badly. The time after diagnosis by which pain is adequately managed was 1.4 years, as against the European average of 1.9 years (Pain Proposal European Consensus Report, 2010).
“And again, as a measure of satisfaction about how well pain is controlled, we are doing pretty well: 35 per cent of people feel their pain is not adequately managed, so we are doing better than the European average [38 per cent].”
Interestingly, the best performing countries expend the highest amount of training hours on identification, treatment and management of chronic pain. Ireland is positioned in the latter half of the table, which Dr Gallagher said underlines the importance of educational meetings.
He noted that addressing pain in primary care can be challenging. A Canadian study (Zlateva I et al, 2012) highlighted four salient points with regard to addressing chronic pain issues in primary care.
This research referred to prior negative experiences among GPs in effectively managing patients with chronic pain, which could relate to medication management, misuse of drugs, diversion of drugs and unpleasant social interactions.
Secondly, the study noted uncertainty about the assessment of chronic non-cancer pain (CNCP), such as whether the pain was really there. Thirdly, uncertainty existed about the most effective treatment of chronic pain. Finally, there were concerns over the potential for opioid addiction and misuse.
Presentation of patients with pain is a very significant issue for primary care, in respect of workload, and people in Ireland with chronic pain visit their GP 8.3 times per year, on average.
The next portion of Dr Gallagher’s presentation focused on the physiology of pain, before he touched on variance in tolerance among people and in the same person over time.
In respect of pain descriptors, this could be broken down into somatic pain — “pain which is, if you like, outside the organs” and visceral pain at the centre of the body and in the organs.
Nociceptive pain is directly related to tissue damage and can be either external (somatic) or internal (visceral). It is the most common type of pain, can be superficial or deep, and is usually described as sharp, shooting, throbbing, burning or stinging. It occurs in a well-defined area and usually lasts from seconds to days. Examples include postoperative pain and fracture.
Severe, unrelieved, acute pain results in abnormally-enhanced physiological responses that lead to pronounced and progressively increasing pathophysiology
Visceral pain originates in the walls of visceral organs. It is vague and poorly defined. It is described as deep, aching or pressing and usually lasts days to weeks. It is virtually a symptom of all diseases at some point during disease progression. Examples include angina and labour pain.
Meanwhile, neuropathic pain is defined as pain initiated or caused by a primary lesion or dysfunction of the nervous system. It is problematic because of its severity, chronicity and resistance to simple analgesics and affects 2-to-3 per cent of the population. It has multiple causes, including diabetes, lower back injury, cancer, and following herpes viral infection.
Dr Gallagher underlined that not all patients with chronic neuropathic pain would have the same mechanism(s). Multiple pain mechanisms could occur in the same patient, and polypharmacy may be necessary to target these different mechanisms. He said that recognising the underlying pain mechanism could help with pain management planning.
When assessing pain, it is useful to utilise the acronym OPQRS(T): Onset/evolution, Pattern, Quality, Relieving/exacerbating factors, Severity, (Tests).
However, Dr Gallagher warned that imaging could be misleading, with many abnormalities as common in pain-free individuals as in those with back pain, for example.
In respect of diagnosing neuropathic pain, Dr Gallagher said it relies on accurate history and examination. Diagnostic tools include the DN4 or LANSS scoring tools.
It is very important to treat pain, said Dr Gallagher. As he described, tissue damage has the potential to elicit mechanisms that could create disabling, refractory, chronic situations that may prolong and even outlast the period of healing
Severe, unrelieved acute pain results in abnormally enhanced physiological responses that lead to pronounced and progressively increasing pathophysiology.
In his wide-ranging talk, Dr Gallagher outlined a treatment algorithm for chronic pain, adapted from the WHO analgesic pain ladder. This moves in a stepwise fashion, commencing with medicines such as paracetamol, ibuprofen and aspirin; moving on to co-codamol and tramadol; and onwards to morphine, oxycodone, fentanyl and tapentadol.
The opening session on the second day was chaired by Cavan GP Dr Aine Sullivan, who introduced the morning’s first speaker, Dr Paul Gregan, a GP and Consultant in Palliative Medicine at the Blackrock Hospice in Dublin. Pain associated with cancer was the focus of Dr Gregan’s talk.
Dr Gregan opened by referring to the evidence-base supporting the provision of good palliative care. He referred to a 2010 study by Temel et al in the New England Journal of Medicine, concerning 150 patients with non-small cell lung cancer. This study found that good oncology care resulted in an average survival time of just under nine months, but when combined with good palliative care, this increased to 11.6 months.
“Palliative care alongside good oncology care will probably increase survival across all cancers, it certainly does in non-small cell lung cancer,” said Dr Gregan.
In respect of managing pain in palliative care, Dr Gregan said believing the patient is a vital aspect, “and seeing you believe them is a really important part of the therapy”.
About 80 per cent of people with advanced cancer experience pain, and in most cases this involves two or more pains. Therefore, it is always important to ask patients where else they have pain.
Dr Gregan presented on different types of pain. He said visceral pain, in particular, is opioid sensitive, whereas somatic pain is only partially sensitive to opioids. According to Dr Gregan, there is often frame pain as a patient becomes increasingly bed-bound when a disease advances, and one needs to examine other ways of treating that pain other than opioids.
