So M Atic Neuropathic Viscera L

Going beyond the pain threshold

ROPATH NEU IC V IC I T SC A E M R A O S L

TYPES OF PAIN

This newsletter is sponsored through an independent grant in the interests of CPD Accredited continuous medical education.

Edition 4 - January/February 2018

1035_08_16 XEFO NOCICEPTIVE VIEWS NEWSLETTER 7_10_16 PRINT READY.indd 1 2016/11/18 1:41 PM Proven Performance in Relieving Pain and Inflammation1-8

Comparable Safety Potent Efficacy Multiple Solutions Potent, effective relief of pain Comparable tolerability and safety profile Range of formulations for flexible 1-3 and inflammation1-6 with balanced COX-1/COX-2 inhibition 5, 7-10 dosing to suit patient needs

References: 1. XEFO 4 and 8 mg Tablets South Africa Package Insert, October 1998. 2. XEFO 8 IV/IM Injection South Africa Package Insert, October 1998. 3. XEFO RAPID Tablets South Africa Package Insert, September 2012. 4. Balfour JA, Fitton A, Barradell LB. Lornoxicam. A Review of its Pharmacology and Therapeutic Potential in the Management of Painful and Inflammatory Conditions. Drugs 1995;51(4):639-657. 5. Bernatzky G, Beubler E, Dunky A, Erlacher L, Hermann J, Herold M, et al. Lornoxicam. Expert Statement. Expert Meeting on 3rd April 2003. CliniCum 2004:1-8. 6. Berg J, Fellier H, Christoph T, Grarup J, Stimmeder D. The analgesic NSAID lornoxicam inhibits cyclooxygenase (COX)-1/-2, inducible nitric oxide synthase (iNOS), and the formation of interleukin (IL)-6 in vitro. Inflamm Res 1999;48:369-379. 7. Papadima A, Lagoudianakis EE, Antonakis PT, Pattas M, Kremastinou F, Katergiannakis V, et al. Parecoxib vs. lornoxicam in the treatment of postoperative pain after laparoscopic cholecystectomy: a prospective randomized placebo-controlled trial. Eur J Anae 2006:1-5. 8. Yakhno N, Guekht A, Skoromets A, Spirin N, Strachunskaya E, Ternavsky A, et al. Analgesic Efficacy and Safety of Lornoxicam Quick-Release Formulation Compared with Diclofenac Potassium. Randomised, Double-Blind Trial in Acute Low Back Pain. Clin Drug Invest 2006;26(5):267-277. 9. Kidd B, Frenzel W. A Multicenter, Randomized, Double Blind Study Comparing Lornoxican with Diclofenac in Osteoarthritis. J Rheuma 1996;23(9):1605-11. 10. Pleiner J, Nell G, Branebjerg PE, Geersten MS, Ilias W. Safety of lornoxicam: an interim meta-analysis of comparative clinical trials. Eur J Pain 2009;13(S1):S191.

TAKEDA (PTY) LTD. Reg No: 1982/011215/07. Building A, Monte Circle, 64 Montecasino Boulevard, Fourways, 2191. Tel: 0861 (TAKEDA) 825 332. Fax: 0861 (TAKEDA) 825 372. ZA/XEF/0816/0002

1129_09_16 XEFO MALE ADVERT 28_09_16.indd 1 2016/09/28 2:35 PM Editorial

Contents Editor: Dr Pauline du Plessis Anaesthetist Editorial 3 Olivedale Clinic Dr Pauline du Plessis Randburg, Johannesburg

Referring patients with chronic non-cancer pain to 4 reetings to all of you and welcome to our 4th edition of Nociceptive Views. This pain clinics edition has our first ethics article by Ms Ulundi Behrtel. She highlights the big Dr Tarin Penberthy problem we all have when treating complicated pain patients. On the one side Cannabis - more than just we have the increased deaths due to opioid overdose and on the other side we THC! (Part 2) 7 have the right of the patient for his pain to be treated. Dr Ernest Buitendag Being the doctor who will treat the pain implies that you will be the one to make the decision Chronic Heel Pain 11 if a patient should be on opioids or not. You will also need to know the ethical rulesof Dr Andries Oberholzer prescribing these type of drugs. There is no way of always making the right decisions, but I think the golden rule is regular follow-up visits of the patient. Once a strong opioid is started, The ethics of treating patients this should be monitored and managed. with pain 17 Ms Ulundi Behrtel This same concept is emphasised by the “cannabis frenzy” that is grabbing our country at the moment. I see patients taking all forms of cannabis every day in an attempt to control their pain. Dr Ernest Buitendag shares his excellent knowledge on this topic in the second part of Editor: Dr Pauline du Plessis Production Editors: Ann Lake Publications his review on cannabis. What is great about this article is that it gives us practical information Ann Lake, and informative pictures on how these substances look and which ones are presumed for Helen Gonçalves medical use. Design: Jane Gouveia Enquiries: [email protected] Telephone: 011 802 8847 As Dr Buitendag states, while the rules of cannabis control are so strong, we cannot do Fax: 086 671 9397 research. The only people who can do ‘research’ are the people that are illegally growing and selling this plant. He also mentions that this has all been done before and that we should look Disclaimer: This information is intended towards the Canadian model. for educational purposes only and does Proven not replace independent professional The previous two topics tie in nicely with Dr Tarin Penberthy’s article. She gives us a practical, judgment. Statements of fact and opinions useful review of when to refer a patient to a pain clinic. This is all good and well, but the expressed are those of the authors Performance individually and, unless expressly stated problem is that there are very few of these multidisciplinary pain clinics around. The to the contrary, are not the opinions or complicated patient on multiple opioids and various substances, including cannabis, is the in Relieving Pain position of Takeda or the publishers. ideal patient for a pain clinic. A pain clinic is not some magical dumping ground. If patients Takeda and publishers do not endorse or could not be sorted out by a single physician, the pain clinic doctor will probably also not 1-8 approve and assume no responsibility for manage to do this. The strength of a well functioning pain clinic lies in the multidisciplinary and Inflammation the content, accuracy or completeness of the information published in the articles. setup thereof. This implies more than one physician and other health care professionals to No content of this publication may be share the burden and to put their minds together.

reproduced in any way without the Potent Efficacy Comparable Safety Multiple Solutions express prior permission from the author An example of how a simple symptom could be more complex, is heel pain. Dr Andries Potent, effective relief of pain Comparable tolerability and safety profile Range of formulations for flexible and publishers. Anyone in breach of this Oberholzer highlights the complicated anatomy of the heel’s nerve supply. Everything is not 1-6 1-3 copyright will be held personally liable. and inflammation with balanced COX-1/COX-2 inhibition 5, 7-10 dosing to suit patient needs simply plantar fasciitis, like I thought.

