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Exploring the Future of Pain Medicine: Caring for the Patient and the Clinician

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Exploring the Future of Pain Medicine: Caring for the Patient and the Clinician 1 THE BRITISH PAIN SOCIETY Special Interest Group for Philosophy and Ethics Exploring the future of pain medicine: caring for the patient and the clinician RYDAL HALL 24th-26th June 2019 2 Introduction Peter Wemyss-Gorman This year the group explored a variety of themes ranging from the link between childhood trauma and chronic pain to the future of pain medicine. A welcome departure from our past tradition was that two of our speakers were general practitioners, reflecting the neglected reality that the great majority of chronic pain sufferers, and indeed all of them for most of the time, are cared for by their GP’s, and that pain specialists only know them for a relatively brief episode within a lifelong of suffering. Topics included integrating the art of healing and the science of medicine, the need to look beyond the biospsychosocial model and accept the complexity both of the needs of chronic pain patients and the world they inhabit, the challenge of providing a truly holistic pain service in a large complex department, and facing the reality that almost everything we think we know about pain enough to express in conventional language is probably wrong. Although we were encouraged to believe that more and more people recognise what needs to be done or changed to provide a better service for suffering people, any optimism was overshadowed by the many accounts of the frustrations and administrative and financial restrictions people have experienced when trying to put these changes into operation, or even stop things changing for the worse. More depressing still, as I write in the spring of 2020, we have hanging over us the spectre of the Covid19 pandemic which threatens to devour all the available resources of the NHS. As it says in our web page, one of the important functions of our group is to provide ‘mental and physical recreation so much needed by people wearied by their daily work with human pain and distress.’ (and, one could add, struggling with the problems referred to above). A lovely innovation to this end was our time of ‘forest bathing’ (from the Japanese shinrin-yoku) – simply wandering meditatively in the lovely woods above the Hall, just noticing our surroundings and savouring the sounds, smells and sights of nature. 3 Contents: Chronic Pain after Surgery and the role of Developmental Trauma 5 Deepak Ravindran Trauma informed care 23 Jonathan Tomlinson Going beyond the Bio Psycho Social 39 Betsan Corkhill : Integrating the Art of Healing With The Science of Curing 68 Paul Dieppe The future of pain management 81 David Laird Striving for a truly holistic pain service – the journey so far 90 Jamie Watson The human kind: what pain tells us about our nature 106 Peter Dorward Inflammation: new ideas 119 Maureen Tilford Have we made any progress toward changing the culture of pain medicine? Peter Gorman 123 4 Editor Peter Wemyss-Gorman: Consultant in anaesthesia and pain management, Haywards Heath (retired) Contributors Deepak Ravindran: Royal Berkshire Hospital. Jonathan Tomlinson: General Practitioner, London Betsan Corkhill: Lifestyle Health Coach, Bath Paul Dieppe: Emeritus Professor of Health and Wellbeing at the University of Exeter Medical School David Laird: Consultant in anaesthesia and pain management, Durham Jamie Watson: Senior Physiotherapist, North Tees and Hartlepool NHS trust Peter Dorward: General Practitioner, London Maureen Tilford: retired General Practitioner, Norwich 5 Chronic pain after surgery and the role of developmental trauma. When will we talk about the elephant in the room? Deepak Ravindran I have been fascinated to find that this approach and its psychological underpinnings are being used across all healthcare now, but in secondary care we have been slow to take it on board. This is partly because we are not sure whether it fits https://www.rcoa.ac.uk/sites/default/files/KingsFund_9-02- 2016_HR.pdf This is the mural at the Royal College of Anaesthesia and Perioperative Medicine (out college is rebranding itself as the latter).The focus is on high risk and frail patients. You can see that pain is there; the whole big picture is messy and and. complicated but I hope to convince you that we are missing a bigger elephant in the room. CHRONIC PAIN – THE SILENT PANDEMIC? 