Neuropathic pain is a particular problem in palliative care and one of the most severe types of pain that presents, “particularly pelvic or head and neck pain, because of the concentration of nerves in those areas”. Neuropathic pain is often referred and poorly opioid-sensitive.
As Dr Gregan recounted, from the 1990s onwards, palliative care gained traction in Ireland, resulting in formal recognition of the specialty. Dr Gregan said it is a holistic specialty and noted the spiritual aspect of care, such as exploring with the patients their hopes around their pain and how it could be improved. Sometimes the pain is associated with something they have not resolved during their lives.
Dr Gregan also presented on assessment of pain, including scales that rated pain. Later in his presentation, he described the aforementioned WHO algorithm that categorises analgesics into a ladder system for mild, moderate and severe pain, and outlined the pros and cons of the various types of drugs available for pain.
During this portion of the talk, Dr Gregan reminded GPs that codeine, a weak opioid, is demethylated to morphine, and that demethylation is blocked by fluoxetine and paroxetine. “So if you have patients who aren’t getting an effect from their codeine, that probably is why,” he said.
Concluding his presentation, Dr Gregan advised that the National Medicines Information Service provides a telephone and email advice line for health professionals on medicines in palliative care and this is open to all GPs.
Dr Dominic Hegarty, Consultant in Pain Management and Neuromodulation, Cork University Hospital, delivered the final clinical presentation of the seminar, titled ‘Neuropathic Mechanisms in Chronic Low Back Pain’.
Dr Dominic Hegarty
The definition of neuropathic pain, according to the International Association for the Study of Pain (IASP) Task Force 2010 Update, is noted as “pain caused by a lesion or disease of the somatosensory nervous system”.
Dr Hegarty referred to the impact of neuropathic pain on quality of life, and also pointed to the significant economic toll. A study of the costs of back pain in Germany (Wenig et al, 2009) found that one-in-five with low back pain had neuropathic pain. As low back pain affected 30 per cent of the general population, this equated with 6 per cent, or five million people, amounting to a cost of $22.6 billion.
Dr Hegarty commented: “The bigger point is that if an individual with low back pain has neuropathic pain, they are going to cost the system 70 per cent more than the individual who doesn’t… that is probably because they are going to be in the system longer. They are not going to get fixed within the five-, six-day window; they won’t respond to non-steroidal basic management…”
There is no “gold-standard test” in respect of diagnosis of neuropathic pain, continued Dr Hegarty. As it results from disease or injury to the nervous system, positive and negative sensory symptoms and signs are typical, he pointed out.
Research had shown that high proportions of physicians find it difficult to recognise neuropathic pain, but Dr Hegarty emphasised that “it is out there”. He said the challenges in recognising it makes it all the more important to “look harder to try and find it”.
The key elements of diagnosis involve looking for the lesion or the location of the pain. He said it is always perceived within the innervation territory of the nerve. Pain maps and pain scoring are important tools, he added.
“Pain scoring is very important,” he said. “It doesn’t matter what the pain is, it is something that you can work to, you can reduce, you can see the treatment working.” Dr Hegarty referred to the importance of assessing the patient’s functionality over time.
He said: “Sometimes the pain may stay the same, but they are able to walk longer, they are able to sleep better, so you may need to look at other factors — secondary outcomes, if you like.” In this manner, the patient can see tangible signs of progress, which can be very reassuring.
In respect of neuropathic pain management, Dr Hegarty said it requires a long-term solution. There is no “silver bullet”, as such, and it is likely that combination treatment would be utilised. It is important that any possible agent interactions, over a variety of illnesses, are carefully assessed.
“Fortunately, we now have more products available to us than we did 10, 15 years ago,” added Dr Hegarty.
There are a number of agents available including pregabalin, gabapentin, the tricyclic antidepressant amitriptyline and tapentadol, for example.
When a patient presents with clinical features of neuropathic pain, Dr Hegarty said it is important to rule out a physical cause.
In respect of considering how to treat, one would first consider the simpler versions, such as the tricyclics for example, and then consider moving through to other options if necessary.
Overall, it is a matter of achieving a balance for the patient, using medications carefully, and individualising treatment, he emphasised.
Dr Hegarty encouraged GPs to be watchful for neuropathic pain. “You will probably surprise yourself how much more you will see it in your clinics,” he said.
He also underlined that simple, straightforward assessments could be utilised, and medication chosen in a sequenced fashion.
Dr Eamonn Shanahan
Before the concluding presentation on technology and health by Mr Adrian Weckler, Irish Independent Technology Editor, the participants assembled into teams and discussed case studies. These centred on lower back pain with radicular symptoms; chronic neuropathic pain following multiple fractures; thoracic wall pain; and new-onset neuropathic pain in a diabetic patient. This interactive session, which also involved input from the presenters, was chaired by Farranfore GP Dr Eamonn Shanahan.
At the conclusion of proceedings, Mr Coogan, General Manager of Grunenthal Pharma Ireland, thanked participants and said the company anticipated hosting further such meetings in the future.