Takeda Educational Grant This issue reminds me of the continuous education we all need as doctors. To be a good This newsletter is sponsored doctor, you can truly never stop reading and refreshing. Thank you to all our wonderful through an independent grant authors who provided us with such an opportunity. from Takeda in the interests of continuous medical education. Therefore, read on and enjoy and be amazed at the complexity of it all! References: 1. XEFO 4 and 8 mg Tablets South Africa Package Insert, October 1998. 2. XEFO 8 IV/IM Injection South Africa Package Insert, October 1998. 3. XEFO RAPID Tablets South Africa Package Insert, September 2012. 4. Balfour JA, Fitton A, Barradell LB. Lornoxicam. A Review of its Pharmacology and Therapeutic Potential in the Management of Painful and Inflammatory Conditions. Drugs 1995;51(4):639-657. 5. Bernatzky G, Beubler E, Dunky A, Erlacher L, Hermann J, Herold M, et al. Lornoxicam. Expert Statement. Expert Meeting on 3rd April 2003. CliniCum 2004:1-8. 6. Berg J, Fellier H, Christoph T, Grarup J, Stimmeder D. Pauline The analgesic NSAID lornoxicam inhibits cyclooxygenase (COX)-1/-2, inducible nitric oxide synthase (iNOS), and the formation of interleukin (IL)-6 in vitro. Inflamm Res 1999;48:369-379. 7. Papadima A, Lagoudianakis EE, Antonakis PT, Pattas M, Kremastinou F, Katergiannakis V, et al. Parecoxib vs. lornoxicam in the treatment of postoperative pain after laparoscopic cholecystectomy: a prospective randomized placebo-controlled trial. Eur J Anae 2006:1-5. 8. Yakhno N, Guekht A, Skoromets A, Spirin N, Strachunskaya E, Ternavsky A, et al. Analgesic Efficacy and Safety of Lornoxicam Quick-Release Formulation Compared with Diclofenac Potassium. Randomised, Double-Blind Trial in Acute Low Back Pain. Clin Drug Invest 2006;26(5):267-277. 9. Kidd B, Frenzel W. A Multicenter, Randomized, Double Blind Study Comparing Lornoxican with Diclofenac in Osteoarthritis. J Rheuma 1996;23(9):1605-11. 10. Pleiner J, Nell G, Branebjerg PE, Geersten MS, Ilias W. Safety of lornoxicam: an interim meta-analysis of comparative clinical trials. Eur J Pain 2009;13(S1):S191. Page 3

S3 XEFO RAPID Tablets. Reg No. 44/3.1/0331. Each film-coated tablet contains 8 mg lornoxicam and is sugar-free. S3 XEFO 4 mg Tablets. Reg No. 33/3.1/0247. Each film-coated tablet contains 4 mg lornoxicam. S3 XEFO 8 mg Tablets. Reg No. 33/3.1/0248. Each film-coated tablet contains 8 mg lornoxicam. S3 XEFO IV/IM Injection. Reg No. 33/3.1/0249. Each vial contains 8 mg lornoxicam. Going beyond TAKEDA (PTY) LTD. Reg No: 1982/011215/07. Building A, Monte Circle, 64 Montecasino Boulevard, Fourways, 2191. Tel: 0861 (TAKEDA) 825 332. Fax: 0861 (TAKEDA) 825 372. the pain threshold Continuing Medical Education Edition 4 | January/February 2018 ZA/XEF/0816/0002 ZA/XEF/1016/0013a(1)

1129_09_16 XEFO MALE ADVERT 28_09_16.indd 1 2016/09/28 2:35 PM Referring patients with chronic non-cancer pain to pain clinics

to say that the pain physician serves as a consultant to other Dr Tarin Penberthy physicians or more often as the principal treating physician General Practitioner and Medical Officer - Pain Management (as distinguished from the primary care physician) who may Helen Joseph Hospital provide care at various levels. Johannesburg According to the IASP, a multidisciplinary pain clinic is a health care delivery facility staffed by physicians of different he origin of modern multidisciplinary pain clinics specialties and other non-physician health care providers has been attributed largely to Bonica, an (HCPs) who specialise in the diagnosis and management of anaesthetist working at an army hospital in the patients with chronic pain. Non-physician HCPs include nurses, USA following World War II.1 Bonica noted that psychologists, physiotherapists, occupational and vocational some patients responded well to his nerve therapists and dieticians. Therefore, in addition to the blocks, whilst others did not. As per standard practice, he medications prescribed, the pain management programme referred these non-responders to colleagues from other incorporates the biopsychosocial aspects of the patient. specialties for second opinions. He found this mode of operating slow and inefficient, so he started to arrange regular When do you refer to a pain clinic? meetings with these colleagues to discuss the patients they Referral should be done once a work up has been completed. had in common. Together, they reached a degree of consensus Either an established medical diagnosis has been made on their diagnoses and composed a treatment plan. Bonica or where the diagnosis is unclear or non-specific, serious found this multidisciplinary mode of operating much more conditions such as neoplasms or spinal cord injuries should effective and efficient in the treatment of these complex cases have been excluded (see red flags below).2 than the previous ‘serial referral’ approach. He began to 2 promote this concept more widely’. The most appropriate time may vary according to the patient’s condition. For Complex Regional Pain Syndrome and other In this article, I would like to elaborate on the role and value of neuropathic pain conditions, the earlier the referral, the multidisciplinary pain clinics. Particular attention will be paid better. For conditions such a non-specific chronic low back to the optimal time to refer to a pain clinic, as well as which pain, referral is generally later after traditional treatments 2 patients will benefit the most from such a referral. have proven unsuccessful.2

Some definitions However, if a referral is made many years after the onset Bonica defined chronic pain as “pain which persists past of pain, this usually results in poorer outcomes of the the normal time of healing”. According to the International multidisciplinary pain management programme, due to the Association for the Study of Pain (IASP), ‘this may be less fact that the biopsychosocial and environmental sequelae have than one month, or more often, more than six months. With already become thoroughly ingrained.2 Another confounding nonmalignant pain, three months is the most convenient point factor is concern about the potential for reinforcement of the of division between acute and chronic pain, but for research disability role when patients have been for multiple, and often purposes six months will often be preferred’. unnecessary, investigations. These patients have generally overlooked opportunities to accept their condition and Chronic pain is multidimensional consisting of biological, develop more of a self-management approach.2 There is some psychological and social (biopsychosocial) factors. The evidence4,5 that early recognition of, and intervention in, the collaboration of these factors lead to the patient’s own unique biopsychosocial and environmental factors may prevent the pain experience. development of a secondary disability.

