Pain Common : Pain Common
Pain Common : Pain Common 45% of people seek medical treatment for pain at some point in their lives.
http://grants.nih.gov/grants/guide/pa-files/PA-01-115.html
SES Canadian Pain Survey 2007 : SES Canadian Pain Survey 2007 1/3 Canadian household have at least 1 adult who complains of moderate – severe pain on all or most days of the week
1/5 experience pain daily
1/6 have constant pain
1/3 lost a job because of pain
½ suffered an income loss due to pain on average $12,500 / year
40% suffered from concurrent anxiety or depression CPS, 2007
Slide 4 : Epidemiology of chronic pain from three large, high quality surveys of adult general populations Blyth et al PAIN (2001): N = 17 543 Australia pain most days for 3 months: 18.5%
Eriksen et al PAIN (2003): N = 20 000 Denmark pain lasting more than 6 months: 19 %
Breivik et all EJP (2004): N = 30 701 in 12 European countries
pain >6 months > 5/ 0-10 pain scale = 18%
Incidence of Chronic Post-operative Pain : Incidence of Chronic Post-operative Pain Breast surgery
Breast/chest pain 11 to 57%
Post-mastectomy phantom pain 13 to 24%
Arm/shoulder pain 12 to 51%
Gallbladder surgery 3 to 56%
Cardiac surgery 15 to 56%
Inguinal hernia surgery 0 to 37% Perkins, Kehlet. Anesthesiology, 2000 (Review).
Macrae. British Journal of Anaesthesiology, 2001 (Review).
Elderly Hardest Hit : Elderly Hardest Hit Seniors have higher chronic pain rates.
Canadian study suggested a minimum of 25% of seniors living at home and 40% of seniors in care facilities have chronic pain.
Dean Tripp, 2008
http://www.canada.com/topics/news/national/story.html?id=f740b3c5-ccef-451e-80ab-c01f79285357&k=11786
Pain Undertreated : Pain Undertreated
First Legacy - Undertreated Cancer Pain Patients : First Legacy - Undertreated Cancer Pain Patients “Even if effective treatments are available for 70%– 90% of cases”
Yet “Nearly one of two patients is undertreated”
Particularly if rated less ill (less likely to have palliative pain specialist)
Ann Oncol. 2008 Dec;19(12):1985-91. Epub 2008 Jul 15. Prevalence of undertreatment in cancer pain. A review of published literature. Deandrea S, Montanari M, Moja L, Apolone G.
http://annonc.oxfordjournals.org/cgi/reprint/19/12/1985
Doctors Continue to Under-treat : Doctors Continue to Under-treat ``a survey of several hundred ambulatory AIDS patients found that fewer than 8% of patients reporting "severe" pain were prescribed a strong opioid such as morphine, despite published guidelines.``
http://grants.nih.gov/grants/guide/pa-files/PA-01-115.html
Chronic Pain is Poorly Managed(SES Canadian Survey) : Chronic Pain is Poorly Managed(SES Canadian Survey) Chronic pain was of at least moderate (6/10) intensity and present for at least 10 years
Only 36% of patients felt their pain was very effectively treated
Only 32% of MDs thought chronic pain was effectively treated
45% of people with moderate to severe chronic pain were not taking any prescription medication Moulin DE, et al. Pain Res Manag 2002; 7(4):179-84.
Morley-Forster PK, et al. Pain Res Manag 2003; 8(4):189-94.
SES Canadian Pain Survey 2007.
Pain in the Emergency Department: Results of the Pain and Emergency Medicine Initiative (PEMI) Multicenter Study. : Pain in the Emergency Department: Results of the Pain and Emergency Medicine Initiative (PEMI) Multicenter Study. 70% of patients with pain had mod-severe pain
?40% of these had a chronic pain problem Todd KH, Ducharme J, et al. PEMI Study Group. J Pain. 2007 Feb 14
Pain in the Emergency Department: : Pain in the Emergency Department: Results of the Pain and Emergency Medicine Initiative (PEMI) Multicenter Study.
