ESSENTIAL PAIN MANAGEMENT

and

EPM Lite

Hyderabad, India 24 – 26 January 2014

Executive Summary

Globally, pain (of all types) is often unrecognised or inadequately treated.

Fortunately many effective pain management strategies are “low tech” and cheap, and can offer

significant improvement to individuals’ quality of life.

The Essential Pain Management (EPM) Workshop has been developed:

to improve knowledge about pain

to provide a simple framework for treating pain

to address pain management barriers

to allow early handover to local health care providers

We ran a series of workshops at the Kamineni Hospital in Hyderabad

one full day EPM workshop on 24th January

an EPM Instructors Workshop on 25th January

four EPM Lite 5 hour workshops on 26th January taught by local instructors

Hyderabad and parts of India now have an enthusiastic group of EPM instructors, some of whom

are specialists at several of the larger hospitals throughout India.

Recommendations

to encourage and support the Hyderabad instructors along with the Travelling Pain

School to run further EPM and EPM Lite courses in India

to consider a repeat visit in 2015 to run a further Instructors course

Background

Hyderabad is the capital and largest city of the southern Indian state of Andhra Pradesh. It has a population of 6.8 million and a metropolitan population of 7.75 million, making it the fourth most populous city and sixth most populous urban agglomeration in India. Established in 1591 by Muhammad Quli Qutb Shah, Hyderabad remained under the rule of the Qutb Shahi dynasty for nearly a century before the Mughals captured the region. In 1724, Mughal viceroy Asif Jah I declared his sovereignty and created his own dynasty, also known as the Nizams of Hyderabad. The Hyderabad State ultimately became a princely state during British rule, and remained so for 150 years, with the city serving as its capital. The city continued as capital of a new Hyderabad State after joining the Indian Union in 1948.

Relics of Qutb Shahi and Nizam rule remain visible today, with the Charminar—commissioned by Muhammad Quli Qutb Shah himself—coming to symbolise Hyderabad. That legacy is also evident in the city's distinctive cuisine, which includes Hyderabadi biriyani and Hyderabadi haleem. The Qutb Shahis and Nizams established Hyderabad as a cultural hub, attracting men of letters from different parts of the world. Hyderabad emerged as the foremost centre of culture in India with the decline of the Mughal Empire in the mid-19th century, with artists migrating to the city from the rest of the Indian subcontinent. While Hyderabad is losing its cultural pre-eminence, it is today, due to the Telugu film industry, the country's second-largest producer of motion pictures.

Hyderabad was historically known as a pearl and diamond trading centre, and it continues to be known as the City of Pearls. Many of the city's traditional bazaars have remained open for centuries. However, industrialisation throughout the 20th century has also attracted major Indian manufacturing, research and financial institutions. Special economic zones dedicated to information technology have encouraged companies from across India and around the world to set up operations with the emergence of pharmaceutical and biotechnology industries. With an output of US$74 billion, Hyderabad is the fifth-largest contributor to India's overall gross domestic product.

Introduction

In 2013 Dr Vijay Palanisamy met Dr Goucke in Trivandrum, Kerala and discussion began about a

follow up visit to Hyderabad. Dr Vijay and Dr Murali had significant experience promoting pain

awareness with education through the Travelling Pain School (TPS).

(http://travelingpainschool.com/).

These discussions developed into the proposal that we run both an EPM full day program, an

instructor workshop and then a series of EPM Lite workshops at one of the Hyderabad Medical

schools. EPM partnered with the Travelling Pain School for this pain education program in India.

Dr Vijay introduced us to Dr Murali Joshi who was able to facilitate introductions to the Heads of two

of the undergraduate medical programs Dr SM Patil, Principal, Kamineni Academy of Medical

Sciences, Dr Shruthi Mohanty, Principal, Kamineni Institute of Medical Sciences and Dr Amaresh,

Medical Superintendent, Kamineni Institute of Medical Sciences.

We also met with the Secretary of the Indian Society of Anaesthesiologists Dr MV Bhimeswar and

Vice President of the Indian Society for the Study of Pain Dr BB Mishra, together with some other

senior practitioners. All were very supportive of running both EPM and EPM Lite.

