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2013: ISSUE 2
Feature
the impact of an ageing
population on palliative care
With significant population ageing comes an
increasing demand for optimal, patient-centred
palliative care, explains Dr Tony O’Brien
Page 4
Opinion
defining opioid tolerance
and dependency
Dr César Margarit Ferri discusses opioid tolerance
and dependence with a view to enabling better
communication with patients
Page 6
Feature
effective pain management in
survivors of conflict
Joint Editors
Other highlights …
Professor Elon Eisenberg
research update
Director, Pain Research Unit, Technion Institute of Technology,
Haifa, Israel
Dr Karen H Simpson’s review of the journals highlights sex differences
in pain, gene therapy and neuropathic pain subgroups.
Page 2
Professor Margarita Puig
Your questions answered
Director, Unidad de Investigación en Anestesiología, UAB,
Barcelona, Spain
Professor Harald Breivik discusses the differences in pain management
programmes across Europe.
Page 7
Dr Karen H Simpson
case study
Consultant in anaesthesia and pain medicine, Leeds, UK
Dr Dagmar Westerling
Smärtmottagningen, Centralsjukhuset i Kristianstad and associate
professor, Lunds Universitet, Sweden
Dr Martin Johnson
GP with a special interest in pain, Yorkshire, UK and honorary senior
lecturer in community pain, Cardiff, UK
A clinician presents a case of chronic pain management. Two European
specialists provide their perspectives on the treatment.
Page 10
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Dr Mark Wyldbore and Dr Dominic J Aldington
provide a glimpse into the world of battlefield
analgesia, its challenges and aims
Page 8
2
Research
Joint editor comment
Dr Karen H Simpson
highlights the problem of
obesity and its links with pain
Obesity is a growing public health problem
in industrialised countries. There is regional
variation in prevalence, probably related to
lifestyle choices. For example, the female
obesity rate in the UK is 23.9%, but is much
less in Germany (15.6%), Spain (14.4%),
France (12.7%) and Italy (9.3%).1 The easy
availability of cheap energy-dense foods
and lack of regular exercise are some of the
factors that have seen the average weight of
the population increase.2
Obesity hastens death through cardio­
vascular problems and diabetes; the World
Health Organization statistics report for 2012
showed that 1 in 3 adults had high blood
pressure and 1 in 10 had diabetes.3 Obesity
is also associated with many chronic pain
problems,4 placing a huge burden on the
health economy.5
Meta-analysis has shown a strong link
between overweight/obesity and back pain
resulting in seeking healthcare.6 Studies of
children and adolescents with chronic pain
also highlight an association with obesity
but it is not clear if this is a cause or an
effect.7 We know too that pain and obesity
together negatively affects quality of life.8 The
mechanism of this relationship may include
mechanical and metabolic abnormalities,
possibly secondary to lifestyle choices.
Some studies demonstrate that treatments
for obesity reduce pain secondary to weight
loss.9,10 It is therefore essential that healthcare
providers address and promote the issue of
obesity when treating chronic pain.
From the Joint Editor, Dr Karen H Simpson,
consultant in anaesthesia and pain medicine,
Leeds, UK
References
1. Eurostat. Overweight and obesity - BMI statistics
Available from: http://epp.eurostat.ec.europa.eu/
statistics_explained/index.php/Overweight_and_
obesity_-_BMI_statistics (accessed 9 March 2013).
2. WHO. Obesity and overweight. Fact sheet No 311.
Geneva, WHO, 2013. Available from: http://www.who.
int/mediacentre/factsheets/fs311/en/ (accessed
9 March 2013).
3. WHO. News release. May 2012 Available from:
www.who.int/mediacentre/news/releases/2012/world_
health_statistics_20120516/en/ (accessed 9 March
2013).
4. Hitt HC, McMillen RC, et al. Journal of Pain
2007;8(5):430-436.
5. Von Lengerke T, Krauth C. Maturitas 2011;69(3):220-229.
6. Shiri R, Karppinen J, et al. American Journal of
Epidemiology 2010;171(2):135-154.
7. Wilson AC, Samuelson B, et al. Clinical Journal of
Pain 2010;26(8):705-711.
8. Hainsworth KR, Davies WH, et al. Clinical Journal of
Pain 2009;25(8):715-721.
9. McGoey BV, Deitel M, et al. Journal of Bone and
Joint Surgery 1990;72(2):322-323.
10.Shapiro JR, Anderson DA, et al. Journal of
Psychosomatic Research 2005;59(5):275-282.
www.paineurope.com
paineurope 2013: Issue 2
Research
UPDATE
Pain specialist and
joint editor Dr Karen
H Simpson reviews
the latest research in
pain, including papers on sex
differences in pain, gene therapy
and neuropathic pain subgroups
Mogil JS.
Sex differences in pain and pain inhibition: multiple explanations of a controversial phenomenon.
Nature Reviews Neuroscience
2012;13(12):859-866.
For decades, research has indicated that
gender differences exist in pain perception, with many common pain problems
occurring more frequently in women, for
example, migraine, fibromyalgia and IBS. In
addition, females typically report more negative responses to pain than males. The sexes
also use and benefit from different coping
strategies when in pain; females prefer emotion-focused coping, whereas males prefer
sensory-focused coping. It is known that emotional focusing increases the affective pain
experience of females.
We know that important differences exist
between men and women in the experience
of pain. A majority of patients with chronic
pain are women, but it is difficult to determine whether this sex bias corresponds to
actual sex differences in pain sensitivity. The
paper presents a survey of the available epidemiological and laboratory data that shows
that the evidence for clinical and experimental sex differences in pain is overwhelming.
Various explanations for this are explored by
the author.
Williams AC, Eccleston C, et al.
Psychological therapies for the management of
chronic pain (excluding headache) in adults.
Cochrane Database of Systematic Reviews
2012;11:CD007407.