6 Although we talk a lot about chronic pain and the increasing numbers of sufferers we aren’t doing much about it, and my mission is to bring it up to salience and get people aware and talking about it so we can come up with some suggestions as to what to do about it. We as anaesthetists have potentially a great place to optimise the patients’ journey from entering the hospital till they are safely home. We want to optimise fitness for surgery, to lower the risk and get fully informed consent to surgery. We want to see what lifestyle modifications we can be part of. We look at the systems: cardiovascular, respiratory etc.. The RCOA – the Perioperative Medicine College - want to provide personalised patient-centred care for complex patients and have introduced the Pathway to Better Surgical Care: ½ of UK 1/3 to Upto population PERIOPERATIVE 28 million MEDICINE –RCOA DOCUMENT This does not talk about PATHWAY TO BETTER chronic pain post operative at all SURGICAL CARE There is one thing missing: there is no mention of chronic pain. There is a tacit assumption that if perioperative care is satisfactory chronic pain won’t exist. But the numbers are high and increasing. There are apparently more fibromyalgia patients in the UK than stroke and diabetes combined, but all the funding goes to the latter two. We need to we need to have a better plan in place for recognising it and managing it. So if we are going to deal with a pandemic of this sort what are the questions we should be asking? What is the root cause? Are we operating on more people than necessary? Are we medicalising normal life experiences? Are we taking people on the wrong surgical journey. In perioperative care, are we not doing the right things at the right time? We have a very siloed* approach in secondary care with the biomedical model: if you’ve got a knee pain you go to a knee consultant, for back pain you need a spinal surgeon, If after L5 surgery you have bladder problems you to a urologist, and so on. But that really doesn’t work. *kept in isolation in a way that hinders communication and cooperation : separated or isolated in a silo 7 “Debbie” I’m going to tell you a story about a patient you will all probably recognise. Debbie has been in the pain clinic in the Royal Bath Hospital for the better part of eight years now. It all started with a trivial episode of low back pain while at work which rumbled on. A scan at that time revealed an L4/5 disc bulge. Her GP referred her to the pain clinic; she was initially seen by my colleagues . She had a discectomy in 2012 which left her with more persistent and intense low back pain with left-sided L4/5 radiculopathy. She then developed knee pain so went to the knee surgeon and had an arthroscopy and where they found some medial compartment changes so she had a knee replacement in 2013 which left her with some persistent post- surgical pain. Then she got some shoulder pain for which she had a subacromial decompression; that seemed to have worked but three months later she developed pain in her right shoulder. Over the years she had several arthroscopies for various joints. In the pain clinic we did facet joint injections and an epidural. She was sent to London for spinal stimulation but ended up with an implant infection so it was taken out. She saw the neurologists who diagnosed atypical migraine and put her on a migraine drug. She saw the GI people with tummy problems for which they offered her a diagnosis of IBS, and was also treated for an ‘irritable bladder’. She was on codeine, cocodamol, naproxen, tramadol , opiates and … - what were we doing? What was the real problem? I took her on about three years ago during which time she has seen me at least eight times for drug changes etc. About a year ago she was seen by a rheumatologist who diagnosed fibromyalgia and suggested she went to the pain clinic. She was already my patient – by the way she had also accumulated diabetes and hypertension . But she didn’t want to keep taking so many drugs. I wondered: where do I go? - this is her third volume of notes. And then I thought – you know what? – I am seeing so many Debbies in the perioperative situation for anaesthetic care; some of them only for a small procedures in day care; I am seeing them on ward rounds, in outpatients and community clinics. So where does the problem lie – is it the patient or the service? It got me thinking and reading and wondering what we can do about process. So we got together with the Community Health Trust in my area who look after mental health and set up an integrated pain and spinal service involving physiotherapy psychology, consultants from spinal surgery, rheumatology and pain. We got funding for one day of a pain consultant and a 300% increase in physiotherapy and psychology provision at a stroke with that kind of rearrangement. We were able to provide one to one physio and psychology and group support, all at an intermediate care level, quickly where there was none. Being part of that process made sure that some patients were coming to a triaging set up so we introduced complexity into secondary care.
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