A well attended press conference was held to promote EPM and video clips can be seen at Hybiz.tv

A total of 33 press reporters assembled and the EPM programme was covered in seventeen

newspapers and ten television channels. The press notes came in various local languages and one

English Language Newspaper the New Indian Express

Dr Murali and Dr Vijay had preselected the participants for Day 1 and Day 2 so that it was more likely

that EPM/EPM Lite would be taken back to their states and hospitals from here they came. A list of

participants is shown in Appendix 2.

External course Instructors for the first workshop:

Dr Linda Huggins, Palliative Care Physician, Auckland

Dr Lynda De Souza, Anaesthetist, Adelaide

Dr Roger Goucke, Pain Medicine Physician, Sir Charles Gairdner Hospital, Perth

Course participants: see appendix 1

On day 1, Friday 24th January 2014, the course was run with 26 participants.

The following day most of the Day 1 participants and some observers made for 30 people attending

the instructors’ workshop.

On day 3, Sunday 26th January 2014 which was coincidentally both Australia day and Indian Republic

Day, four parallel workshops containing a total of 88 participants were run. Four groups of the newly

qualified instructors consisting of a team leader, time keeper and 3 presenters delivered the course.

Course Program

The one-day EPM Workshop program is shown in Appendix 2, and the half-day EPM Instructor

Workshop program is shown in Appendix 3, and for the first EPM Lite workshop in India the program

is shown in Appendix 4.

EPM Workshop: the morning session consisted of a series of short interactive lectures and group

discussions where “RAT” (RAT = Recognise, Assess, Treat) was used to consider the management of

various pain problems. The group then brainstormed some strategies for overcoming pain

management barriers.

EPM Instructor Workshop: this workshop was conducted over 4.5 hours and began with a series of

short interactive lectures. These were followed by a session in which participants practised giving a

lecture and running a discussion group. At the completion of the instructor workshop the new

instructors planned for the one day workshop they were to run the following day.

The EPM Lite workshops were run in parallel with 4 groups of instructors, time keepers did their best

to keep the busy morning on schedule and all the workshops finished by 1pm.

At the conclusion of each workshop, participants were presented with a certificate of attendance,

printed on heavy paper.

Venue

The workshops were conducted in the seminar rooms of the Kamineni Hospital administration block.

This was an excellent venue with enough breakout space, air-conditioning and data projectors. The

Kamineni Hospitals provided all the facilities to TPS organisers at a subsidised cost.

Assessment

Course participants completed a test prior to and at the conclusion of the workshop to assess

learning during the day. A new MCQ written test (pre and post) was used at this course. At the end

of the course the answers were presented to the whole group on a ppt presentation. Scores showed

improvement in knowledge for most participants. The data are included in Appendix 5 (only the

results for those participants who completed both pre- and post-tests are included). Subjectively

there was great improvement demonstrated in both knowledge and its clinical application in case

studies designed to practise the use of the RAT framework.

Catering

Morning tea, lunch and afternoon tea was provided by the Kamineni Hospital at a subsidised cost

for TPS organisers and was very adequate and enjoyed by all in particular the students on day 3 were

the lunch was provided in the large restaurant on the top floor of the building.

Feedback

Participants and instructors were asked to provide written anonymous feedback at the conclusion of

teaching on each of the three days. Overall feedback was very positive: Comments such as: “More

frequent workshops, live video demo of patient and their relief after treatment would be good, It

looks very simple but it is very difficult to conduct an EPM workshop. Time management is essential,

Pain management is one of the most important things which should not be

neglected/underestimated. Misconception about opioid analgesics, that they should not be used

because of fear of addiction is not a correct one. EPM shows us about the different types of pain”.

Constructive comments such as “participants must respect the schedule”. “Maybe put in place/to

agree on the "game rules" before starting”, this reflected a feeling that holding the course out of

town would improve a timely start. Several participants requested the course manual be sent to

them before the course as pre reading.

Barriers

The seniority of many of the participants of the day 1 EPM led to some in depth discussion of the

major barriers to effective pain management in India.

Language, culture awareness and patient expectation were identified early.