“Despite efforts to improve pain management practice, oligoanalgesia remains a problem for emergency medicine.” Todd KH, Ducharme J, et al. PEMI Study Group. J Pain. 2007 Feb 14
Post Surgery Pain Uncontrolled : Post Surgery Pain Uncontrolled Post-op home pain levels – three studies
Apfelbaum, Anesth and Analg 2003
Rocchi, Can Jour of Anesth; 2002
Warfield, Anesth 1995
2 weeks post-op surgery 70% patients still in moderate to severe pain
Chronic Pain Huge Impact : Chronic Pain Huge Impact
The Economic Impact of Pain on Work 2003 U.S.A. Data : The Economic Impact of Pain on Work 2003 U.S.A. Data 13% of workers report loss of productive time due to common pain conditions
Loss of 4.6 h/week
Costs to industry – $61 billion/year (U.S.)
76% of loss due to reduced performance at work rather than work absence
More costly than depression ($51 billion) and diabetes ($40 billion) Stewart WF, et al. JAMA 2003; 290(18):2443-54.
Greenberg PE, et al. J Clin Psychiatry 2003; 64(12):1465-75.
Hogan P, et al. Diabetes Care 2003; 26(3):917-32.
The High Price of Pain Australia, 2007 : The High Price of Pain Australia, 2007 3.2 million people living with chronic pain
16% of population (20 million)
Total cost: $34 billion AUD ($10,847/person affected)
Loss of productivity: $11.7 billion
Burden of illness individuals: $11.5 billion
Health care costs: $7 billion $100.00 AUD = $87.00 CAD The High Price of Pain, 2007 MBF Foundation, Australia.
Undertreated Pain Is a Major Public Health Problem : Undertreated Pain Is a Major Public Health Problem Chronic pain ranks among the top reasons for health care visits and health-related work absences
Chronic pain negatively affects all aspects of a person’s biopsychosocial life
Patients with pain – high cost to society
Both patients and physicians are not satisfied with current care
Although few people die of pain, many die in pain and even more live in pain : Although few people die of pain, many die in pain and even more live in pain WHO/EFIC Declaration on Chronic Pain Chronic Pain Devastation
Can Drive to Suicide : Can Drive to Suicide ``Almost a third of the subjects reported some form of recent suicidal ideation``
Pain. 2006 Dec 15;126(1-3):272-9Pain-related catastrophizing as a risk factor for suicidal ideation in chronic pain. Edwards RR, Smith MT, Kudel I, Haythornthwaite J.
Poor Pain Control and Suicidal Thoughts : Poor Pain Control and Suicidal Thoughts 82 cases followed over 9.5 years
50% reported that they had considered suicide due to feelings of hopelessness associated with their pain
50% inadequate pain relief
J Pain Symptom Manage. 1994 Jul;9(5):312-8. The experience of chronic nonmalignant pain. Hitchcock LS, Ferrell BR, McCaffery M.
Slide 21 : April 1, 2003 An 89-year-old man who smothered his 85-year-old wife in her nursing home bed to end her pain will face murder charges, U.S. prosecutors said yesterday.
Morris Meyer, who uses a wheelchair, told police his wife had begged him to help her die, so he made his way to her bed and held a pillow over her face.
Robert Latimer kills Daughter, 1993 : Robert Latimer kills Daughter, 1993 12 years child hopelessly afflicted with severe quadriplegic cerebral palsy – bedridden, bed sore, diapers, could not speak
Had endured painful surgery including therapeutic breaking of her hip and was scheduled for more
Lived in unremitting pain
Why is pain so poorly treated? : Why is pain so poorly treated?
Barriers for Physicians : Barriers for Physicians Pain management not seen as a priority in the disease-centered model of care
Limited training in medical schools
IgnoranceForgive them for they know not what they do... : IgnoranceForgive them for they know not what they do... Lack of up to date knowledge
Much of non-surgical chronic pain management involves a field known as orthopedic medicine. There are only about 20-30 members in Canada.
Field is changing so fast impossible to keep up.
Poor Medical Training : Poor Medical Training Canadian Pain Curriculum Survey 2007
Medical colleges give only 2 days worth (16 hours) training in pain treatment
Vet colleges give almost 6 times that (87 hours)
Poor Ability to Judge Level of Pain : Poor Ability to Judge Level of Pain Untrained university students were better at assessing chronic pain levels than doctors and health care workers
Fear : Fear Opioid prescriptions can be challenged by the College of Physicians and Surgeon who could then take the opportunity to scrutinize all aspects of ones practice and documentation.
