3 - Chronic Pain and Multimorbidity Flashcards
What is multimorbidty and some risk factors for this?
The presence of two or more long-term health conditions, including: physical or mental health conditions, learning disabilities, symptom complexes such as chronic pain, sensory impairments and alcohol or substance misuse
What are some complications of multimorbidity?
- Decreased quality of life and expectancy
- Increased treatment burden: difficulties in understanding and self-managing condition as well as adherence to lifestyle changes
**- Mental health issues
- Polypharmacy: Adverse drug events
- Negative impact on carers welfare
When may someone need a multimorbidity assessment?
- Have difficulties with daily activities
- Are frail
- Prescribed over 10 medications
- Frequently seek emergency care services
Investigate how their treatment burden affects their daily activities
Ask about social circumstances and assess their health literacy
Assess the adequacy of pain management
How can you manage multimorbidity?
- Reduce the number of high risk medications being prescribed and consider the use of non-pharmacological treatments
- Consider a ‘bisphosphonate holiday’ in those taking bisphosphonates for longer than three years
- Consider the use of screening tools such as STOPP/ START
- Develop an individualised management
plan: Record what actions will be taken, include goals, prioritise healthcare appointments, anticipate changes and explore other areas of importance to the patient - Promote self-management through education and engagement strategies
What is the definition of chronic pain?
Pain that persists for more than 3 months
Chronic primary pain has no clear underlying condition or is out of proportion to any observable injury or disease.
Chronic secondary pain is a symptom of an underlying condition. Chronic secondary pain and chronic primary pain can coexist.
What are some examples of chronic primary and chronic secondary pain?
Primary:
- Fibromyalgia
- Chronic primary headache
- Chronic primary MSK pain
- Chronic primary visceral pain
Secondary
- IBS
- Endometriosis
- RA
- OA
What is the first advice/education you can give a patient with suspected chronic primary pain?
- the likelihood that symptoms will fluctuate over time and that they may have flare-ups
- the possibility that a reason for the pain (or flare-up) may not be identified
- the possibility that the pain may not improve or may get worse and may need ongoing management
-there can be improvements in quality of life even if the pain remains unchanged
When making a care plan for someone with chronic primary pain what needs to be included?
- Impact on their life and relationships
- Their priorities, abilities and goals
- What they are already doing that is helpful
- Their preferred approach to treatment
- Any support needed for young adults (aged 16 to 25) to continue with their education or training
What non-pharmacological management options can you offer for chronic primary pain?
- Group exercise programme
- Encourage them to stay active
- Consider acceptance and commitment therapy (ACT) or CBT
- Acupuncture if limited
What non-pharmacological treatment should you not offer for chronic primary pain?
- Biofeedback
- TENS
- US
- Inferential therapy
What pharmacological management can you give to patients for chronic primary pain?
Consider an antidepressant, either amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine or sertraline
Explain that this is because these medicines may help with quality of life, pain, sleep and psychological distress, even in the absence of a diagnosis of depression.
Which drugs should not be used for chronic primary pain?
- Antiepileptic drugs including gabapentinoids, unless offered as part of a clinical trial for complex regional pain syndrome
- Antipsychotic drugs
- Benzodiazepines
- Corticosteroid trigger point injections
- Ketamine
- Local anaesthetics (topical or intravenous), unless as part of a clinical trial for complex regional pain syndrome
- NSAIDs
- Opioids
- Paracetamol
What should you do if someone with chronic primary pain is on regular strong pain relief?
- Explain the lack of evidence for these medicines for chronic primary pain and
- Agree a shared plan for continuing safely if they report benefit at a safe dose and few harms OR
- Explain the risks of continuing if they report little benefit or significant harm, and encourage and support them to reduce and stop the medicine if possible.
What is a good tool to use for managing a patient asking for more opioids/strong pain relief?
Draw the pain clinic pain map and cross out what has already been tried/isn’t suitable
Explain the side effects of continuing them
Explain the mechanism of tolerance
What is a good resource to make in primary care?
Make your own PILS
e.g explaining SSRI take 6-8 weeks to work, why they aren’t addictive, why may feel worse before better
e.g resources for mental health e.g papyrus
