Current pain managementCurrent pain management in Lithuania: in Lithuania:

system and practice system and practice

Alfredas Vaitkus, MD, FIPP

The In-patient Day Department of Pain TreatmentCentre of Anaesthesiology, Intensive Therapy and Pain Management

Vilnius University Hospital Santariskiu Clinics

Vilnius, Lithuania

A piece of historyA piece of history

1953 - 11953 - 1stst pain clinic in USA pain clinic in USA1961 - 11961 - 1stst pain clinic in Europe pain clinic in Europe1994 - 11994 - 1stst pain clinic in Lithuania pain clinic in Lithuania

A piece of historyA piece of history 1990-1993 - sporadic enthusia1990-1993 - sporadic enthusiassm in the meaning of m in the meaning of

interests and practiceinterests and practice

1993-1994 – several anesthesiologist visit to Norwegian 1993-1994 – several anesthesiologist visit to Norwegian hospitals (Oslo and Bergen) with support from hospitals (Oslo and Bergen) with support from Norwegian Cancer Society and Rotary OrganizationNorwegian Cancer Society and Rotary Organization

1994 - establishment of the 1994 - establishment of the 11stst pain clinic in Lithuania pain clinic in Lithuania (Vilnius University Hospital Santariskiu Clinics)(Vilnius University Hospital Santariskiu Clinics)

Dr. Lorens Gran

Dr. Jane Baubliene

Short review of presentationShort review of presentation

Juridical baseJuridical base System in workSystem in work Specialized pain centersSpecialized pain centers MedicinesMedicines Interventional pain managementInterventional pain management Postoperative pain managementPostoperative pain management Palliative carePalliative care OrganizationsOrganizations EducationEducation

Juridical baseJuridical base

1997 m.1997 m.“Pa“Patients should receive scientifically tients should receive scientifically

based analgesic measures in order not to suffer based analgesic measures in order not to suffer due to their health disordersdue to their health disorders““

Law of patients’ rights and compensation for harm Law of patients’ rights and compensation for harm (LR)(LR)

Recognition of patients’rights to receive pain helpRecognition of patients’rights to receive pain help

Juridical baseJuridical base

20012001 “Pain is a major healthcare problem. Although acute “Pain is a major healthcare problem. Although acute pain may reasonably be considered a symptom of pain may reasonably be considered a symptom of disease or injury, chronic and recurrent pain is a specific disease or injury, chronic and recurrent pain is a specific healthcare problem, a disease in its own right.”healthcare problem, a disease in its own right.”

European Federations of IASP Chapters (EFIC) DeclarationEuropean Federations of IASP Chapters (EFIC) Declaration

Approved by Minister of Health of Approved by Minister of Health of Lithuania inLithuania in 2002. 2002.

Recognition of pain problemRecognition of pain problem

Juridical baseJuridical base

20032003“Concerning invasive pain management “Concerning invasive pain management procedures for adults and children in health care procedures for adults and children in health care institutions and base price approval.”institutions and base price approval.” Order of Minister of Health (LR)Order of Minister of Health (LR)

Legitimation:Legitimation:

of invasive proceduresof invasive procedures

of reimbursementof reimbursement

of in-patient day departmentof in-patient day department

Juridical baseJuridical base

Neurolytic proceduresNeurolytic procedures radiofrequency destructionradiofrequency destruction neurolytic proceduresneurolytic procedures

Instantaneous curative proceduresInstantaneous curative procedures facet blocksfacet blocks single epidural injection - cervical, thoracic, sacralsingle epidural injection - cervical, thoracic, sacral single epidural injection – lumbarsingle epidural injection – lumbar trigger point injectionstrigger point injections somatic nerve blocksomatic nerve block

Long-lasting curative proceduresLong-lasting curative procedures catheterisation of epidural spacecatheterisation of epidural space intravenous farmacological test or infusion pump installationintravenous farmacological test or infusion pump installation

Juridical baseJuridical base20042004

“Concerning obligatory medicinal help and the “Concerning obligatory medicinal help and the order of obligatory medicinal help services and order of obligatory medicinal help services and extent.”extent.”