Methods the Bullet-proof oneself from that have grown so onerous that busy physicians (who likely don't keep good notes) may find it more expedient to throw away their opioid prescription pads and not do any opioid prescribing at all.
Nursing Barriers : Nursing Barriers Limited training
Lack of up to date knowledge
Lack of institutional systems for pain management
Biases and fears about use of opioid analgesics
Too many patients, not enough time!
Patient and Family Barriers : Patient and Family Barriers Communication problems in a stressed health care system
Fear of taking opioids – biased media reports
Confusion regarding: dependence, tolerance vs. addiction to therapeutic opioids
Poor pain management is accepted as normal
Chronic Pain Stigma : Chronic Pain Stigma Smart & Smart: ”Biomedical Model”
defective, biologically inferior,
responsible - too fat, mentally ill, deconditioned, no motivation
prey on vulnerabilities - fear avoidant, catastophizers, poor copers, mentally ill
Subject to poor services and job prejudice.
Legitimized Prejudice : Legitimized Prejudice Their fault - embarrassed
Victims of the false precision of medical diagnosis
Victims of disability ratings that do not consider full impact of chronic pain and lack of accommodation -without any recourse
Subjected to “Try Harder syndrome” counseling “help”
Is Rehab Helping? : Is Rehab Helping? Qual Health Res. 2005 Jan;15(1):30-48.
Victims twice over: perceptions and experiences of injured workers.
Beardwood BA, Kirsh B, Clark NJ.
“Interviewees believed that the process victimizes them and renders them powerless and dependent on others. Furthermore, they considered that health professionals and bureaucrats impede their rehabilitation.”
Canadian Pain Human Rights : Canadian Pain Human Rights
WHO view : WHO view Undertreated pain is a major health care system issue
Pain relief should be seen as a human right
Canadian Pain Society View : “Patients have the right to the best pain relief possible” Canadian Pain Society, Patient Pain Manifesto, 2001 Canadian Pain Society View
History of Chronic Pain Human Rights : History of Chronic Pain Human Rights 1987 Workers' Compensation Appeals Tribunal Decision 915
“Victims of the failure or limitations of medical science”
Thin skull rule - Vulnerable to effects of pain still eligible
Secondary gain - cannot bar compensation
Slide 38 : 2001 – Canada Pension Plan court case changes
``incapable regularly of pursuing any substantially gainful occupation ``
Regionally available employment
http://www.ocrt-bctr.gc.ca/dapdep/r012002/sc07-eng.html
2003 - Chronic Pain syndrome declared exists in Canada (Martin vs WCB Nova Scotia Supreme Court)
2005 - Chronic pain syndrome compensatable in Canada (Valic vs WCB NWT Supreme Court)
Pain ReliefBegins with You : Pain ReliefBegins with You
First Steps Find Out As Much as You Can About Your Affliction : First Steps Find Out As Much as You Can About Your Affliction
Slide 41 :
Slide 42 :
World Wide Web : World Wide Web Painmuse.org
Many sites some just want to sell you stuff; some more authentic ones I have given links at my site – but there are many more for specific problems
Second StepDo Not Do This Alone : Second StepDo Not Do This Alone Join a support group – This is an online part of one
There is a support group at Wascana Hospital that meets regularly
The Fibromyaglia Group in Regina is now linked to Action Canada – a Canadian support group that has various educational resources
There is a Trigeminal Neuralgia support group in Regina
Dealing with Doctor : Dealing with Doctor Be clear on specific goals – pain, sleep, activity, etc.
Bring your medications with you – NOT a list
Categorize pain level from 0-10 and whether this is better than before or not
Note any side effects
Document whether medications and treatments are helping quality of life – do more
Keep diary of factors that effect pain – especially headaches
Exercise : Exercise Regular exercise – Water Based:
in Regina we have
Water moves and
an arthritis society water based program
Merely walking around the block is a minimum
Relaxation Training : Relaxation Training Meditation
Yoga
Hypnosis
Relaxation tapes