The American Board of Pain Medicine defines the specialty of Reasons for referral can be related to advice on ongoing Pain Medicine as a discipline within the field of medicine that management options, symptom control measures, assistance is concerned with the prevention of pain and the evaluation, with the final diagnosis and management of the patient or to treatment, and rehabilitation of persons in pain. They request for assessment for the suitability for interventional describe pain specialists as physicians who use a broad-based procedures (see section below). approach to treat all pain disorders, ranging from pain as a symptom of disease to pain as the primary disease. They go on

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Going beyond the pain threshold Continuing Medical Education Edition 4 | January/February 2018 Who do you refer to a pain clinic? 4. Patients needing high dose opioids or tertiary drugs Pain clinics offer an opportunity for a fresh, comprehensive are often best handled by a Pain Specialist.8 Opioids review of a patient. Symptom control rather than curative pose their own challenges, including abuse, addiction, treatment is the normal expectation of a chronic pain clinic. diversion, adverse effects and fears of regulatory scrutiny. These challenges may be overcome by adherence to the The following types of patients would benefit from being local guidelines, signing opioid agreements, the use of referred to a pain specialist: random urine drug screening, monitoring for aberrant behaviours, and anticipating adverse effects.8 When 1. Patients at high risk of poor outcomes are those with a psychiatric comorbidities are present, risk of substance history of comorbidities such as:8 abuse is high and pain management may require • Mental health problems (including depression, anxiety, specialised treatment or consultation. Another reason personality disorder, post-traumatic stress disorder) patients need referral are those needing tertiary drugs • Cognitive impairment such as Ketamine or Capsaicin 8% (only available via a • Substance misuse section 21 through the Medicine Control Council in South • Pregnancy Africa). • Polypharmacy • Significant renal or hepatic impairment Tips for referral to a pain clinic • Presence of yellow flags11 which are biopsychosocial • Ensure that the patient is aware that the pain management indicators suggesting increased risk of progression to programme will be a multimodal based treatment. It long-term distress, disability and pain is important that the patient understands the likely composition of the multidisciplinary team and is willing to Table 1. Yellow Flags participate in the relevant therapies offered. • It is critical that the patient does not think that the referral Severe pain or increased disability at represents disbelief or abandonment by the referring Biomedical presentation, previous significant pain yellow flags episodes, multiple site pain, non-organic doctor. To avoid this, patients need to be counselled about signs, iatrogenic factors. the reason for referral with emphasis on the potential value of the referral.2 Psychological Belief that pain indicates harm, an expectation yellow flags that passive rather than active treatments are most helpful, fear avoidance behaviour, Red Flags catastrophic thinking, poor problem solving Red Flags are features, signs and symptoms that indicate ability, passive coping strategies, atypical serious spinal pathology. Red Flags must be excluded at every health beliefs, psychosomatic perceptions, consultation and the patient is to be referred immediately to a high levels of distress. spinal or neuro surgeon or to an emergency department should Low expectation of return to work, lack of any Red Flags be present as it may indicate the development confidence in performing work activities, of a cauda equina syndrome or spinal compression, which are Social yellow heavier work, low levels of control over rate flags both medical emergencies. of work, poor work relationships, social dysfunction, medico-legal issues. Features • Previous history of malignancy (however long ago) 2. Patients who show a slower than expected progress • Age 16< or >50 with NEW onset pain include those with: • Weight loss (unexplained) • Intolerable side effects to the medications • Previous longstanding steroid use, drug use • Preference for a self management rather than a • Patients that are immunosuppressed medical approach • Recent serious illness • Patients claiming from a 3rd Party • Recent significant infection

3. Another reason for referring patients to a pain clinic for Symptoms advice on whether interventional pain procedures may help • Non-mechanical pain (worse at rest) the patient. The procedures are mainly used in conjunction • Thoracic pain with medications and multidisciplinary management or • Fevers/rigors rarely to provide an alternative to medications. The aim of • General malaise these interventions is to ease pain severity (and often sleep • Urinary retention and distress)with the expectation that this will enable the patient to have a better quality of life.

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Going beyond the pain threshold Continuing Medical Education Edition 4 | January/February 2018 Signs • Saddle anaesthesia • Reduced anal tone Take-home message • Hip or knee weakness • Generalised neurological deficit • Referral to be done once the patient had been worked • Progressive spinal deformity up and Red Flags excluded • Urinary retention • The treatment of chronic pain has to be multidisciplinary in nature It is important to have a high index of suspicion when any of • Not all chronic pain patients need referral to a pain the above are present and the majority of information is in the clinic history with a simple examination. • Optional time for referral varies: • Neuropathic pain as early as possible • Nociceptive pain after other treatments have proven Conclusion 12 unsuccessful As Mayer et al have argued, the rationale for referral to • Be careful not to refer too late either, as this can result such tertiary rehabilitation ‘is that accurate assessment of in poorer outcomes the many interrelated factors of chronic disability and pain, • Symptom control, rather than curative treatment is linked to skilful implementation of multifaceted treatment the normal ecpectations of a pain clinic programmes, can usually enable recovery or at least reduce the degree of permanent disability’

It is important to note that not every chronic pain patient References needs a referral to a pain specialist to help manage their 1. Loeser, J.D. Bonica’s Management of Pain. (3rd ed.). pain. However, when a patient’s pain is not controlled, not Philadelphia: Lippincott Williams and Wilkins; 2001. following a typical pattern, or just beyond a practitioner’s 2. Nicholas, M.K. When to refer to a pain clinic. Best Practice & comfort level, it may be time to refer to a specialist. Having Research Clinical Rheumatology. 2004;18(4): 613–629. the correct diagnosis can greatly change a patient’s therapy 3. Iasp-painorg. [Online]. Available from: https://www.iasp- and future prognosis. pain.org/Education/Content.aspx?ItemNumber=1471 4. Pither, C.E, Nicholas, M.K. Identification of iatrogenic This review has suggested that the decision of when to refer factors in the development of chronic pain syndromes: to a multidisciplinary pain clinic should be based on the abnormal treatment behaviour? Pain Research and Clinical identification of a need for comprehensive, multidisciplinary Management, vol 4. Amsterdam: Elsevier; 2001. pp. 429- assessment, especially when progress is stalled or not 434 proceeding as expected. 5. Kouyanou, K, Pither, C.E, Wessely, S. Iatrogenic factors and chronic pain. Psychosomatic Medicine. 1997;59(6 ): 597- Treatment goals focus on improving the quality of life while 604. decreasing, but not necessarily curing, the pain of the 6. Linton, S.J. Why does chronic pain develop? A behavioural patient. This is done by improving the social, occupational, approach New Avenues for the Prevention of Chronic psychological, interpersonal, and physical disabilities that Musculoskeletal Pain and Disability, Pain Research and Clinical Management, vol 12, pp 67-82. (12 ed.). Amsterdam: are affected by the chronic pain, which adversely affect the Elsevier; 2002. patient’s quality of life.10 7. Lakha, S.F, Yegneswaran, B, Furlan , J.C, Legnini , V, Nicholson, K. Referring patients with chronic noncancer pain to pain clinics: Survey of Ontario family physicians.Canadian Family Physician. 2011;57(3): 106-112. 8. Jackman, R.P, Mallett, B.S. Chronic Nonmalignant Pain in Primary Care. Am Fam Physician. 2008;78(10): 1155-1162. 9. Scotnhsuk. [Online]. Available from: http://www.ckp.scot. nhs.uk/Published/PathwayViewer.aspx?id=609 10. Brookoff, D. Chronic pain: 1 A new disease?. Hosp Pract (Minneap). 2000;35(7): 45-52, 59. 11. Patientinfo. [Online]. Available from: https://patient.info/ doctor/chronic-pain 12. Mayer, T, Polatin, P, Smith, B, Gatchel, R, Fardon, D. Spine rehabilitation: secondary and tertiary nonoperative care. The Spine Journal. 2003;3(3): 28–36.

