duelling with pain - Faculty of pain medicine - Australian and New ...
duelling with pain - Faculty of pain medicine - Australian and New ...
duelling with pain - Faculty of pain medicine - Australian and New ...
Create successful ePaper yourself
Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.
2009 SPRING MEETING<br />
FACULTY OF PAIN MEDICINE, ANZCA<br />
ACUTE PAIN SPECIAL INTEREST GROUP OF ANZCA, ASA AND NZSA<br />
‘DUELLING<br />
WITH PAIN’
Major Sponsor<br />
Exhibitors
2009 SPRING MEETING<br />
FACULTY OF PAIN MEDICINE, ANZCA<br />
ACUTE PAIN SPECIAL INTEREST GROUP OF ANZCA, ASA AND NZSA<br />
‘DUELLING<br />
WITH PAIN’<br />
Contents<br />
Welcome message 2<br />
Invited speakers 4<br />
Scientific program 6–8<br />
Abstracts<br />
Opioids, Pain <strong>and</strong> Addiction – Facts vs Fiction 10<br />
Intrathecal Analgesia – Duelling <strong>with</strong> Efficiency <strong>and</strong> Safety 12<br />
Non Neuronal Opioid Actions 14<br />
Novel Approaches to Cancer Pain 15<br />
Spinal Cord Magic Bullets –<br />
Current <strong>and</strong> Future Analgesic Developments 15<br />
Opioids in Dyspnoea <strong>and</strong> Sleep Apnoea 16<br />
Contemporary Approaches to Opioid Addiction 16<br />
Methadone Pharmacology 17<br />
Methadone Re-visited in Cancer Pain 18<br />
Methadone in Chronic Pain 20<br />
Managing Placebo <strong>and</strong> Nocebo Effects –<br />
Mechanisms <strong>and</strong> Implications for Clinical Practice 21<br />
Pain <strong>and</strong> Addiction – Treatment Strategies 22<br />
Predictors <strong>of</strong> Persistent Pain after Trauma 24<br />
Procedural Pain Analgesia 25<br />
Psychological Adjuncts for Pain Occurring <strong>with</strong><br />
Dressing Changes in Burns Patients 26<br />
Australia’s Worst Bushfire Disaster:<br />
The Medical Response to Victoria’s Black Saturday 27<br />
PBLD <strong>and</strong> Topical Session outlines 28–39
Welcome<br />
Welcome message from the Dean<br />
As a <strong>Faculty</strong>, it is my pleasure to<br />
welcome you to the 2009 Spring<br />
Meeting ‘Duelling <strong>with</strong> Pain’ being<br />
held at the S<strong>of</strong>itel Hotel, Melbourne.<br />
Acute, Chronic <strong>and</strong> Cancer Pain<br />
Specialists need to work closely<br />
together for the good <strong>of</strong> our patients<br />
<strong>and</strong> to promote “Pain Medicine” to<br />
our colleagues.<br />
The concept <strong>of</strong> bringing acute, chronic<br />
<strong>and</strong> cancer <strong>pain</strong> expertise together<br />
follows on from the goodwill generated<br />
at the 2008 Spring Meeting in Uluru.<br />
Dr Carolyn Arnold as Convener <strong>with</strong><br />
support from Dr Jane Trinca, Chair<br />
<strong>of</strong> the Acute Pain SIG, <strong>and</strong> a regional<br />
organising committee have put together<br />
an innovative program over three days.<br />
Dr Roman D. Jovey from Canada <strong>and</strong><br />
Dr Suellen Walker, currently residing in<br />
the UK, are our international speakers.<br />
There is a focus on opioid use in chronic<br />
<strong>pain</strong> <strong>and</strong> addiction <strong>and</strong> new knowledge<br />
about analgesic medications from the<br />
laboratory. The program is also rich <strong>with</strong><br />
clinically-based topics for small-group<br />
discussion.<br />
Spring time in Melbourne is beautiful,<br />
so come <strong>and</strong> enjoy good <strong>medicine</strong>,<br />
good food <strong>and</strong> catch up <strong>with</strong> friends<br />
<strong>and</strong> colleagues.<br />
Dr Penelope Briscoe<br />
Dean, <strong>Faculty</strong> <strong>of</strong> Pain Medicine<br />
2<br />
2009 SPRING MEETING • FACULTY OF PAIN MEDICINE, ANZCA • ACUTE PAIN SPECIAL INTEREST GROUP OF ANZCA, ASA AND NZSA
Welcome message from the Convenors<br />
It is <strong>with</strong> great pleasure that the <strong>Faculty</strong><br />
<strong>of</strong> Pain Medicine, in association <strong>with</strong> the<br />
Acute Pain Special Interest Group <strong>of</strong> ANZCA,<br />
ASA <strong>and</strong> NZSA welcomes you to the third<br />
Spring Meeting.<br />
The theme <strong>of</strong> the meeting is “Duelling <strong>with</strong> Pain”.<br />
This stimulating <strong>and</strong> practical programme is presented<br />
by a faculty <strong>of</strong> international <strong>and</strong> national speakers<br />
who will highlight the challenges we face in managing<br />