The need for more “pain champions” and pain not being a priority needed recognising. The

availability of opioids was a serious issue in some states and areas.

A summary of the Barriers and possible Solutions is shown in Appendix 6

Finance

We are grateful to the Ronald Geoffrey Arnott Foundation for financial assistance for air travel and

accommodation costs for Dr Goucke. Dr Huggins and Dr De Souza were able to use their hospital

CME funds for travel and accommodation costs. The Kamineni Hospital co sponsored along with the

Travelling Pain School costs for the venue, printing services, stationery, house keeping services and

audio-visual equipment.

Success and relevance of the visit

The workshops were very successful. This was the first EPM Lite to run outside Auckland and we

were very pleased with the reception by both the teachers/instructors and the participants

/students.

Overall we trained 26 participants including nursing, occupational therapy, physiotherapy,

psychology and anaesthesia in EPM. We ran the Instructors Workshop for 30 people, and ran four

parallel EPM Lite sessions for 88 medical and nursing students.

The 3rd day workshops were run entirely by the local instructors.

The course instruction material worked well. The “RAT” approach to pain management provided a

simple framework for managing a variety of pain problems. Course participants contributed

enthusiastically, and some lively discussions ensued.

EPM is cheap to run, and emphasises low cost management strategies; quality of life can be

markedly improved by some very simple improvements. Education and training to provide

appropriate pain management earlier in the patient’s disease is more effective than waiting for

severe pain to become established.

An important part of EPM is early handover of teaching to local instructors. This encourages

cooperation between different levels of health workers as well as the development of local solutions

to local problems.

Thank you

A very big thank you must go to Drs Murali and Vijay for their commitment to this project and their

organising skills in regard to venue, equipment, printing, catering and enrolment, despite the many

other calls on their time. Thanks also to the management of the Kamineni Hospital and Group for

their considerable support.

Thanks again to ANZCA and the Ronald Geoffrey Arnott Foundation for financial support.

Roger Goucke

Linda Huggins

Lynda De Souza

Appendix 1

EPM Attendance list 24 January 2014 Hyderabad

Attendance list Instructor Course 25 January 2014

Attendance list EPM Lite 26 January 2014

Appendix 2 EPM WORKSHOP PROGRAM One day program

Time Duration

(mins)

Lecture / Discussion Instructor/s

0830-0915 45 Welcome

Local perspective

Pre-test

0915-0930 15 Introduction

0930-0945 15 What is pain?

0945-1000 15 Why should we treat pain?

1000-1015 15 Classification of pain

1015-1045 30 Morning tea

1045-1115 30 Physiology and pathology

1115-1135 20 Pain treatment overview

1135-1155 20 Pain drugs

1155-1230 35 Barriers to pain management

1230-1330 60 Lunch

1330-1400 30 Basic approach to pain management

1400-1500 60 Case discussions

1500-1530 30 Afternoon tea

1530-1630 60 Overcoming barriers

1630-1700 30 Post-test

Feedback

Certificates

Photo

Appendix 3 EPM INSTRUCTOR WORKSHOP HALF DAY PROGRAM

Time Duration

(mins)

Lecture / Discussion Instructor/s

Session 1: Introduction and Teaching Basics

15 Welcome

Introduction

0845-0900 15 Adult learning

0900-0915 15 Teaching overview

0915-0930 15 Giving a lecture

0930-0945 15 Running a discussion group

0945-1000 15 Morning tea

Session 2: Teaching Rotations

Divide into 2 groups:

Giving a lecture

Running a discussion group

1000-1045 45 Teaching rotation 1

1045-1130 45 Teaching rotation 2

Session 3: How to Run an EPM Workshop

1130-1145 15 EPM planning

1145-1215 30 Workshop preparation – venue, lecturers,

catering etc

1215-1230 10 Feedback

Certificates

Photo

Appendix 4

EPM Lite Workshop Timetable

Time Duration

(mins)

Lecture / Discussion Instructor/s

0815 - 0830 15 Start - introductions

0830 - 0845 15 Welcome & Pre-test

0845 - 0900 15 Introduction

0900 - 0930 30 What is pain and why should we treat it?