Order of Minister of Health (LR)Order of Minister of Health (LR)

NecessityNecessity::

to evaluate intensityto evaluate intensity

to use pain scalesto use pain scales

to document painto document pain

to treatto treat

Juridical baseJuridical base

20072007

„Inventory for requirements of palliative care „Inventory for requirements of palliative care services for adults and children.“services for adults and children.“

Order of Minister of Health (LR)Order of Minister of Health (LR)

Legitimation of palliative care servicesLegitimation of palliative care services

SystemSystem in work in work

Nonmedical help – patient educationNonmedical help – patient educationGeneral helpGeneral help

general practitionersgeneral practitioners ambulatory specialistsambulatory specialists hospital specialisthospital specialist

Specialized helpSpecialized help pain centres and consultationspain centres and consultations postoperative pain servicespostoperative pain services palliative care institutionspalliative care institutions rehabilitations centresrehabilitations centres surgical centerssurgical centers

7 hospital based pain clinics (in-patient day departments)

2 of them - C-arm fluoroscopy

several ambulatory pain consultations

~15 physicians of different specialties

2/3 of them – anesthesiologists

0 to 2 nurses available for 1 physician

Pain centres and consultations in LithuaniaPain centres and consultations in Lithuania

Specialized pain help in LithuaniaSpecialized pain help in Lithuania

~ 12.000/year visits to pain centres and ~ 12.000/year visits to pain centres and consultationsconsultations

~ ~ 2/3 visits are due to back pain and joint pain2/3 visits are due to back pain and joint pain ~ ~ 20% visits due to oncological pain20% visits due to oncological pain

~ 6.000/year interventional procedures~ 6.000/year interventional procedures

2008 year data2008 year data

Medicines availabilityMedicines availabilityOpioidsOpioids

InjectionsInjections tramadoltramadol,, morphine, pentazocine, pethidine, buprenorphine morphine, pentazocine, pethidine, buprenorphine

OralOral tramadoltramadol,, morphine, methadon morphine, methadon

RectalRectal tramadoltramadol

TransdermalTransdermal fentanylfentanyl

ReimbursementReimbursementOncologicalOncological: morphine (inj., oral), tramadol (inj., oral), fentanyl (transdermal): morphine (inj., oral), tramadol (inj., oral), fentanyl (transdermal)Non-oncological for disabledNon-oncological for disabled: tramadol (inj., oral): tramadol (inj., oral)

Medicines availabilityMedicines availability

Non-steroidal antiinflammatory medicinesNon-steroidal antiinflammatory medicinesover over 15 chemical substances15 chemical substances

AntiepilepticsAntiepilepticsAntidepressantsAntidepressantsOther (Other (FlupirtineFlupirtine))

ReimbursementReimbursementOncologicalOncological: : several NSAIDsseveral NSAIDsTrigeminal neuralgiaTrigeminal neuralgia: carbamazepine: carbamazepineReumatological: Reumatological: several NSAIDsseveral NSAIDsDiabetic polineuropathyDiabetic polineuropathy: pregabaline, duloxetine: pregabaline, duloxetineFFor disabledor disabled: : several NSAIDs, amitriptilineseveral NSAIDs, amitriptiline

Interventional pain managementInterventional pain management Trigger point inj.Trigger point inj. Intraarticular inj.Intraarticular inj. Facet joint block & radiofrequency denervationFacet joint block & radiofrequency denervation Peripheral nervesPeripheral nerves Sacroiliac joint block & radiofrequency denervationSacroiliac joint block & radiofrequency denervation Epidural steroid inj.Epidural steroid inj. Selective transforaminal epidural steroid inj.Selective transforaminal epidural steroid inj. Stellate ganglion, thoracic sympathetic, splanchnic nerves, coeliac Stellate ganglion, thoracic sympathetic, splanchnic nerves, coeliac

plexus, hypogastric plexus, ganglion imparplexus, hypogastric plexus, ganglion impar Long-term epidural cathetersLong-term epidural catheters Long-term subcutaneous & intravenous infusionsLong-term subcutaneous & intravenous infusions Intravenous farmacological tests: opioids, lidocaine, ketamine etc.Intravenous farmacological tests: opioids, lidocaine, ketamine etc.