This update of a previous 2009 review
(Cochrane Database of Systematic Reviews
2009;2:CD007407) should be read by all
pain clinicians. The authors are international
experts and they have evaluated the effectiveness of psychological therapies for
chronic pain compared with treatment as
usual, waiting list control (whereby participants receive the intervention after a waiting
period) or placebo control for pain, disability, mood and catastrophic thinking. They
identified RCTs until September 2011 using
good search and exclusion criteria; 42 studies
were found and 35 (n=4788) provided data
– an impressive cohort. Two authors rated
all studies. They compared cognitive behavioural therapy (CBT) and behaviour therapy
with two control conditions (treatment as
usual; active control) at two assessment
points (immediately after treatment and
at ≥6 months). They assessed treatment
effectiveness for pain, disability, mood and
catastrophic thinking.
Their findings are fascinating and perhaps
do not fit with clinicians’ firmly held beliefs
that are often non-evidence based! There is
an absence of evidence for behaviour therapy,
except a small improvement in mood immediately following treatment when compared
with an active control. CBT has small positive
effects on disability and catastrophising, but
not on pain or mood, when compared with
active controls. CBT has small to moderate
effects on pain, disability, mood and catastrophising immediately post-treatment when
compared with treatment as usual/waiting list,
but all except a small effect on mood had disappeared at follow-up. The authors observed
that quality of trial design has improved over
time but quality of treatments had not. They
concluded that different types of studies and
analyses are needed to identify which components of CBT work for which type of patient
on which outcome/s, and to try to understand why. In times of financial constraints
on services we need to find answers to these
questions.
Saavedra-Hernández M, Castro-Sánchez AM, et al.
The contribution of previous episodes of pain,
pain intensity, physical impairment, and painrelated fear to disability in patients with chronic
mechanical neck pain.
American Journal of Physical Medicine and
Rehabilitation 2012;91(12):1070-1076.
Musculoskeletal neck pain is a common
problem and whiplash associated disorder
is almost at epidemic proportions in some
Western countries. The influence of physical
and psychosocial variables on self-rated disability in patients with chronic mechanical
neck pain is examined in this interesting study.
The authors assessed the relationship of pain,
physical impairment, and pain-related fear to
disability in individuals with chronic mechanical neck pain. They prospectively recruited
Research 3
©iStockphoto/Thinkstock
paineurope 2013: Issue 2
Meetings and events update
12-15 June 2013
Madrid, Spain
2013 Annual European Congress
of Rheumatology
Website: www.eular.org
14-16 June 2013
Warsaw, Poland
3rd International Conference
on Interventional Pain Medicine
and Neuromodulation
Website: http://www.painandneuromodulationwarsaw.blogspot.co.uk/
97 subjects with chronic neck pain; 28 men
and 69 women with mean age 39 years. They
recorded demographic information, duration of pain, pain intensity, pain-related fear,
cervical range of motion and self-reported
disability (Neck Disability Index). Significant
positive correlations existed between disability and previous history of neck pain, pain
intensity and kinesiophobia. A significant
negative correlation existed between disability and range of motion in cervical extension.
Previous neck pain episodes, intensity of neck
pain, kinesiophobia, and cervical extension
range of motion were significant predictors
of disability. The clinical implications of these
findings need more detailed study.
Goins WF, Cohen JB, et al.
Gene therapy for the treatment of chronic peripheral nervous system pain.
Neurobiology of Disease 2012;48(2):255-270.
Chronic pain affects millions of people
worldwide leading to significant morbidity
and poor quality of life. Chronic pain can
result from many pathological sources, for
Further key clinical papers
Kiss ZH, Becker WJ.
Occipital stimulation for chronic migraine:
patient selection and complications.
Canadian Journal of Neurological Sciences
2012;39(6):807-812.
Warner EA.
Opioids for the treatment of chronic
noncancer pain.
American Journal of Medicine
2012;125(12):1155-1161.
Djurasovic M, Glassman SD, et al.
Changes in the Oswestry Disability Index
that predict improvement after lumbar
fusion.
Journal of Neurosurgery Spine
2012;17(5):486-490.
example, cancer, infectious diseases, autoimmune-related syndromes, trauma and surgery.
Current therapies have not provided an effective long-term solution. Medications are
often limited by tolerance and the potential for abuse. The efficacy of gene therapy
for pain has been reported in numerous preclinical studies. There has also been some
encouraging phase I work. For example a
replication-defective herpes simplex virus
(HSV) vector was used to deliver the human
pre-proenkephalin gene, encoding the natural opioid peptides met- and leu-enkephalin,
to patients with painful bone metastases.
The therapy was well tolerated and patients
receiving higher doses of the vector experienced a substantial reduction in their pain
scores for up to a month. These early clinical
results demonstrate potential for new treatments that may herald other gene therapies
for chronic pain.
Baron R, Förster M, et al.
Subgrouping of patients with neuropathic pain
according to pain-related sensory abnormalities:
a first step to a stratified treatment approach.
Lancet Neurology 2012;11(11):999-1005.
Any paper on neuropathic pain (NeP) by
this group is a must read! Patients with NeP
present with various pain-related sensory
abnormalities that form different patterns in
individuals. Classifying patients on the basis of
individual profiles may reduce heterogeneity
and improve trial design. A new classification
of neuropathic pain should take into account
these subgroups. Such sensory phenotyping
has the potential to improve clinical trial
design by enriching the study population with
potential treatment responders. Eventually
it is hoped that this might lead to a stratified treatment approach and, ultimately, to
personalised treatment.
●● Dr Karen H Simpson is a consultant in
anaesthesia and pain medicine, Leeds, UK
17-20 June 2013
Stockholm, Sweden
9th International Symposium
on Pediatric Pain
Website: www.ispp2013.org
4-7 September 2013
Glasgow, UK
32nd Annual European Society of
Regional Anaesthesia Congress
Website: http://www2.kenes.com/esra/Pages/
Home.aspx
18-20 September 2013
Yalta, Ukraine
1st East European Congress on Pain
Website: http://www.paincongress.com.ua/
9-12 October 2013
Florence, Italy
8th Congress of the European Federation of
IASP Chapters: Europe Against Pain 2013
Website: http://www1.kenes.com/efic/
www.paineurope.com
the home of paineurope online
Paineurope.com is a comprehensive and
free-to-access portal to information on
pain and its management for healthcare
professionals within Europe.