(a)

0930 - 0950 20 Classification of pain

0950 -1010 20 Morning tea

1010 -1040 30 Pain physiology and pathology - revision

1040 -1100 20 Pain Treatment Overview

1100 -1200 60 RAT approach to pain management (b)

1200 -1215 15 Post-test, answers & feedback

Notes

(a) Experience of pain – pre-prepared cases (split into 4 groups then brainstorm as whole group) – 1 instructor per group

(b) Use prepared cases – analysis using RAT and discussion of management including importance of non-drug treatment – 4 groups - 1 instructor per group

Appendix 5

Change in scores pre and post testing

EPM Day 1 -- 24 Jan 2014

EPM Hyderabad 24 Jan 14

39.75

42.6

35

36

37

38

39

40

41

42

43

TOTAL PRE TOTAL POST

Improvement Hyderabad 24 Jan 14

-10

-5

0

5

10

15

20

5 4 6 3 11 20 17 8 10 15 16 19 13 1 18 2 7 14 12 9

Participant number

Ch

an

ge

in

sc

ore

EPM Lite Day 3 -- 26 Jan 2014

Group A Improvement

-6

-4

-2

0

2

4

6

8

10

12

14

20 19 11 3 7 10 14 15 12 18 6 9 13 16 17 21 2 22 8 1 5 23 4

Participant number

Ch

an

ge i

n s

co

re

Group B improvement

-6

-4

-2

0

2

4

6

8

10

12

7 11 12 19 13 14 15 6 8 10 17 1 2 5 9 3 4 16 18

Participant number

Ch

an

ge i

n s

co

re

Group C improvement

-6

-4

-2

0

2

4

6

8

10

12

13 7 3 9 4 12 6 10 14 8 2 1 5 11

Participant number

Ch

an

ge i

n s

co

re

Group D improvement

-6

-4

-2

0

2

4

6

8

10

12

13 11 15 20 19 6 9 16 17 1 3 4 10 12 2 8 14 18 5 7

Participant number

Ch

an

ge i

n s

co

re

Combined Data for EPM Lite

EPM Lite Combined Data

35.07

37.24

33

34

35

36

37

38

TOTAL PRE TOTAL POST

Appendix 6

HYDERABAD January 2014

BARRIERS SOLUTIONS PATIENT: Family Language Culture Awareness/Beliefs Expectations Knowledge Incorrect Assessment/Expression “Pain is natural” Not a priority Issues with Dr. Google DRUGS: Dose/Errors/Storage Frequency administration Individual variation Licensing Availability Cost Quality Control (fakes) Efficacy HEALTH WORKERS: Knowledge Opiophobia Lack of interest/Attitude Too busy Too few champions Not profitable/too simple Not a priority/Valid consent/No protocols

PATIENT: Use a translator Respect beliefs but educate Signboards in wards and hospitals Videos TV Screens Patient Education Pamphlets in the side ward Create a Pain Department Group Discussion Realistic/Change Expectations Pain is inevitable

DRUGS: Develop Protocols Better Access Re-licensing Quality Control Bar coding Use of an essential medicine list

HEALTH WORKERS: Educate particularly relatives Awareness Fifth vital sign Fundamental right Teach more people Explore myths Run more EPM Courses Start small Share Protocols National Agreements Opportunities at meetings Collaboration with orthopaedic,

general surgery, physiotherapy

HYDERABAD January 2014

BARRIERS SOLUTIONS SYSTEM ISSUES: Lack of prestige in pain Cost Corporate view Dr. Google Career pathway/Training Insurance issues Legislation Surgical Collaboration Medical/Legal

SYSTEM ISSUES: Use of generic drugs Increase awareness Fifth vital sign Chronic pain is a disease More EPM Decrease chronic pain is preventative Shared care better Multimodal approach invisible Understand Dr. Google Facebook: share guidelines; know what is being said on internet Develop guidelines for insurance Documentation is essential Run audits Evidence-based medicine guidelines including postgraduate and undergraduate training.

EPM Course participants Hyderabad 24 January 2014

Group discussion Small group teaching

On completion of one of the four EPM Lite workshop groups