Intradiscal proceduresIntradiscal procedures (coblation nucleoplasty) (coblation nucleoplasty) VertebroplastyVertebroplasty

Postoperative pain servicesPostoperative pain services

No uniform model of No uniform model of postoperative postoperative pain servicepain service

Available models of services:Available models of services: Intermitent analgesics according to patient requestIntermitent analgesics according to patient request

Intermitent analgesics according to scheduleIntermitent analgesics according to schedule

Continuous analgesic methods with separate postoperative pain serviceContinuous analgesic methods with separate postoperative pain service

Decision is upon the hospitalDecision is upon the hospital

Larger hospitals tend to provide more consistent servicesLarger hospitals tend to provide more consistent services

Pain service availability

University hospitals Regional cetres hospitals Local hospitals

Yes 82% 42 19%

dr.G.Laurinenas data, 2004

Palliative care situationPalliative care situation

Services are at the very begining of systemic Services are at the very begining of systemic developmentdevelopment

Many long-term nursing and supportive Many long-term nursing and supportive treatment hospitals are licenced to provide treatment hospitals are licenced to provide palliative carepalliative care

Not many of them provide palliative care in its Not many of them provide palliative care in its full extendfull extend

Lack of education is considerableLack of education is considerable

OrganiOrganizzationsations related to pain related to pain managementmanagement

Lithuanian Society of Lithuanian Society of Anaesthesiology and Anaesthesiology and

Intensive CareIntensive Care

Lithuanian Lithuanian Pain SocietyPain Society

(chapter of IASP)(chapter of IASP)

Association of Association of Pain ClinicsPain Clinics

Lithuanian Society of Lithuanian Society of Palliative MedicinePalliative Medicine

Information sourcesInformation sources ““Pain medicinePain medicine”” ( (Lithuanian Pain SocietyLithuanian Pain Society, j, journal ournal in Lithuanian)in Lithuanian) ““Pain NewsPain News”” ( (Lithuanian Pain SocietyLithuanian Pain Society, b, bulletinulletin in Lithuanian) in Lithuanian)

““Pain conception and managementPain conception and management”” ( (J.BaublieneJ.Baubliene, book in , book in Lithuanian)Lithuanian)

““Chronic non-oncological pain and its treatment with opioid Chronic non-oncological pain and its treatment with opioid analgesicsanalgesics”” ( (AA.. ScSciupokiupokas, book in Lithuanian)as, book in Lithuanian)

““Pain treatment with opioid analgesicsPain treatment with opioid analgesics” (A.Vaitkus, book in ” (A.Vaitkus, book in Lithuanian)Lithuanian)

““Postoperative pain management – good clinical practicePostoperative pain management – good clinical practice” ” (Lithuanian translation of ESRA recommendations)(Lithuanian translation of ESRA recommendations)

““Principals of diagnostics and treatment of malignant tumors of main Principals of diagnostics and treatment of malignant tumors of main localizationslocalizations” (group of authors, book in Lithuanian)” (group of authors, book in Lithuanian)

““Diseases of nervous systemDiseases of nervous system” (group of authors, book in Lithuanian)” (group of authors, book in Lithuanian)

EducationEducation Patient educationPatient education

several programs (e.g. artseveral programs (e.g. arthhritic, diabetic patients)ritic, diabetic patients) individual individual educationeducation in the course of treatment in the course of treatment

Medical students:Medical students: Incorporated in Anesthesiology programme (during 5Incorporated in Anesthesiology programme (during 5thth year) year) Incorporated in Neurology programme (during 5Incorporated in Neurology programme (during 5thth year) year)

ResidencyResidency:: Anesthesiology-reanimatology: 2 months obligatory round in pain Anesthesiology-reanimatology: 2 months obligatory round in pain

clinicclinic Neurology: obligatory round in pain clinicNeurology: obligatory round in pain clinic

Nursing studiesNursing studies

Continuous medical education Continuous medical education (CME)(CME)

Anesthesiology:Anesthesiology: children postoperative pain, postoperative pain managementchildren postoperative pain, postoperative pain management

specialized pain managementspecialized pain management

General therapeutics:General therapeutics: acute, chronic pain, oncologicalacute, chronic pain, oncological

NeurologicalNeurological pain in neurology practice, headachespain in neurology practice, headaches

RehabilitationRehabilitation back painback pain

Palliative carePalliative care

Vilnius UniversityVilnius University

and and

Kaunas University of Medicine Kaunas University of Medicine

ConclusionsConclusions During 15 years of development many systemic changes During 15 years of development many systemic changes

achievedachieved Continuous development & growingContinuous development & growing

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2000 2001 2002 2003 2004 2005 2006 2007 2008

Consultations Interventional procedures

Data from Vilnius University Hospital Santariskiu Clinics

ConclusionsConclusions

Still, improvement needed in:Still, improvement needed in: pain education,pain education, specialist preparation,specialist preparation, reimbursements for pain medicines and services,reimbursements for pain medicines and services, palliative care,palliative care, introduction of modern technologies.introduction of modern technologies.

Thank you !Thank you !