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Going beyond the pain threshold Continuing Medical Education Edition 4 | January/February 2018 Cannabis - more than just THC! (Part 2) (If you missed part 1, it is available electronically at www.mpconsulting.co.za)

Dr Ernest Buitendag Anaesthetist Port Elizabeth

Recreational vs medicinal, dosing and effects Figure 1. RSO

Strains • Sativa –Tall, laxly leaved, grows in warm lowlands. Myrcene < 0.5% = More uplifting, vibrant effect. • Indica – Short, bushier, grows in cooler mountains. Myrcene > 0.5% = “couch locked” – stoned effect. • Ruderalis – Non-psychoactive, not recognised by all. • Hybrids - Mixtures of above or a wild type. • Hemp – Grown for fibre and medicinal properties Figure 2. BHO

Most cannabinoids and terpenes are contained in trichomes, on the female plant’s flowers. • Kief – Powder rich in trichomes. Consume the powder or compress to form hashish • Hashish – Concentrated resin cake. Consumed orally, smoked or vaped • Tincture – Extracted cannabinoids using preferably >190% Figure 3. PSupercritical CO2 proof grain alcohol • Hash oil – Obtained by solvent extraction – Butane or supercritical CO2. Hard or viscous mass. Potentially the most potent due to a high level of psychoactive component per volume. • Solvents – Plant material mixed with various non-volatile solvents. Figure 4. Rosin Types of cannabis oils • Rick Simpson Oil (RSO) – Crude, dark colour, simple hydrocarbon/alcohol solvent extraction. High in cannabinoids and associated compounds (Fig 1). • Butane Honey Oil (BTO) – Extracted using butane. Mainly recreational use. High in THC and flavour (Fig 2). • Supercritical O C 2 oil – Extraction via carbon dioxide at extremely high pressure. Provides medicinal grade oil and Figure 5. Tinctures most likely the safest option (Fig 3). • Rosin – Resin extract using heat and pressure. Mostly recreational (Fig 4). • Tinctures – Use solvents or oils to produce concentrated liquid with small amounts of alcohol to allow for rapid oral absorption. Packaged in drop bottles to allow easy and precise dosing (Fig 5). • Natural Oils (Fig 6). • Balms and creams (Fig 7). Figure 6. Natural Oils Figure 7. Balms and creams

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Going beyond the pain threshold Continuing Medical Education Edition 4 | January/February 2018 Dosing Guideline Table 1. Medicinal use There is a very large inter-personal variability with no “one CBC, CBD, CBG, CBN, THC, ALS dose fits all”. It is important to start low and go slow until the THCa ‘therapeutic window’ is reached. Experimentation is required, CBC, CBD, CBG, CBN, THCv Osteoporosis too little and there will be minimal beneficial effect, too much CBD, CBG, CBN, THC, THCa Spasticity and you could experience uncomfortable sensations. The Parkinson’s route of administration and the type of product also plays a Neurological CBC, CBD, CBG, THC, THCa significant role. Alzheimer’s CBD, CBN, THC, THCa Multiple Sclerosis 1 Joint = 0.5g to 1g Seizures CBD, CBN, THCa, THCv 3g = 3 to 6 joints or 10 to 12 vaporisations/day Epilepsy Dry - oral ingestion (bake, tea) will require 2.5 x the amount. THC Tourette’s Depending on the manufacturing, product and ratios: 1g dry/ CBD, CBG Anxiety day ~ 1ml oil/day ADD/ADHD CBD,THC The average use as per: Stress • Health Canada = 1 to 1,25g /day Mood and Bipolar • Netherlands = 0,68 g /day Behaviour CBD, CBG, THC OCD • Israel = 1.5g / day PTSD Effective medicinal dosing range is 0.05 – 25mg/kg/day

CBC, CBD, CBG, THC, Depression As mentioned before the THC:CBD ratio is important. A THC Appetite Loss Canadian Medical Cannabis company (CanniMed) offers the Anorexia following product ratios as an example: Cachexia CBD, THC Gastrointestinal Table 2. Product ratio examples Gastrointestinal Disorders Dry Oil Nausea THC % : CBD % THC % : CBD % CBD, THCv Diabetes 1:13 18:0 CBD, THC, THCa Crohn’s 4:10 10:10 CBC, CBD, CBN, CBG, CBN, Inflammation 9:9 1:20 THC, THCa Arthritis 12:0 Pain 15:5 CBC, CBD, CBN, THC, THCv Insomnia 17:1 Fibromyalgia Pain/Sleep 22:1 Spinal Injury Phantom Limb CBD, THC Migraine/Headache Health Risks Medicinal cannabis is non-toxic and non-lethal. In monkeys Cramps 9000mg/kg orally caused no fatalities. In a longitudinal study THC Sleep Apnea in chronic, heavy users the only significant medical finding was CBC, CBD, CBDa, CBG, THC, 10 Cancer in poor peridontal health. THCa CBC, CBD, CBG, THC Muscular Dystrophy Drug Interactions

THC, THCA HIV/AIDS Opioids Other CBG, THC Glaucoma • Synergistic effect • Very few cannabinoid receptors in the brainstem, thus no CBD, THC Hypertension cardiorespiratory depression. Fatigue • Minimal pharmacokinetic interaction with morphine or THC Asthma oxycodone CBC = cannabichromene, CBD = cannabidiol, CBG = cannabigerol, CBN = −− In pre-clinical work on animals there was decreased Cannabinol, THC = delta 9-tetrahydrocannabinol, THCa = tetrahydrocannabinolic development of opioid tolerance, retention of the acid, THCv = tetrahydrocannabivarin