the spectrum <strong>of</strong> complex acute <strong>and</strong> chronic <strong>pain</strong><br />
problems. In particular there will be an emphasis on the<br />
growing knowledge base surrounding <strong>pain</strong> <strong>medicine</strong><br />
<strong>and</strong> addiction <strong>medicine</strong>. The program will encompass<br />
discussion about dealing <strong>with</strong> difficult patients, advances<br />
in management <strong>of</strong> acutely <strong>pain</strong>ful procedures <strong>and</strong> new<br />
advances in intrathecal analgesia.<br />
This multidisciplinary faculty will show how input from<br />
anaesthetists’ acute <strong>and</strong> chronic <strong>pain</strong> clinicians, nurses,<br />
general practitioners, psychiatrists, surgeons <strong>and</strong><br />
addiction <strong>medicine</strong> specialists may lead to better patient<br />
outcomes. The program will challenge participants to<br />
exp<strong>and</strong> their horizons to better manage <strong>pain</strong> in a broad<br />
spectrum <strong>of</strong> patients <strong>and</strong> settings.<br />
Melbourne is a wonderful city to visit in spring, <strong>with</strong> the<br />
racing carnival, wonderful theatre, restaurants, shopping<br />
precincts <strong>and</strong> parks. Our social programme will give you<br />
the chance to experience an insider’s view <strong>of</strong> Melbourne.<br />
Our thanks are extended to our sponsors <strong>and</strong> exhibitors<br />
for their generous support <strong>of</strong> the meeting.<br />
Dr Carolyn Arnold<br />
Convenor<br />
Dr Jane Trinca<br />
Co-Convener, Chair <strong>of</strong> The Acute Pain SIG<br />
3
International keynote speakers<br />
Dr Roman D. Jovey<br />
Dr. Jovey, a graduate <strong>of</strong> the University <strong>of</strong> Toronto,<br />
was a general practitioner <strong>and</strong> emergency physician<br />
for almost 20 years. In 1999, he closed his family<br />
practice to focus exclusively on outpatient chronic <strong>pain</strong><br />
management <strong>and</strong> addiction <strong>medicine</strong>. Dr. Jovey has<br />
had a career-long interest in addiction <strong>medicine</strong>. He<br />
has been the Physician Director <strong>of</strong> the Credit Valley<br />
Hospital, Addictions <strong>and</strong> Concurrent Disorders Centre,<br />
in Mississauga, since 1991.<br />
Since 1991, Dr. Jovey has been treating patients <strong>with</strong><br />
chronic non-cancer <strong>pain</strong> using pharmacotherapy - <strong>with</strong><br />
a special interest in the use <strong>of</strong> long-term opioid therapy.<br />
He has presented workshops <strong>and</strong> seminars on this topic<br />
to over 9000 health care pr<strong>of</strong>essionals in Canada<br />
<strong>and</strong> abroad.<br />
He is the Program Medical Director at CPM Centres<br />
for Pain Management, an outpatient chronic <strong>pain</strong><br />
management company. He is the Past-President <strong>of</strong> the<br />
Canadian Pain Society <strong>and</strong> a medico-legal expert for<br />
the Canadian Medical Protective Association.<br />
Dr Suellen Walker<br />
Dr Suellen Walker is a Clinical Senior Lecturer <strong>and</strong><br />
Consultant in Paediatric Anaesthesia <strong>and</strong> Pain Medicine<br />
at University College London Institute <strong>of</strong> Child Health<br />
<strong>and</strong> Great Ormond Street Hospital for Children, London.<br />
Her recent research has investigated longterm effects<br />
<strong>of</strong> <strong>pain</strong> <strong>and</strong> surgery in clinical <strong>and</strong> laboratory studies.<br />
She has also developed a model for investigating toxicity<br />
<strong>of</strong> spinally administered analgesics during postnatal<br />
development in collaboration <strong>with</strong> Tony Yaksh at UCSD.<br />
She has been a major contributor to national documents<br />
including “Acute Pain Management: Scientific Evidence”<br />
(ANZCA/ FPM) <strong>and</strong> “Good Practice in Procedural<br />
<strong>and</strong> Postoperative Pain” ( Association <strong>of</strong> Paediatric<br />
Anaesthetists <strong>of</strong> Great Britain <strong>and</strong> Irel<strong>and</strong>).<br />
Travel for Dr Roman D. Jovey is<br />
generously sponsored by Mundipharma.<br />
4<br />
2009 SPRING MEETING • FACULTY OF PAIN MEDICINE, ANZCA • ACUTE PAIN SPECIAL INTEREST GROUP OF ANZCA, ASA AND NZSA