The website contains an archive of past and
present articles from paineurope, in addition
to exclusive online content. All articles are
peer-reviewed by an editorial advisory board
of pain specialists.
www.paineurope.com
4
FEATURE
paineurope 2013: Issue 2
The impact of an ageing
population on palliative care
Key learning points
●● By
2050 it is predicted that 26% of the population will be aged
80 and over.
●● Although older people have much to contribute, one challenging
aspect of an ageing population is the increasing rate of dementia.
●● Palliative care is now included as part of the care pathway of a
wide variety of non-malignant diseases.
●● European Association for Palliative Care (EAPC) and the European
Union Geriatric Medicine Society (EUGMS) have jointly called for
every older citizen with chronic disease to be offered the best
possible palliative care approach wherever they are cared for.
Significant population ageing is a worldwide phenomenon.
In 1950, there were 205 million persons aged 60 or over in the
world. Currently, that figure stands at 810 million and is predicted
to increase to 2 billion by 2050.
In Europe, 20% of the population is currently aged 60 and older
(144 million) and 15% are aged 80 and older (108 million). By
2050, the proportion of the population aged 80 and older will
reach 26% (187 million).1 This is the inevitable consequence
of declining fertility rates and increasing survival.2 Predictably,
this change in demographics will result in greater levels of disability and comorbidity with consequent higher demand for
palliative care.3
Increasing longevity is a major public health and social care triumph and reflects the impact of improved nutrition, sanitation,
medical advances, improved healthcare, education and economic
well-being.2 Thus, increased longevity should be welcomed and
celebrated.
Nevertheless, all countries are challenged to address the major
social, economic and cultural changes associated with this unprece­
dented shift in demographics. It is how we choose to address these
challenges and maximise the opportunities of an ageing population that will determine whether society will reap the benefits of
an ageing population.2
homes, many elderly residents are disadvantaged with respect to
palliative care services, particularly those in rural areas and those
with impaired cognition.5 There is also a high prevalence of chronic
pain in these and hospital settings (box 1).6,7
However, older persons are not a homogenous group. It is
important to avoid negative stereotyping that leads to the issue
being seen as the ‘problem of the elderly’. Individually, older persons may have particular needs and a caring society is charged
with identifying and addressing these needs in a respectful and
dignified manner.
Older persons want to remain active and respected members
of society and they undoubtedly have much to contribute.2 The
Madrid Plan recognises that older persons make a vast contribution to society. It explicitly calls for the recognition of their
contribution and for the inclusion of older persons in decisionmaking processes at all levels.8
End of life
A proportion of older people, especially those in late old age, will
spend their last year of life in poor health and with a significant
burden of palliative care needs associated with co-morbidity, frailty and social isolation.9 The older person approaching
©Comstock/Thinkstock
With significant ageing of the population
comes an increasing demand for optimal,
patient-centred palliative care across a range
disease states, explains Dr Tony O’Brien
Challenges of an ageing population
This demographic change presents particular challenges for elderly and palliative care services. Within the acute hospital setting,
numerous factors are identified that hinder the optimal provision
of palliative care to elderly patients. These include differences in
attitudes towards the care of older people, a focus on curative
treatment and lack of resources.
Additionally, there is confusion regarding the precise roles of
specialist and non-specialist palliative care providers.4 In nursing
www.paineurope.com
Every older citizen with chronic disease should be offered the
best possible palliative care approach
FEATURE 5
paineurope 2013: Issue 2
the end of life is likely to suffer from multiple progressive
and debilitating diseases rather than a single organ-specific
pathology.3
One particularly challenging aspect of an ageing population
relates to dementia. The prevalence of dementia rises with age
such that approximately one-quarter of people aged 85 years and
older have dementia.10 The characteristics of the older members
of our societies as described above will ‘inevitably lead to higher
demand for palliative care’.3
Palliative care
Historically, palliative care was particularly associated with end
of life care of patients with cancer. Moreover, palliative care
was viewed as a separate and distinct specialty that became relevant only after all other approaches to disease management
had failed.
This is an entirely discredited and redundant model of care provision. There is now a growing acceptance of the value of early
involvement of palliative care in parallel with a whole variety
of disease modifying and supportive therapies across a range of
malignant and non-malignant disease states. Palliative care is now
included in the care pathways of a wide variety of non-malignant
diseases such as COPD, cardiac failure, chronic kidney disease,
liver failure and dementia.
However, we need to move beyond an exclusive focus on disease pathways and specific pathologies; we are concerned with
people. As such, it is becoming increasingly absurd to speak about
palliative care solely in terms of specific disease states. The vast
majority of older patients with palliative care needs are suffering
from multiple distinct pathologies and their ultimate needs will
be determined by the combined effect and impact of these various pathologies. Therefore, it is far more appropriate to develop
strategies based upon a rigorous and dynamic assessment of the
total patient need.
Services across Europe
Palliative care services have evolved at an unequal pace across various European countries. Even within a single country, inequalities
may exist in terms of ease of access to appropriate expertise. One
useful measure of the impact of palliative care is the national use
of medicinal opioid medication. In 2003, the Council of Europe
made specific recommendations in this regard:11 ‘Patients must
have ready access to all necessary medications, including a variety of opioids in a range of formulations.’
The total global consumption of opioids increased significantly
following the publication of the WHO analgesic ladder in 1986.
This coincided with a rapid growth in hospice and specialist palliative care services in many countries. However, the global increase
in opioid use was not uniform and, even within Europe, considerable variations are noted.
There are many reasons for these reported variations including regulatory and attitudinal barriers.12 Cherny et al note that in
many countries, excessively zealous or poorly considered laws and
regulations designed to restrict the diversion of medicinal opioids
into illicit markets profoundly interfere with medical availability
of opioids for the relief of pain.13
In 2004, Jerant et al identified significant shortfalls in the quality of palliative care provided to the elderly. They recommend
a more integrated, proactive and team-based approach delivered across all care domains that seeks to identify and address
the individual palliative care needs of our elderly population
in a collaborative and comprehensive way and over a period
of time.14
Box 1. Pain in the elderly – key facts6,7
●● Chronic
pain affects more than 50% of older people in the
community and more than 80% of nursing home residents.
●● Pain is the most frequently reported symptom by older people,
reported by 73% of community-dwelling older people.