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Going beyond the pain threshold Continuing Medical Education Edition 4 | January/February 2018 anti-nociceptive effect and up-regulation of opioid Tolerance receptors in the spinal cord. • Tolerance to the effects of cannabis can happen over time. This requires “resetting” i.e. stop using for 48 to 72 hours, Alcohol and Benzodiazepines allowing the receptors to up-regulate. • Potentiates sedation Dependence NSAIDS especially Indomethacin can antagonise the effects of • Similar to caffeine. If you don’t get your daily fix you THC. become irritable, impatient, develop headaches and sleep disturbance. Anticholinergic • May have an increase in the psychoactive effects. Addiction - Dependence liability or risk for habitual use • Caffeine = 7% Adverse Effects • Cannabis = 9% A distinction has to be made between high, regular, • Alcohol = 20% recreational use in conjunction with nicotine, alcohol, cocaine • Nicotine = 30% and heroin abuse versus low dose, controlled, medicinal use. −− The addiction cannot be equated with that of cocaine, heroin, opioids or alcohol. Withdrawal is mild and Naïve users are prone to more adverse events until some short-lived, with no serious consequences unless there tolerance has been built up i.e.: is a underlying medical condition. • Euphoria, altered consciousness • Acute panic or paranoid reactions Overdose • Altered motivation • There is no documented evidence of a pure cannabis • Impaired attention, memory and psychomotor overdose (Numerous OTC and prescription drugs with performance FDA approval are dangerous and deadly if abused or • Tachycardia and orthostatic hypotension misused). • Xerostomia • Increased appetite South African Legal Aspect In June 2016, the Central Drug Authority (CDA) advised that Gastrointestinal tract the Government should shift to a middle ground approach • THC can aggravate liver fibrosis if present, while CBD exerts between criminalisation and legalisation → decriminalisation. an anti-fibrotic effect and is hepatoprotective. • Hyper-emesis syndrome is associated with heavy regular Based on the fact that the law as it stands now, has not changed use of high concentration THC preparations. Usually the pattern of marijuana use. But, until more evidence is diagnosed with a history of high use and improves with a available it should not be legalised either. hot bath. This settles with abstinence. In March 2017, the Medicine Control Council (MCC) put forth a Weight gain document: Draft Guidelines for production and manufacturing • Although using cannabis can lead to an increase in appetite, of Medicinal marijuana in South Africa. the general finding is that there are improved metabolic • Anybody can apply for a permit. markers i.e. lower weight, less insulin resistance, lower • You have to get permission from the MCC and the Director blood sugar and higher HDL cholesterol. General of Health. • You have to undergo a suitability test i.e. Intentions, prior Mental health conduct etc. • Elevated levels of CB1 receptors in a hippocampus exposed • If planning agricultural growth you have to ensure: to high concentration THC, leads to increased memory −− Security loss and lower memorising ability. The effect is similar to −− Account for all product before and after production alcohol misuse. • Medicinal marijuana can only be obtained under the • High, regular use of cannabis in pre-adolescence leads supervision of an approved medical practitioner. to a lower IQ by age 38. Use after adolescence or early BUT, NO PERMITS ARE BEING ISSUED CURRENTLY, UNTIL discontinuation has no effect on IQ in the long term. THE CURRENT LAW HAS BEEN AMENDED. • In people predisposed to schizophrenia and psychosis −− Specifically the Medicines and Related Substance Act using cannabis may trigger or aggravate the symptoms. of 2015 and the Draft guideline must be accepted into No causal effect has ever been proven. In countries law. where cannabis is legal, there has been no increase in the incidence of schizophrenia.

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Going beyond the pain threshold Continuing Medical Education Edition 4 | January/February 2018 “Recently the court ruled that current legislation did not pass Constitutional Court muster and that parliament had two years to rectify the law” (Extract from the Citizen newspaper, Take-home message April 2017). • Potentially very useful Effectively, it is still illegal until the law changes. But, you • But being illegal makes research near impossible can use cannabis in the privacy of your own home. If legal • A good recommendation would be to re schedule and action is brought against you for having cannabis for personal decriminalize cannabis (plant and phytocannabinoids). consumption in your own home then you may use “Bridge of • Provide education to doctors who are willing to Privacy” as your defence. prescribe • Ensure it is cultivated and sold in a controlled state. On the 31st July 2017, Myrtle Clarke and Julian Stubbs aka, We don’t have to reinvent the wheel. We can just the “Dagga Couple”, are putting the marijuana plant on trial follow the Canadian model. in the Pretoria High Court (19 court days have been allocated • There is always a case to be made for legalization . to the trial). The question that they are posing to the court As adults we should be able to decide for ourselves is: “How come this benign, useful, non-lethal plant has led to whether to use or not to use the persecution of so many people, in so many countries for • If the sale of cannabis is taxed it could go a long way so long?” to help the GDP.

This case is going to be far more comprehensive than the previously mentioned court case, and more significant for References cannabis rights activists worldwide as they feel it is their 1. Handb Exp Pharmacol 2015; 231:129-83. Zimmer A constitutional right to use cannabis freely. (Genetic Manipulation of the Endocannabinoid System) 2. Reference: Br J Pharmacol. 2014 Sep 171(18): 4155-4176 Conclusion Revolution in GPCR signaling: opioid receptor heteromers The endocannabinoid system ensures homeostasis in the as novel therapeutic targets: IUPHAR Review 10. Fujita, human body. In medical literature and education it has been Gomes, Devi. largely overlooked. 3. PLoS Biol 2015 Jul 9; 13(7). Cognitive Impairment Induced by Delta-9 –THC occurs through Heteromers between There are vast quantities of pre-clinical work on the interaction Cannabinoid Cb1 and Serotonin 5-HT2A Receptors. Vinals, between cannabis and the endocannabinoid system with Moreno et.al. some exciting results. 4. J Pharmacol Exp Ther 2010 Mar; 332(3): 710-719. Ligand- induced regulation and localization of cannabinoid CB1 Anecdotal evidence of the benefits of cannabis makes it and Dopamine Receptor Heterodimers. Przybyla, Watts. difficult to ignore. 5. Neuropsychpharmacology advanced online publication 15/02/2017. Singular location and signaling profile of Worldwide there is a trend to decriminalise and even legalise Adenosine A2A- Cannabinoid CB1 receptor heteromers in the use of cannabis. This will help with furthering the research, dorsal striatum that has been sorely missed in humans. 6. J Biol Chem 2016 May 6; 291(19): 9991-10005. Simultaneous activation of induced heterodimerization between CXCR4 chemokine receptor and cannabinoid receptor CB2 reveals a mechanism for regulation of tumor progression. Coke, Scarlett Chetram et al. 7. Prog Chem Org Nat Prod 2017; 103: 103-131. Molecular Targets of the Phytocannibinoids –A Complex Picture. Morales, Hurst and Reggio 8. www.profofpot.com 9. www.learngreenflower.com 10. www.herb.com 11. www.cannahealth.co.za (Dean Malan) 12. www.cannimed.ca 13. Leafly Holdings.Inc

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Going beyond the pain threshold Continuing Medical Education Edition 4 | January/February 2018 Chronic heel pain

Anatomy of the heel Dr Andries Oberholzer • Bones General Practitioner • Muscles Potchefstroom • Nerves • Plantar aponeurosis (Plantar fascia)

Bones of the foot eel pain is a very common problem in general • Tarsal bones (7) practice. The majority of patients feels pain either • Metatarsals (5) under the foot (plantar fasciitis) or just behind it • Phalanges (14) (Achilles tendinitis). • Talus • Calcaneus Heel pain is typically mild and usually disappears on its own. • Cuneiform ×3 In a small percentage of patients, heel pain can be severe • Navicular and sometimes disabling. When heel pain becomes chronic • Cuboid (present for more than three months), it can be a very difficult and challenging condition to treat. Muscles of the foot

