Preventing pain from becoming chronic short1

Preventing Pain From Becoming Chronic With Early Intervention

Dr Yeo Sow NamDirector, The Pain Specialist,

Mount Elizabeth Hospital & Founder and Past Director,

Pain Management and Acupuncture Services,

Singapore General Hospital

MBBS (Singapore)

MMED (Anesthesiology, S’pore)

FANZCA (Anesthesiology, Aust/NZ)

FFPMANZCA (Pain Medicine, Aust/NZ)

FAMS, Registered Acupuncturist

What Is Chronic Pain?

• Defined as pain persisting over 3 months

• Subdivided into chronic malignant painand chronic non-malignant pain

• Probably not directly related to initial

injury or disease but is secondary to

physiological changes in pain signalling

and detection

• Often associated with the emergence of acomplex set of physical and psychologicalchanges that are an integral part of thechronic pain problem

• Poses particular therapeutic challenges

1. Merskey H, Bogduk N., Classification of Chronic Pain, 1994, IASP Press. ISBN-13: 978-0-931092-05-32. Woolf CJ, Mannion RJ. Neuropathic pain: aetiology, symptoms, mechanisms, and management. Lancet. 1999;353:1959-64.

(Page 1959)

3. Ashburn MA, Staats PS. Management of chronic pain. Lancet. 1999;353:1865-9. (Page 1865 / 1866)

4. Portenoy RK, Kanner RM. Pain Management: Theory and Practice. Philadelphia PA: FA Davis & Co; 1996. (Page 7, Table 1-2)

The World Health Organization

(WHO) notes that “chronic pain

should be accepted as condition in

its own right and highlights the

great burden of chronic pain on

individuals”.

World Health Organization. WHO Normative Guidelines on Pain Management. June 2007. Available at

http://www.who.int/medicines/areas/quality_safety/delphi_study_pain_guidelines.pdf (Page 17) Accessed June 25th 2012.

Chronic Pain: A Disease In Its Own Right

Burden Of Chronic Pain

Carries great economic costs – Direct and Indirect

The costs include –

• Healthcare and medication expenses

• Absenteeism from work, impaired performance and work disruptions

• Income loss

• Loss of productivity in sufferer’s home

• Financial burden on family, friends and employers

• Social and compensation costs

Unrelieved pain: Major Global Healthcare Problem. IASP & EFIC document. Available at http://www.iasp pain.org/AM/Template.cfm?Section=Home&Template=/CM/ContentDisplay.cfm&ContentID=2908 accessed June 28th 2012

Burden Of Chronic Pain

Financial cost of chronic pain is roughly the same as Cancer or CV diseases.

Impact on daily life

Breivik H et al. Eur J Pain 2006;10:287-333Breivik H et al. Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. Eur J Pain. 2006;10:287-

333. (Page 295/309)

Burden of Chronic Pain

Chronic Postsurgical Pain Is A Common But Under-recognized Problem

71. Kehlet H, et al. Lancet 2006;367:1618-1625;2. Durkin B, et al. Expert Opin Pharmacother 2010;11:2751-2758.

Estimated incidence

of chronic

postsurgical pain

Estimated incidence of

severe (disabling) pain

Estimated US surgical

volumes (1000s)

Inguinal hernia repair 10% 2–4% 600

Lower limb amputation 30–50% 5–10% 160

Breast surgery

(lumpectomy or

mastectomy)

20–30% 5–10% 480

Thoracotomy 30–40% 10% 200

Total knee arthroplasty 12% 2–4% 550

Coronary artery bypass

surgery

30–50% 5–10% 598

Caesarean section 10% 4% 220

Surgical

21%

Medical

14%

Pain38%

ADE

3%

N/V

3%

Bleeding

4%

Other

17%

Sub-optimal Pain Management Can Have Economic Consequences

• Mean charges for patients re-admitted due to pain were $1,869±4,553 per visit*

• Of patients re-admitted for pain, 38% had undergone orthopaedic procedures

8

*Mean inpatient re-admissions for pain $13,902±11,732 per visit

ADE, adverse drug event

N/V, nausea/vomitingColey KC, et al. J Clin Anesth 2002;14:349-353.

Re-admissions following day-care surgery

Risk Factors For Development Of Persistent Postsurgical Pain

1. Genetic susceptibility

2. Moderate to severe preoperative pain

3. Psychosocial factors

4. Age and sex

5. Surgical approach with risk of nerve damage

6. Poorly controlled postoperative pain

9

1. Kehlet H, et al. Lancet 2006;367:1618-1625;2. Durkin B, et al. Expert Opin Pharmacother 2010;11:2751-2758;3. Schug SA, Pogatzki-Kahn EM. Pain: Clinical Updates 2011;19:1-5.