●● Pain is present in 67% of elderly hospitalised patients and in
a large proportion of cases is either not treated, or not treated
adequately.
●● Older people tend to under-report pain, and when they do report
it, are likely to be afflicted with greater levels of underlying
pathology than younger individuals who report the same level
of pain.
●● Common chronic pain conditions in elderly adults include
osteoarthritis, postherpetic neuralgia, spinal canal stenosis,
cancer, fibromyalgia, post-stroke pain, diabetic peripheral
neuropathy and others.
Conclusion
The vital dialogue between palliative medicine and geriatric
medicine has begun. In September 2012, a high level engagement took place at the European Parliament between the
European Association for Palliative Care (EAPC) and the
European Union Geriatric Medicine Society (EUGMS). A
joint initiative was issued that calls upon European governments and EU institutions to ensure that every older citizen
with chronic disease, especially at an advanced stage, is offered
the best possible palliative care approach wherever they are
cared for.15
The provision of an optimal level of palliative care to our
older population is a challenge that requires a coordinated and
targeted approach by healthcare professionals, national governments and non-governmental agencies. Every effort must be
made to ensure that our elderly may live full, active and meaningful lives and that they enjoy an optimal individual quality
of life.
●● Dr Tony O’Brien is a consultant physician in palliative medicine
at Marymount University Hospice and Cork University Hospital,
Ireland
References
1. Piers R, Pautex S, et al. Zeitschrift für Gerontologie und Geriatrie 2010;43(6):381-385.
2. UNFPA and HelpAge international. Ageing in the twenty-first century: a celebration
and a challenge. United Nations Population Fund, New York & HelpAge
International, London, 2012.
3. Hall S, Petkova H, et al. Palliative care for older people: better practices. World Health
Organization, Copenhagen, Denmark, 2011.
4. Gardiner C, Cobb M, et al. Age and Ageing 2011;40(2):233-238.
5. Vassal P, Le Coz P, et al. Journal of Palliative Medicine 2009;12(12):1089.
6. IASP. Facts on ‘Pain in Older Persons’. Fact sheet. Available from: www.iasp-pain.org
(accessed 23 April 2013).
7. Gianni W, Madaio RA, et al. Archives of Gerontology and Geriatrics
2010;51(3):273-276.
8. United Nations. The Madrid International Plan of Action on Ageing. New York, United
Nations, 2002.
9. Rolls L, Seymour JE, et al. Palliative Medicine 2011;25(6):650-657.
10.Ferri CP, Prince M, et al. Lancet 2005;366(9503):2112-2117.
11.6.3 European Health Committee (CDSP). Recommendation Rec (2003) … of
the Committee of Ministers to member states on the organisation of palliative
care. Explanatory Memorandum (Adopted by the Committee of Ministers on 12
November 2003 at the 860th meeting of the Ministers’ Deputies).
12.Dalal S, Bruera E. Nature Reviews Clinical Oncology 2013;10(2):108-116.
13.Cherny NI, Baselga J, et al. Annals of Oncology 2010;21(3):615-626.
14.Jerant AF, Rahman SA, et al. Annals of Family Medicine 2004;2(1):54-60.
15.EAPC/EUGMS. Better palliative care for older people. Available from: http://www.
eapcnet.eu (accessed 4 March 2013).
www.paineurope.com
6
opinion
paineurope 2013: Issue 2
Defining opioid tolerance
and dependency
Dr César Margarit Ferri discusses the
definitions of opioid tolerance and dependency
and explains that both patients and physicians
are often confused about them
Although opioids have been used to treat patients with
chronic cancer and non-cancer pain for many years, when
opioids are initiated it can highlight the lack of knowledge regarding some aspects of opioid therapy for both physicians and patients.
One of the most important areas is the confusion surrounding the definitions of opioid tolerance and opioid dependency.
Existing criteria which relate to substance dependence (the term
used in preference to ‘addiction’) have poor applicability when
patients are using opioids for pain relief, and the criteria have
acted as a source of concern to physicians, patients and carers.1
Definitions
Substance abuse problems can be divided into two categories:
dependence and abuse. Addiction and physical dependence are not
the same; any patient taking opioids has the potential to develop
physical dependence and may suffer withdrawal symptoms upon
the discontinuation of the opioid.2
Tolerance is defined as a loss of analgesic potency that leads
to ever-increasing dose requirements and decreasing effectiveness over time.3 Exposure to a drug (the opioid) induces changes
that result in a diminution of one or more of the drug’s effects
over time. There are two types of tolerance: innate (genetically
determined) and acquired (pharmacokinetic, pharmacodynamic
and learned). In contrast to analgesic tolerance, tolerance to
opioid-induced side-effects is a desirable consequence of long-term
treatment, facilitating upward dose titration to attain satisfactory
pain relief.4
Addiction is a more complicated illness: it is a primary,
chronic, neurobiological disease with genetic, psychosocial and
environmental factors influencing its development and manifestation.2 Addiction is comprised of four core elements (the
four C’s):2
●● compulsive use,
●● inability to control the quantity used,
●● craving the psychological drug effects, and
●● continued use of the drug despite its adverse effects.
Addiction should not be confused with physical dependence
which is a drug class-specific withdrawal syndrome (for example, pain, insomnia, tachycardia, tachypnoea and diarrhoea)
that is produced by the abrupt cessation of a drug, a rapid
dose reduction, a decreasing blood level of the drug and/or the
administration of an antagonist.2 In the past, patients who had
non-optimal pain control using medication and who instigated
unauthorised dose escalation were misdiagnosed as addicts
(pseudo­addiction); the difference is that when pain is controlled this
behaviour disappears.2
www.paineurope.com
Table 1. Principles of opioid therapy
Principle
Management approach
Careful selection of patients
Screening tools/risk factors
Individualised information
Informed consent
Caution in dose escalation,
follow guideline recommendations
Monitoring,
urine tests
Taper and discontinue if no benefit
Follow up
Detect misuse, abuse and
tolerance
Referral to secondary care
if needed
Communication
When prescribing opioids, doctors and patients should discuss the
goals of treatment, what a successful opioid trial outcome would be,
what an unsuccesful trial looks like, as well as the further options
available if the trial is unsuccesssful.5 The aim is to alleviate patient
fears including ‘What happens if I’m opioid tolerant?’ and ‘Will
I become an addict?’. This kind of comprehensive assessment is
appreciated by patients, providing an understanding of the goals of
treatment, the secondary effects and the monitoring programme.5
Treatment
Physicians should treat their patients according a balanced multi­
modal treatment strategy where established monitoring and global
follow up are mandatory.6 The risks and benefits of opioid therapy
should be adequately explained to both patients and their carers.