Fast facts about the heel Extrinsic muscles • It is usually felt either under the heel or just behind it. • Arise from the anterior, posterior and lateral compartments • Heel pain has a prevalence of 3,6%. of the leg. • US studies estimate that 7% of older adults report • Responsible for actions such as: tenderness under the heel. −− Eversion • Plantar fasciitis is estimated to account for 8% of all running −− Inversion related injuries. −− Plantar flexion • There are 26 bones in the human foot, of which the heel −− Dorsi flexion is the largest. • Pain typically comes on gradually with no injury to the Intrinsic muscles affected area. It is often triggered by wearing flat shoes. • Located within the foot • In most cases the pain is under the foot, towards the front • Responsible for fine motor actions of the foot, for example of the heel. movement of individual digits • The majority of patients recover with conservative • Can be divided in: treatment within 3-4 weeks. −− Dorsal muscles • Home care such as rest, ice, proper fitting footwear and −− Plantar muscles foot supports are often enough to ease heel pain. ▪▪ 10 intrinsic muscles located within the sole of the • To reduce heel pain, it is recommended to reduce the foot stress on that part of the body. ▪▪ Act collectively to stabilise the arches of the foot and individually to control movement of the digits. ▪▪ The muscles of the plantar aspect are described in 4 layers (superficial to deep)

First layer • Located immediately underneath the plantar fascia • 3 Muscles: −− Abductor hallucis (MPN) −− Flexor digitorum brevis (MPN) −− Abductor digiti minimi (LPN) (MPN = medial plantar nerve, LPN = Lateral plantar nerve) Figure 1. Bones of the foot

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Going beyond the pain threshold Continuing Medical Education Edition 4 | January/February 2018 Second layer • 2 Muscles −− Quadratus plantae (LPN) −− Lumbricalus (most medial MPN, remaining 3 LPN)

Third layer • 3 Muscles −− Flexor hallucis brevis (MPN) −− Abductor hallucis (deep branch of LPN) −− Flexor digiti minimi brevis (superficial branch of LPN)

Fourth layer • Plantar interossei (LPN) • Dorsal linterossei (LPN)

Nerve supply of the ankle and foot

Anatomy • The terminal branches of the sciatic and femoral nerve supply the ankle joint. • The sciatic nerve divides into the tibial nerve and common peroneal or fibular nerve. Figure 2. Tibial Nerve Figure 3. Tibial Nerve • Branches of the tibial and common peroneal nerve form the sural nerve. • The only branch of the femoral nerve which contributes to sensory innervation below the knee is the saphenous nerve. • The saphenous nerve supplies the skin on the medial aspect of the ankle joint.

Tibial nerve • The tibial nerve descends though the middle of the popliteal fossa, posterior to the popliteal vein and artery (when scanning from behind it is more superficial compared to the blood vessels). • In the leg it is accompanied by the posterior tibial artery. • The tibial nerve leaves the posterior compartment of the leg by passing deep to the flexor retinaculum between the medial malleolus and calcaneum. • The tibial nerve lies between the posterior tibial vessels and the tendon of the flexor hallucis longus. • The tibial nerve divides into the medial and lateral plantar nerves.

Common peroneal nerve The common peroneal nerve is one of the terminal branches Figure 4. Common Peroneal Figure 5. Saphenous nerve of the sciatic nerve. It begins in the popliteal fossa and runs Nerve along the medial border of the biceps femoris muscle. It exits Deep peroneal nerve the popliteal fossa by passing over the lateral head of the The deep peroneal nerve begins deep to the peroneous gastrocnemius muscle. (fibularis) longus muscle and then passes under the extensor digitorum longus. It pierces this to lie anterior to the The common fibular nerve then goes around the neck of the interosseous membrane. It then accompanies the anterior fibula under the peroneus longus muscle and then divides into tibial artery between the extensor hallucis longus and tibialis the superficial and deep peroneal nerves. anterior muscles.

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Going beyond the pain threshold Continuing Medical Education Edition 4 | January/February 2018 Superficial peroneal nerve Saphenous nerve • This nerve begins between the peroneus longus muscle The saphenous nerve is the only sensory contribution of the and the fibula. It then passes anterolateral to the fibula femoral nerve below the knee joint. It arises from the femoral between the peroneous longus muscles and the extensor nerve in the femoral triangle and descends through it on the digitorum longus which it supplies along with peroneous lateral side of the femoral vessels to enter the adductor canal brevis. behind its aponeurotic covering. • It pierces the deep fascia at the lower third of the leg. • It passes the superficial fascia to supply the skin on the At the lower part of adductor magnus it separates from the distal part of the anterior surface of the leg, nearly all the artery behind the sartorius muscle. On the medial side of the dorsum of the foot and most of the digits. knee it emerges by piercing the fascia lata between sartorius and gracilis to lie in the subcutaneous plane. In the leg the Sural nerve saphenous nerve follows the great saphenous vein. This is formed from a contribution by the tibial (the medial sural cutaneous nerve) and the common peroneal nerve Sensory innervation of the ankle (sural communicating branch). This nerve supplies the skin of There is normally a considerable overlap between the nerves. the posterolateral side of the inferior third of the leg and the (Figure 6) lateral side of the foot. The sural nerve lies behind the lateral malleolus along with the short saphenous vein. It supplies Plantar aponeurosis (Plantar fascia) the posterior part of the sole, the back of the lower leg, the • The plantar aponeurosis also known as the plantar facia is posterior heel and lateral side of the foot a strong layer of white fibrous tissue located beneath the skin of the foot.

Figure 6. Sensory innervation of ankle

Figure 7. Plantar aponeurosis (Plantar fascia)

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Going beyond the pain threshold Continuing Medical Education Edition 4 | January/February 2018 • It runs from the medial tuberosity of the calcaneus forward Most common conditions to the heads of the metatarsal bones. • Plantar fasciitis • Towards the front of the foot at the mid tarsal level it • Tarsal tunnel syndrome (TTS) divides into 5 sections, each extending in to a toe and • Inferior calcaneal nerve entrapment (ICN) straddling the flexor tendons • Medial calcaneal nerve entrapment (MCN) • It is divided into a medial, central and lateral section. • Medial plantar nerve entrapment (MPN) • The central portion is the most important structurally • Lateral plantar nerve entrapment (LPN) and functionally and is attached at its origin to the medial • Plantar fascia tear (rupture) calcaneal tuberosity. • Atrophy of the plantar fat pad • The medal portion overlies muscles to the hallux (big toe) • Calcaneal stress fracture while the lateral portion overlies the muscles to the little • Retro calcaneal bursitis toe. • Tenosynovitis • It stabilises the arch of the foot and allows flexion of the −− Flexor digitorum longus (FDL) first metatarsal, enabling it to carry the majority of the −− Flexor hallucis longus (FHL) body weight. It also provides shock absorption when the −− Tibialis posterior (TP) foot hits the ground. • Auto immune diseases −− Rheumatoid arthritis (RA) Inflammation or injury of the plantar aponeurosis is known as −− Systemic lupus erythematosus (SLE) plantar fasciitis. −− Ankylosing spondylitis (AS) −− Reiter’s syndrome (RS) Differential diagnosis of heel pain Symptoms and signs Table 1. Differential Diagnosis of Pain • Entrapment neuropathies often present as heel pain that Plantar heel mimics that of plantar fasciitis, so miss diagnosis is not Medial heel pain Others pain uncommon. Flexor digitorum Rheumatoid arthritis, • The presence of bilateral pain should trigger investigation Plantar fasciitis longus tenosynovitis especially if bilateral into an inflammatory source and L5/S1 radiculopathy may Flexor hallucis longus be the cause in a patient with coexisting back pain. Plantar fascia tear Reiter’s Syndrome tenosynovitis • Coexisting small fiber peripheral neuropathy as in diabetes Tibialis posterior and other conditions may complicate the clinical picture Heel pad atrophy Ankylosing spondylitis tenosynovitis • There is always a possibility of coexisting pathology Tarsal Tunnel anywhere along the course of the tibial nerve → “double Syndrome - although Tarsal tunnel crush” syndrome effect the heel may be syndrome Psoriatic arthritis spared if the MCN origin is high Inferior calcaneal Medical calcaneal nerve, entrapment, nerve entrapment Gout dysfunction or dysfunction or neuroma neuroma Calcaneal stress fracture Inferior calcaneal Posterior calcaneal cyst tumour, nerve entrapment enthesopathies osteomyelitis or oedema Calcaneal apophysitis Retrocalcaneal bursitis Behcet’s Syndrome Figure 8. Plantar Fasciitis (Sever’s disease) Systemic lupus Heel spur erythematosus Plantar fasciitis (PF) Fibromyalgia • Plantar fasciitis is a degenerative process due to repetitive Vascular insufficiency, microtrauma of the plantar fascia together with the acute congestion or L5-SI radiculopathy and chronic inflammation varicosities • Pathogenesis • Small tears in the plantar aponeurosis • Causes: −− Traumatic −− Inflammatory