Transition Of Acute To Chronic Pain – Psychological Variables

• Acute pain intensity and depressive

symptoms each positively and directly

influence the persistence of neck and back

pain and disability and are also positively

intercorrelated

• Research suggests exposure to severe

stressors can permanently change

neurobiological processes or structures,

negatively affecting arousal thresholds

and ability to cope with subsequent stress

Casey Y et al. Transition from acute to chronic pain and disability: A model including cognitive, affective, and trauma factors. Pain 2008;134:69–79

Hypothesized Model Of Transition From Acute To Chronic Pain And Disability


Predictive Factors Of Pain Transition

• Greater exposure to past traumatic life events

and depressed mood is most predictive of

chronic pain

• Depressed mood and negative pain beliefs is

most predictive of chronic disability

• More cumulative traumatic life events, higher

levels of depression in the early stages of a new

pain episode, and early beliefs that pain may be

permanent significantly contribute to increased

severity of subsequent pain and disability


Reducing Pain Related Fears Could Reduce Chronicity

• Highest correlations were foundamong the pain-related fearmeasures and measures of self-reported disability and behaviouralperformance

• Questionnaires to quantify pain-related fears, include –

– Fear-Avoidance BeliefsQuestionnaire (FABQ)

– Tampa Scale for Kinesiophobia(TSK)

– Pain Anxiety Symptoms Scale(PASS)

Crombez G et al. Pain-related fear is more disabling than pain itself: evidence on the role of pain-related fear in chronic back pain disability. Pain. Mar 1999; 80(1-2):329-39.

• Controlling for socio-demographics,

multiple regression analyses revealed

that the subscales of the FABQ and the

TSK were superior in predicting self-

reported disability and poor behavioral

performance

• PASS appeared more strongly associated

with pain catastrophizing and negative

affect, and was less predictive of pain

disability and behavioral performance

Crombez G et al. Pain-related fear is more disabling than pain itself: evidence on the role of pain-related fear in chronic back pain disability. Pain. Mar 1999; 80(1-2):329-39.

Reducing Pain Related Fears Could Reduce Chronicity

Early Intervention For Pain

• Inefficient or ineffective treatment of acute pain can lead to chronic pain states

• Chronic pain is associated with morphological changes in the CNS

Early intervention can benefit patients at high risk of developing chronic pain

Gatchel RJ et al. Treatment- and cost-effectiveness of early intervention for acute low-back pain patients: a one-year prospective study. J Occup Rehabil. Mar 2003;13(1):1-9.

Results Of Early Intervention

• Gatchel et al., reported the effect of early intervention

on 124 patients with acute low-back pain

• High-risk patients randomly assigned to –

– Early intervention group (n = 22),

– Non intervention group (n = 48)

• Low-risk subjects (n = 54) who did not receive any early

intervention was also evaluated

• All these subjects were prospectively tracked at 3-month

intervals starting from the date of their initial evaluation,

culminating in a 12-month follow-up



• The early intervention program involved aninterdisciplinary team approach consisting offour major components—

• Psychology

• Physical therapy

• Occupational therapy

• Case management



• High-risk subjects who received early intervention displayed

statistically significant fewer indices of chronic pain

disability on a wide range of work, healthcare utilization,

medication use, and self-report pain variables, relative to

the high risk subjects who do not receive such early

intervention

• In addition, the high-risk non intervention group displayed

significantly more symptoms of chronic pain disability on

these variables relative to the initially low risk subjects

• There were greater cost savings associated with the early

intervention group versus the no early intervention group


Summary• Pain can broadly be classified as acute & chronic

• Chronic pain is often associated with the emergence of a complex set of physical and

psychological changes that are an integral part of the chronic pain problem

• Chronic pain poses special therapeutic challenges

• Chronic pain carries direct and indirect economic costs and has great impact on daily life

• Although most episodes of acute pain resolve within 6 weeks, nearly half of the pain sufferers

have symptoms which persist and debilitate them for years

• Inefficient or ineffective treatment of acute pain can lead to chronic pain states

• Subjects at risk of acute pain turning chronic who receive early intervention show fewer indices

of chronic pain disability and include more work efficiency, less healthcare utilization, medication

use and self-reported pain

• There are greater cost savings associated with early intervention

Preventing pain from becoming chronic short1

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