Three important principles to follow are:7
●● titration: titrate against analgesic response and side-effects
(with regular assessment),
●● tailoring: treatment should be individualised, and
●● tapering: controlled decrease of any opioid treatment which
does not improve pain despite adequate trial.
Screening tools may be useful in identifying patients with risk factors for addiction who will need closer follow-up.7
●● Dr César Margarit Ferri is chief of the pain unit at the
anesthesiology-critical care-pain medicine department,
Alicante Hospital, Alicante, Spain
Go to www.paineurope.com to take part in
the reader’s poll and see more opinion articles
References
1. Stannard C. All Party Parliamentary Group on Drug Misuse Inquiry Response on
behalf of the British Pain Society. Risk of addiction to opioids prescribed for pain
relief. British Pain Society, London, 2007.
2. Jan SA. Journal of Managed Care Pharmacy 2010;16(1 Suppl B):S4-8.
3. Benyamin R, Trescot AM, et al. Pain Physician 2008;11(2 Suppl):S105-120.
4. Adriaensen H, Vissers K, et al. Acta Anaesthesiologica Belgica 2003;54(1):37-47.
5. Pohl M, Smith L. Journal of Psychoactive Drugs 2012;44(2):119-124.
6. Snidvongs S, Mehta V. Postgraduate Medical Journal 2012;88(1036):66-72.
7. Kahan M, Wilson L, et al. Canadian Family Physician 2011;57(11):1269-1276.
forum 7
paineurope 2013: Issue 2
Discussion Forum
Pain expert Professor Harald Breivik offers his views on pain management scenarios
presented by clinicians
Iris Christa Kohler, Fachpsychologin für Psychotherapie FSP,
Praxis, Bern, Switzerland
Thank you for this important question.
You may have read the paper on prevalence, impact and therapy of chronic non-cancer pain in 15 countries in Europe plus
Israel in the European Journal of Pain in 20061 and a similar study
documenting prevalence and treatment of pain related to cancer
published in the Annals of Oncology in 2009, covering 11 European
countries plus Israel.2 Switzerland was represented in the cancer
pain survey but not in the non-cancer survey.
These and other European studies document the immense
burden from chronic pain on individual patients and their families, but also the major cost to health and social budgets.3,4 There
are also a number of high-quality studies which show that treatment at a pain clinic will increase the quality of life of pain-patients
and reduce the economic burden on health budgets, much more
than the cost of running pain clinics.5,6
Cancer pain and chronic non-cancer pain are common health problems in all countries in Europe.1,2 Almost half of the patients indicate
that their pain is not managed satisfactorily.1,2 This varies from country to country, but even these large studies are not really powered to
find statistically significant differences between countries.1,2
The impression I have of pain medicine in Switzerland is that pain
patients there are no worse off than patients in other countries in
Europe. This is based on my experience working for almost a year
in Bern as a visiting professor of anaesthesiology and pain medicine.
A considerable number of excellent pain studies come from
Swiss pain clinicians, notably from Bern University Hospital
(Inselspital) where Professor Michele Curatolo has been Chair
of the Multidisciplinary Pain Centre there for more than 10
years and has been working with clinical pain problems for more
than 20 years.7-9 The Swiss Pain Society, a national chapter of the
Image reproduced with permissions from Bern University Hospital
Q: Several years ago, I read an article which
compared the effectiveness of pain management
programmes for chronic pain patients across
European countries. I can no longer find this
article, but I remember that Switzerland was not
in a good position. Do you know any European
studies that measure this issue? Are there also
percentages of the costs for chronic pain in the
different countries? I would be very grateful if you
could help me. I am a psychotherapist in
Switzerland, working to create an ambulant
interdisciplinary programme for chronic pain
patients, in which training therapy and
psychotherapy would be very important.
Bern University Hospital (Inselspital)
International Association for the Study of Pain has been active in
improving pain medicine for many years.
However, as in most countries in Europe, in Switzerland there
are too few clinical psychologists with interest and experience in
pain medicine. Therefore, I am sure you will be very welcome in
Bern by physicians as well as other health providers striving to
improve the management of acute as well as chronic pain, in cancer
as well as non-cancer conditions.
●● Harald Breivik is emeritus professor of anaesthesiology,
Universitetet i Oslo, Norway. He is also editor-in-chief
of the Scandinavian Journal of Pain
References
1.
2.
3.
4.
5.
6.
Breivik H, Collett B, et al. European Journal Pain 2006;10(4):287-333.
Breivik H, Cherny N, et al. Annals of Oncology 2009;20(8):1420-1433.
Gustavsson A, Bjorkman J, et al. European Journal of Pain 2012;16(2):289-299.
Raftery MN, Sarma K, et al. Pain 2011;152(5):1096-1103.
Heiskanen T, Roine R, et al. Scandinavian Journal of Pain 2012;3(4):201-207.
Eriksen J. Long-term chronic non-cancer pain. Epidemiology, health-care utilization,
socioeconomy and aspects of treatment. Medical Doctoral Thesis, Faculty of Health
Sciences, University of Copenhagen, Copenhagen, 2004.
7. Curatolo M. Scandinavian Journal of Pain 2012:3(4):236-237.
8. Curatolo M. Scandinavian Journal of Pain 2012:3(3):149-150.
9. Sterling M, Hodkinson E, et al. Clinical Journal of Pain 2008;24(2):124-130.
YOUR QUESTIONS …
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Submit your questions on
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8
FEATURE
paineurope 2013: Issue 2
Effective pain management
in the armed forces
Key learning points
●● The
UK Defence Medical Service employs a simple 0-3 pain scoring
system and regards a score of 2 or more as analgesic failure.
●● Analgesic options in field hospitals are the same as other
hospitals in the UK.