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Going beyond the pain threshold Continuing Medical Education Edition 4 | January/February 2018 −− Degenerative Lateral plantar nerve (LPN) entrapment −− Metabolic • Burning pain, paraesthesia and numbness in the lateral side −− Neoplastic of the side of the foot that can extend to the lateral toes −− Genetic • Symptoms increased with activity and decrease with rest Plantar fasciitis • The LPN exits the TT posterior lateral to the MPN into the Influx of inflammatory mediators lateral plantar tunnel ↓ • Divides into deep and superficial branches Fibrosis/Calcifications • Tinel’s sign + ↓ Thickening of the aponeurosis • The plantar flexion /inversion/ compression test is positive ↓ Decrease in blood supply Medial plantar nerve entrapment (internal plantar ↓ Tissue ischaemia nerve) ↓ • Burning pain, dysesthesias and aching in the medial arch of Plantar fasciosis the feet and heel • Symptoms increase with activity and may radiate to the plantar aspect of the first and second toes • Tinel’s test positive • Plantar flexion/inversion/compression test is positive

Inferior calcaneal nerve entrapment (ICN) • Baxter’s nerve, first branch of the lateral plantar nerve, deep calcaneal nerve, nerve to the abductor digiti minimi (quinti/ muscle) • 20% of heel pain • Burning medial heel pain • Radiates to the arch of the foot or ankle • Worsens with standing or walking. Worse at night. Figure 9. Tarsal tunnel syndrome • Gradual onset without a specific turning event • Segregate into two discrete groups: −− Avid runners −− Old people, often those with occupations that require a lot of standing • Co-morbidities (diabetic neuropathy) may exist • Gives sensory branches to the periosteum of the medial calcaneal tuberosity (MCT) and the long plantar ligament • Tinel’s signs often not positive • The posterior and anterior branches of the inferior calcaneal nerve provide sensory innervation to the area where the Figure 10. Lateral plantar nerve (LPN) entrapment plantar fascia originates from the calcaneus

Tarsal tunnel syndrome (TTS) Medial calcaneal nerve entrapment (MCN) • Burning pain and paraesthesia medial ankle (Calcaneal nerve, anterior calcaneal nerve) • Symptoms: (may vary depending on the specific branches • Second most common nerve involved in plantar heel pain. involved) • Sharp neuralgic pain with burning or tingling. −− Aggravated by activity/relieved by rest • Worsens during the day, or the longer they stand or walk. −− Worsens at night (night pain the result of venous stasis) • Night pain (venous stasis) −− Increases with dorsiflexion, eversion and pronation • Compared to the ICN the MCN is posterior, more superficial • Tinel’s sign + (distal tingling on percussion) and thicker. • Triple compression stress test (TCST) + • Divides into two branches: −− (Ankle in full plantar flexion, foot in inversion and constant −− Anterior branch digital pressure applied over the posterior tibial nerve) ▪▪ proximal AbH (motor) −− Will provoke: Pain, tingling, numbness, burning ▪▪ Superficial, inferior heel −− Sensitivity 85.9% ▪▪ Medial aspect of the medial calcaneal tubercle −− Specificity 100%

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Going beyond the pain threshold Continuing Medical Education Edition 4 | January/February 2018 −− Posterior branch Nerve conduction velocity (NCV) ▪▪ Skin over the Achilles tendon, heel and plantar foot pad Needle EMG • Arises sometimes from the LPN and not as usual from the • Abnormalities of the QP, FDMB, AbH main stem of the PTN. High resonance magnetic neurography • Innervation of the more medial aspects of the heel as well • Nerve damage/diameter as the calcaneal bursa regions. Pressure specified sensory device (PSSD) • Ablation of these nerves can reduce the deep heel pain associated with each of these areas. Treatment • Oral treatment Calcaneal Fracture • Physical therapy • Stretching exercises of the heel • Rolling massages of the heel (on an iced bottle) • Arch supports • Night splints • Behaviour modifications • Extra corporeal shock wave therapy • Cortico steroid injections −− Complications ▪▪ Irreversible soft tissue atrophy • Prolo therapy/Platelet rich plasma • Topaz procedure Figure 11. Stress Fracture • Radio frequency neuro ablation (ultra sound guided) • Partial surgical release of the plantar fascia/tarsal tunnel −− Complications: ▪▪ Collapse of the arch ▪▪ Cuboid crush syndrome ▪▪ Painful scar formation

Outcome (evidence-based) radio frequency ablation • Liden and colleagues −− 31 Feet −− Decrease in pain score from 8/10 to 1/10 • Sollitto and co-workers Figure 12. Stable Fracture −− 39 Feet Diagnostic investigations −− 92% success rate • Cozzarelli and colleagues Blood tests −− 82 patients, 12 years follow up • FBC, CRP, ESR −− 89% Success rate • Autoimmune investigations • Blood clotting profile References available on request. Weight- bearing plain radiographs Foot alignment • Fractures Take-home message • Joint degeneration MRI • Know the relevant anatomy. • Masses • Start with conservative treatment for 2-4 weeks. • Tendonitis • The tendency in modern medicine is to treat more • Muscle denervation aggressively in the early stages of the illness. CT scan • Radio frequency ablation of the medial and inferior Ultrasonography calcaneal nerves is indicated if conservative treatment • Masses fails. • Tendonitis • Be informed about the latest evidence based • Bursitis treatment options. • Nerve injuries • Refer the patient whenever in doubt. Electro diagnostic testing