●● For repatriation, a robust plan is put in place to provide additional
analgesia if necessary.
●● Persistent problematic pain is uncommon among British military
casualties and the military pain management system may prove a
good model for other services.
It is a common misconception that battle injuries do not hurt as
much as civilian accidents.1 A survey of battlefield casualties demonstrated that two-thirds of those who could remember recalled
their pain as severe.2
In an attempt to describe trauma pain management this article
will focus on the system used by the UK Defence Medical Services
(DMS) to provide effective analgesia as early as possible after
injury and throughout retrieval, resuscitation and eventual rehabilitation. This is a pathway that stretches over many thousands
of kilometres and many months.
The DMS uses a 0-3 pain scoring system to evaluate pain3 and to
direct administration of analgesia. This system provides a simple,
robust, clinically significant score that guides treatment options.
A score of 2 or more is taken to represent a failure of treatment
and further treatment is required.4
The use of continuous peripheral nerve catheters and epidurals has increased in recent conflicts as a consequence of a high
number of limb injuries and the availability of robust portable
ultrasound machines. These are very effective,7,8 but carry concerns over masking compartment syndrome. To reduce the risk
of compartment syndrome surgeons are encouraged to perform
prophylactic fasciotomies in casualties at risk.9
The second concern is the coagulopathy associated with major
trauma. For peripheral nerve catheters we follow the guidance
of the Association of Anaesthetists of Great Britain and Ireland
(in press), but it is particularly worrying in bilateral lower limb
amputees with epidurals since many of the traditional signs of
an epidural haematoma, such as limb weakness, will be missing.
As a result, a system has been designed to increase the vigilance
of the medical staff.10
Prior to repatriation a casualty will be assessed by the acute
pain team, in communication with the aeromedical team to ensure
adequate analgesia with a robust plan for increasing analgesia as
necessary. This will often include adding a morphine PCA to the
regimen in case of nerve catheter displacement or acute exacerbations in pain due to movement during the transfer.11
On arrival at the Royal Centre for Defence Medicine (RCDM)
in Birmingham, UK casualties’ analgesic needs will be monitored
and tailored on a daily basis by the pain service. Once life-saving
©Crown Copyright 2007
In battlefield analgesia the aim is to provide
effective relief as soon as possible and
throughout the repatriation and rehabilitation
process, Dr Mark Wyldbore and Dr Dominic J
Aldington explain
Immediate analgesia
The cornerstone of battlefield analgesia remains the morphine auto
injector,5 a spring-loaded syringe that delivers 10mg intramuscular morphine. The British forces are rare in that these are issued
to all soldiers, and all deploying personnel are trained in their use.
Further analgesia in the pre-hospital environment will depend on
the severity of the pain and the experience of the person administering the drugs. These include paracetamol, ibuprofen, additional
morphine, fentanyl lozenges and ketamine.
Once in the field hospital the analgesic options are the same as
for any hospital in the UK, and include morphine patient controlled analgesia (PCA). Casualties are triaged and the more seriously
injured are taken to the operating theatre, often within minutes of
their arrival. The less severely injured will have their pain scores
re-assessed and will be started on a multimodal analgesic regimen.
Patients with significant nerve injury will be started on amitrip­
tyline and pregabalin as early as possible.6
www.paineurope.com
A surgeon carries out an operation on a gunshot wound in
the operating theatre at the Camp Bastion Medical Facility,
Helmand, Afghanistan
FEATURE 9
©Crown Copyright 2009
paineurope 2013: Issue 2
Troops carry a wounded comrade to a Blackhawk medivac helicopter
interventions are no longer required, the focus moves to rehabilitation and the development of an analgesic regimen that will
facilitate this.
part of the aim of their treatment being to make them experts in
their own pain control.
Rehabilitation
The final thread, and possibly the most important, is the structure
of the system. The entire process is overseen by the Military Pain
Special Interest Group that reports in turn to the defence consultant
advisor in anaesthesia. Within this group there is a recognised subject matter expert in pain who is in effect the ‘pain czar’. Having this
focus to coordinate an integrated and sustainable pain management
service is probably the one significant difference between the military
approach to managing survivors of trauma and the civilian version.
Although battlefield injuries are significantly painful, problems
with persistent pain following trauma are thankfully relatively
uncommon among British military casualties. The reasons for this
remain unclear but may relate to the system that has been developed. If that is the case, then this should serve as a good model for
any trauma pain management service, military or civilian.
Rehabilitation generally takes place at the Defence Medical
Rehabilitation Centre (DMRC), currently at Headley Court,
Surrey, UK. If during rehabilitation the analgesic regimen is not
considered optimal the casualties are referred to the pain clinic.
Contrary to popular belief, persistent pain is not often a problem
in this group. More often than not they are keen to reduce rather
than increase their pain medications. The idea that the ‘soldier’s
disease’ of opioid dependence is prevalent appears to be a myth.12,13
The prevalence of post-traumatic stress disorder (PTSD) is much
lower than many believe, currently effecting approximately 4% of
soldiers returning from Iraq or Afghanistan.14 Although this has to
be recognised, it is not within the remit of the pain clinic to manage;
specialist services exist for this as with any other co-morbidity.
The pain clinic at DMRC has one very clear aim: to optimise
pain management in an attempt to optimise rehabilitation. If the
clinic’s interventions will not do this, and therefore will not help
keep an individual employed within the military, this has to be recognised early and must have an effect on the treatments proposed;
in many senses it is an ‘occupational pain clinic’.
Audit and research
After the clinical component, efforts are made to support clinical
audit and research.
Research is difficult because the numbers of casualties are relatively low and the conditions in which they exist are not always
conducive to research. Surveys are used and where possible civilian data is used and extrapolated to this population.15
Education
Education is another important thread in the military’s approach
to managing the pain of conflict. By giving training to all personnel and more advanced training to clinical practitioners, a group
awareness and sense of taking responsibility for pain is developed.
This concept of education extends to the casualties themselves, with
Processes and procedures
●● Dr Mark Wyldboreis a senior anaesthetic trainee in London, UK.
He is also a Major in the Royal Army Medical Corps. Dr Dominic
J Aldington works as a consultant in pain medicine for both the
National Health Service and the Defence Medical Services, UK.
He is a Lieutenant Colonel in the Royal Army Medical Corps
References
1. Beecher HK. Annals of Surgery 1946;123(1):96-105.
2. Aldington DJ, McQuay HJ, Moore RA. Philosophical transactions of the Royal
Society of London. Series B, Biological Sciences 2011;366(1562):268-275.
3. Looker J, Aldington D. Journal of the Royal Army Medical Corps 2009;155(1):42-43.
4. Moore RA, Straube S, et al. Anaesthesia 2013;68(4):400-412.
5. Gaunt C, Gill J, et al. Journal of the Royal Army Medical Corps 2009;155(1):46-49.
6. Aldington D. Current Opinion in Supportive and Palliative Care 2012;6(2):172-176.
7. Woods KL, Aldington D. Journal of the Royal Army Medical Corps 2010;156(4 Suppl
1):393-397.
8. Hughes S, Birt D. Journal of the Royal Army Medical Corps 2009;155(1):57-58.
9. Clasper JC, Aldington DJ. Journal of the Royal Army Medical Corps 2010;156(2):77-78.
10.Wood PR, Haldane AG, et al. Journal of the Royal Army Medical Corps 2010;156(4
Suppl 1):308-310.
11.Flutter C, Ruth M, et al. Journal of the Royal Army Medical Corps. 2009;155(1):61-63.
12.Hickman TA. The Journal of American History. Oxford University Press;
2004;90(4):1269-1294.
13. Jagdish S, Aldington D, et al. Journal of the Royal Army Medical Corps. 2009;155(1):64-66.
14.Fear NT, Jones M, et al. The Lancet 2010;375(9728):1783-1797.
15.Park CL, Roberts DE, et al. Journal of the Royal Army Medical Corps 2010;156(4
Suppl 1):295-300.
www.paineurope.com
10 CASE STUDY
paineurope 2013: Issue 2
Managing a chronic pain patient
in the perioperative period
This challenging case required a combined
analgesia method, pre- and perioperative
education and opioid rotations, as
Professor Andreas Kopf describes
Background
The American Society of Anesthesiologists (ASA) has published
practice guidelines for management of acute perioperative pain
and for chronic pain.1,2 However these guidelines and other publications do not specifically consider management of the chronic
pain patient in the perioperative setting. Thus whilst published
recommendations for the management of chronic pain patients
perioperatively are relevant, there is no evidence base.
Case assessment
A 69-year-old man had been a ‘chronic low back pain patient’ for
more than 20 years. His therapy included physiotherapy, repeated
periradicular and facet joint injections, stabilising surgery (two years
previously) and increasing dosages of different opioids. He was to be
considered for further surgery.
The anaesthesiologist in the preoperative anaesthesia evaluation
identified the perioperative risks of a chronic opioid-dependent pain
patient. At that time the patient was complaining of unrelieved
thoraco-lumbar pain with a visual analogue scale (VAS) pain score
of 8 out of 10. He was using transdermal fentanyl patches at a dose
of 200 microgram/hour (oral morphine equivalence approximately
600mg in 24 hours). He was scheduled for a revision spondylodesis
surgery because of extension instability. Because of major comorbidity
(two recent myocardial infarctions), it was planned to place an
epidural catheter intraoperatively for the postoperative analgesia.
Due to the expected sudden drop of opioid demand in the period
of epidural analgesia the transdermal fentanyl patch dosage was
reduced by 50% and replaced by a 4mg/hour IV infusion of
morphine to better be able to control withdrawal and overdosing.
The epidural was managed with bupivacaine 0.175% (6-10mL/hour
depending on the analgesia level). Preoperative education took
place with twice-daily supportive conversations for seven consecutive
days by a communication-trained pain nurse. On postoperative
day 6 the epidural analgesia was switched to oral oxycodone
(the calculated equianalgesic dose of 150mg/day of oxycodone
was reduced by 20% to 120mg/day because of presumed incomplete
cross tolerance).
Psychiatric assessment revealed moderate depressive comorbidity,
hence duloxetine 60mg in the morning and mirtazapine 30mg at
night were started for mood stabilisation. In the postoperative period,
the opioid dosage was able to be reduced stepwise to 60mg/day of
oxycodone.
Owing to a recurrent problem of constipation the oxycodone was
given in the form of prolonged release combined oral oxycodone 30mg/
naloxone 15mg twice daily (Targin®*). Follow-up was arranged with
our outpatient pain team.
www.paineurope.com
Key learning points
●● The
chronic pain patient with and without chronic opioid
medication is at risk for under- and overtreatment perioperatively.
●● Careful planning of the perioperative period by the
anaesthesiologist, the pain service and the surgeon is crucial.
●● Epidural analgesia requires reduction of preoperative opioid doses
to a maximum of 50% to avoid withdrawal as well as continuous
post-anaesthesia care unit-monitoring for the first 24 hours.
●● Brief cognitive behavioural interventions pre- and postoperatively
contribute to successful pain management.
●● The perioperative period may be used to re-evaluate the patient’s
opioid requirements.
●● A follow-up by an experienced pain management service should
be available after discharge of the chronic pain patient.
●● Individualised assessment by a pain management team is
necessary for this increasing group of patients.