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Going beyond the pain threshold Continuing Medical Education Edition 4 | January/February 2018 The ethics of treating patients with pain

informed consent from patients. Section 6 of the National Health Ulundi Behrtel BLC LLB (UP) Cert Med Law cum laude (UNISA) Act9 prescribes the requirements for valid informed consent. Cert Legislative Drafting cum laudeU ( P), PG Dip International In terms of this section, medical practitioners must inform Research Ethics cum laude (UCT) patients of their health status as well as the treatment options Health Law and Ethics Consultant in private practice, Pretoria available for any health condition. Patients suffering from acute or chronic pain are, therefore, entitled to information about the management of their pain and to choose the treatment option n June 2017, opioid addiction was declared a national public best suited for them. health emergency in the United States of America (USA). The American National Institute on Drug Abuse estimates that Section 10 of the Bill of Rights states that everyone has more than 90 people die from an opioid overdose every day1 inherent dignity and the right to have their dignity respected and that approximately 3 million Americans become addicted and protected. This right is particularly relevant when it comes to prescription pain relievers each year.2 to the management of pain in terminally ill patients. Medical practitioners have a duty to respect a patient’s right to die a This alarming trend is, however, not unique to the USA. dignified death, free from pain and suffering. According to Dr David Bayever of South Africa’s Central Drug Authority, South Africa is among the top 10 in the world with The Declaration of Montreal 3 regard to narcotics and alcohol abuse. In the July 2017 Update At the 13th World Congress on Pain held in Montreal during 4 5 of the SACENDU Project, it was reported that for the period September 2010, the International Association for the Study July to December 2016: of Pain (IASP)10 emphasised the inadequate management of pain care in patients worldwide. IASP accordingly created “The abuse of Over-The-Counter (OTC) and Prescription the Declaration of Montreal11 in an attempt to address the Medicines such as slimming tablets, analgesics, and lack of national policies on the management of pain and the benzodiazepines (e.g. diazepam and flunitrazipam) inadequate knowledge of pain management techniques by 6 continues to be an issue across sites.” many medical practitioners.

In the light of the above statistics, it is opportune to consider The Declaration states that: the legal and ethical duties of medical practitioners in treating “Recognizing the intrinsic dignity of all persons and that patients with pain. withholding of pain treatment is profoundly wrong, leading to unnecessary suffering which is harmful; Pain treatment as a human right we declare that the following human rights must be In the foreword to the latest South African Acute Pain recognized throughout the world: Guidelines,7 Dr Milton Raff, chairperson of the World Federation of Societies of Anaesthesiologists Pain Relief Article 1. The right of all people to have access to pain Committee, reiterated his statement of six years ago when management without discrimination. he said “acute pain management is not a luxury, it is a human right!”. This statement is consistent with section 27 of the Bill Article 2. The right of people in pain to acknowledgment of of Rights which states that everyone has the right of access their pain and to be informed about how it can be assessed and to healthcare services. The management of acute or chronic managed. pain as a symptom of disease or injury is an integral part of the practice of medicine. Medical practitioners, therefore, have Article 3. The right of all people with pain to have access a constitutional obligation to ensure that patients with pain to appropriate assessment and treatment of the pain by have access to and receive timeous, adequate and appropriate adequately trained health care professionals.” treatment as part of the healthcare services offered. In order to assure these rights, the Declaration places the In addition to section 27, other rights in the Bill of Rights are following obligation on medical practitioners: also relevant. Section 12 stipulates that everyone has the right “ …all health care professionals in a treatment to freedom and security of the person.8 This right includes the relationship with a patient, within the scope of the right to security in and control over their body, which underpins legal limits of their professional practice and taking into the legal and ethical duty of medical practitioners to obtain account the treatment resources reasonably available,

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Going beyond the pain threshold Continuing Medical Education Edition 4 | January/February 2018 to offer to a patient in pain the management that would examined and assessed by the treating medical practitioner be offered by a reasonably careful and competent health before a new prescription for the relevant medicine is issued. care professional in that field of practice. Failure to offer such management is a breach of the patient's human Another rule that medical practitioners must take note of, is rights.” Ethical Rule 17(2). This rule reads as follows: “17. Issuing of prescriptions The obligation by medical practitioners to effectively and (2) A practitioner authorized in terms of the Medicines appropriately treat patients with pain must, however, be and Related Substances Act, 1965 (Act No. 101 of considered against the prevailing rules in the ETHICAL RULES 1965), to prescribe medicines shall issue handwritten OF CONDUCT FOR PRACTITIONERS REGISTERED UNDER THE prescriptions for medicine scheduled in Schedules 5, 6, HEALTH PROFESSIONS ACT, 197412 (“Ethical Rules”) as published 7 and 8 of the Medicines and Related Substances Act, by the Health Professions Council of South Africa (HPCSA). 1965 (Act No. 101 of 1965), under his or her personal and original signature.” (underlined parts represent my HPCSA Ethical Rules emphasis) In terms of Ethical Rule 23(5), practitioners “may prescribe or supply medicine or a medical device to a patient: Provided Finally, medical practitioners must adhere to the fundamental that such practitioner has ascertained the diagnosis of the principles of medical ethics,14 i.e. autonomy, beneficence, non- patient concerned through a personal examination of the maleficence and justice. Based on these principles, read with patient or by virtue of a report by another practitioner under Ethical Rule 27A,15 medical practitioners are required to at all whose treatment the patient is or has been and such medicine times act in the best interests of their patients. This, ultimately, or medical device is clinically indicated, taking into account remains the most important duty of a medical practitioner the diagnosis and the individual prognosis of the patient, and regarding the treatment of patients with pain. affords the best possible care at a cost-effective rate compared to other available medicines or medical devices and the patient References is informed of such other available medicines or medical 1. https://www.drugabuse.gov/drugs-abuse/opioids/opioid- devices.” This rule, however, does not apply in the case of a crisis patient with a chronic disease. 2. http://time.com/5006944/what-doctors-facing-the-opioid- crisis-need-next/ Medical practitioners treating patients with chronic pain are 3. SA drug abuse trends paint a grim picture, reported in the reminded of the provisions of section 22A(6)(g) of the Medicines Boksburg Advertiser on 23 June 2017, available online at and Related Substances Act13 which stipulate that in the case of https://boksburgadvertiser.co.za/297238/sa-drug-abuse- a schedule 5 substance, the prescription shall not be repeated trends-paint-grim-picture/ for longer than six months. This means that patients must be References 4-15 available on request.

For Drug Safety reporting of ADRs: Please note our new address is: [email protected] Takeda (Pty) Ltd T: +27 11 514 3109 Building A, Monte Circle M1: +27 72 441 6626 64 Montecasino Boulevard Additional information about Takeda M2: +27 82 525 3040 (Drug Safety) Fourways, 2191 South Africa: F: +27 86 558 7816 http://www.takeda.co.za

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Going beyond the pain threshold Continuing Medical Education Edition 4 | January/February 2018 #1 Prescribed by Paediatricians for pain and fever 1

• Effective relief from pain and fever • Exact dose, every time • No loss of efﬁ cacy due to vomiting • Non-sedative 2 • Alternative to oral therapy • Easy to use • Two dosage strengths available (125 mg and 250 mg paracetamol) • No sugar, colourants or preservatives

Effective relief from pain and fever

For use in infants from 3 months and in children up to 5 years of age

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