Figure 1. Pedicle
subtraction
osteotomy L3
and revision
spondylodesis T9 to
S1. Postoperative
CT with dorsal
spondylodesis
extension T9 to
S1 with correct
positioning of
material (actual
patient)
Discussion
Chronic pain patients are often managed with opioids, cyclooxygenase inhibitors (selective and non-selective) and/or co-analgesics,
often antidepressants and anticonvulsants. These patients frequently have comorbid conditions including loss of cardiovascular
fitness, neurological deficits caused by the chronic pain or following
previous surgeries, and polypharmacy including opioid tolerance,
drug-interactions and chronic side-effects.3-9
Undertreatment with opioids in the perioperative period may
pass unnoticed and result in opioid withdrawal in chronic pain
patients receiving prior high-dose opioid therapy. This may result
in serious cardiopulmonary strain. Patients with a long history of
opioid use and tolerance may require higher opioid dosages to effectively treat postoperative pain than other patients. Chronic pain
patients with prior opioid consumption have been observed to have
higher pain readings postoperatively with both IV patient-controlled
analgesia (PCA) and epidural analgesia. PCA-use is significantly
increased beyond mere replacement of preoperative doses.3-9
In the Minnesota Multiphasic Personality Inventory (MMPI),
chronic pain patients score highly on the hypochondria and hysteria scales. This can be relevant to the perioperative period and it
is important for clinicians to be on the look-out for inappropriate
CASE STUDY 11
paineurope 2013: Issue 2
behaviours. Uncontrolled anxiety is another factor that may complicate postoperative recovery. Simple cognitive behavioural
approaches are useful in decreasing the patients’ distress, helping the patient regain control and improve daily functioning.3-9
●● Dr Andreas Kopfis professor of clinical physiology, University of
Nairobi, Kenya, and Director of the Pain Clinic, Charité University
Medicine Berlin, Campus Benjamin Franklin, Germany
* Targin® is licensed for severe pain which can be adequately managed only with
opioid analgesics. Targin® is also known as Targiniq® and Targinact®
in other countries. Prescribing information can be found attached to the
back cover and/or on the outside back cover.
References
1. American Society of Anesthesiologists Task Force on Acute Pain Management.
Anesthesiology 2012;116(2):248-273.
2. American Society of Anesthesiologists Task Force on Chronic Pain Management;
American Society of Regional Anesthesia and Pain Medicine. Anesthesiology
2010;112(4):810-833.
3. Rozen D, Grass GW. Pain Practice 2005;5(1):18-32.
4. Carroll IR, Angst MS, et al. Regional Anesthesia and Pain Medicine
2004;29(6):576-591.
5. Stein C, Reinecke H, et al. Current Opinion in Anaesthesiology 2010;23(5):598-601.
6. Hadi I, Morley-Forster PK, et al. Canadian Journal of Anesthesia
2006;53(12):1190-1199.
7. Pogatzki-Zahn EM, et al. Current Opinion in Anaesthesiology 2009;22(5):627-633.
8. Farrell C, McConaghy P. British Medical Journal 2012;345:e4148.
9. Kopf A, Banzhaf A, et al. Best Practice & Research Clinical Anaesthesiology
2005;19(1):59-76.
Case review: Ireland
Dr Liam Conroy
Department of pain medicine, Mercy University
Hospital, Cork, Ireland
This is an interesting case from a number of perspectives:
Firstly, the patient suffered from chronic low back pain for 20 years
with ongoing interventional therapy and systemic opioid therapy of
transdermal fentanyl 200 microgram/hour. Despite this potent opioid
therapy the patient reported his pain at 8/10.
Secondly, revision spondylodesis is a major anaesthetic and
surgical undertaking in any patient, not least one with significant
cardiac disease. In most cases such as these, the conventional
practice is to continue the background chronic pain medication and to
employ supplementary analgesic techniques such as opioid patientcontrolled analgesia or neuraxial blockade, as was employed in this
case, in order to contribute to opioid-independent analgesia.
It would not be my practice to switch opioids as was done in this
case (transdermal fentanyl was converted to IV morphine at a rate
of 4mg/hour). Later this regimen was further altered by a switch
to oral oxycodone. It would be my preference to keep prescribing
as simple as possible in these situations, to avoid potential pitfalls
due to incomplete cross tolerance, opioid-induced hyperalgesia and
physical dependence. I also feel that opioid dosage reduction in this
setting is a complex undertaking.1 I must admit that I am envious
of the author’s ability to utilise the services of readily available CBT
conducted on a twice-daily basis by an experienced pain nurse.
Finally, it is worth mentioning exciting new work on the use of
ketamine infusions in perioperative period in patients using long-term
opioid therapy for chronic pain (see Loftus et al 2010).2
References
1. Gordon D, Inturrisi CE, et al. Journal of Pain 2008;9(5):383-387.
2. Loftus RW, Yeager MP, et al. Anesthesiology 2010;113(3):639-646.
Case review: Israel
Dr Simon Wein
Pain and Palliative Care Service, Davidoff Center,
Rabin Medical Center, Petach Tikvah, Israel
The case presented raises practical issues about opioid management
of chronic non-malignant pain and what to do perioperatively.
It is important to know how much opioid the patient is receiving
preoperatively. This is an essential first step to planning perioperative
opioid requirements.1 The other important point in calculating
equianalgesic doses is the need to reduce the new opioid dose by up
to 25% because of incomplete cross-tolerance between opioids.
A prudent rule-of-thumb, as pointed out in the case report, is to
reduce the calculated morphine equivalent (oral) daily dose by at least
50%. Although opioid withdrawal is unlikely, poor pain control may be
a problem which can be readily solved by a short-acting opioid via a
patient-controlled analgesia set-up. It is also important not to neglect
using co-analgesics such as paracetamol (IV), NSAIDs and tramadol.2
This multi-drug approach takes into account multiple pain mechanisms.3
One final factor, as noted by the author, is the bi-directionality of pain
and anxiety. Chronic pain patients with depressive or anxiety disorders
often receive higher doses of opioids and are at increased risk for
overdose.4 One should never treat severe pain with benzodiazepines
alone, nor treat existential anxiety with opioids alone. To avoid this,
it is imperative to take a careful history and examination, correlate
clinical with radiological findings and of no lesser importance, to
share notes with the family doctor and the psychosocial team.5
References
1. Lawlor P, Pereira J, et al. Dose ratios among different opioids: underlying issues and
an update on the use of the equianalgesic table. In: Bruera E, Portenoy RK (editors).
Topics in Palliative Care, Volume 5. Oxford University Press, New York, 2001.
2. Myles PS, Power I. The Lancet 2007;369(9564):810-812.
3. Elia N, Lysakowski C, et al. Anesthesiology 2005;103(6):1296-1304.
4. Boyer EW. New England Journal of Medicine 2012;367(2):146-155.
5. Turk DC, Okifuji A. Journal of Consulting and Clinical Psychology
2002;70(3):678-690.
Visit www.paineurope.com to see more discussion from the case study reviewers
and to read further case studies on all aspects of chronic pain management
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LINDH & PARTNERS
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11–TAR–53–SL
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