<strong>Australian</strong> invited speakers<br />
Mr Damien Finniss<br />
Damien Finniss is a Clinician at the University <strong>of</strong> Sydney<br />
Pain Management <strong>and</strong> Research Institute at Royal North<br />
Shore Hospital <strong>and</strong> a Clinical Lecturer at the University<br />
<strong>of</strong> Sydney <strong>Faculty</strong> <strong>of</strong> Medicine. Damien is currently the<br />
Chairman <strong>of</strong> the International Association for the Study<br />
<strong>of</strong> Pain (IASP) group on Placebo <strong>and</strong> has published<br />
multiple papers in International Peer Reviewed Journals<br />
<strong>and</strong> book chapters on the topic area.<br />
Pr<strong>of</strong>essor Andrew A. Somogyi<br />
Andrew Somogyi is Pr<strong>of</strong>essor in Clinical <strong>and</strong><br />
Experimental Pharmacology <strong>and</strong> Associate Dean<br />
(Research) in the <strong>Faculty</strong> <strong>of</strong> Health Sciences at the<br />
University <strong>of</strong> Adelaide. His major research interests<br />
are in the clinical pharmacology <strong>of</strong> the opioid class<br />
<strong>of</strong> drugs <strong>with</strong> specific reference to examining the genetic,<br />
biological <strong>and</strong> environmental factors that contribute<br />
to efficacy <strong>and</strong> toxicity in <strong>pain</strong> <strong>and</strong> addiction therapies.<br />
He has NHMRC project grant funding, serves<br />
on several journal editorial boards <strong>and</strong> has established<br />
a pharmacogenetics service at the Royal<br />
Adelaide Hospital.<br />
National Invited Speakers <strong>and</strong> Facilitators<br />
Dr Charles Brooker<br />
Royal North Shore Hospital,<br />
NSW<br />
Dr Robert Brzozek<br />
Health Services Group <strong>of</strong><br />
TAC <strong>and</strong> Worksafe, VIC<br />
Dr Chui Chong<br />
Royal Perth Hospital, WA<br />
Pr<strong>of</strong>essor Jon Currie<br />
St Vincent’s Hospital, VIC<br />
Dr Bronwen Evans<br />
Western Health Service, VIC<br />
Pr<strong>of</strong>essor Julia Fleming<br />
Royal Brisbane Hospital,<br />
QLD<br />
Pr<strong>of</strong>essor Colin Goodchild<br />
Monash University, VIC<br />
Dr Chris Hayes<br />
Hunter Integrated Pain<br />
Service, NSW<br />
Dr Malcolm Hogg<br />
Royal Melbourne Hospital,<br />
VIC<br />
Dr Alex Holmes<br />
Royal Melbourne Hospital,<br />
VIC<br />
Dr Winnie Hong<br />
Concord Repatriation<br />
General Hospital, NSW<br />
Assoc Pr<strong>of</strong>essor Kate<br />
Jackson<br />
Southern Health <strong>and</strong><br />
Monash University, VIC<br />
Dr Charles Kim<br />
St Vincent Hospital <strong>and</strong><br />
Melbourne Health, VIC<br />
Dr Alex Konstantatos<br />
Alfred Hospital, VIC<br />
Ms Dale Long<br />
Peter MacCallum Cancer<br />
Centre, VIC<br />
Assoc Pr<strong>of</strong>essor Pam<br />
Macintyre<br />
Royal Adelaide Hospital, SA<br />
Assoc Pr<strong>of</strong>essor Christine<br />
McDonald<br />
Austin Health, VIC<br />
Dr Mike McDonough<br />
Western Health, VIC<br />
Dr John Moloney<br />
Alfred Hospital, VIC<br />
Dr Tobie Sacks<br />
St Vincent’s Hospital, VIC<br />
Ms Cathy Senserrick<br />
Austin Health, VIC<br />
Mr Andrew Shelton<br />
Austin Health, VIC<br />
Dr Lisa Sherry<br />
Health Services Group <strong>of</strong><br />
TAC <strong>and</strong> Worksafe, VIC<br />
Dr Odette Spruyt<br />
Peter MacCallum Cancer<br />
Center, VIC<br />
Dr Helen Sweeting<br />
St Vincent’s Hospital, VIC<br />
Dr Joel Symons<br />
Alfred Hospital, VIC<br />
Dr Brett Todhunter<br />
Wodonga Regional Health<br />
Service, VIC<br />
Dr Jane Trinca<br />
Austin Health <strong>and</strong> St<br />
Vincent’s Hospital, VIC<br />
Ms Jill Woods<br />
Western Health, VIC<br />
Pr<strong>of</strong>essor Barbara<br />
Workman<br />
Monash University,<br />
Southern Healthcare<br />
Network, VIC<br />
5
Program<br />
FRIDAY 16 OCTOBER<br />
0900–1000 REGISTRATION<br />
1005–1015 Opening Welcome<br />
Dr Penny Briscoe<br />
1015–1230 PLENARY LECTURES – Arthur Streeton Auditorium<br />
Chair: Dr Carolyn Arnold<br />
Dr Roman D. Jovey<br />
Opiods, Pain <strong>and</strong> Addiction – Facts vs Fiction<br />
Dr Suellen Walker<br />
Intrathecal Analgesia – Duelling <strong>with</strong> Efficiency <strong>and</strong> Safety<br />
Pr<strong>of</strong>essor Andrew A. Somogyi<br />
Non Neuronal Opioid Actions<br />
1200–1230 Lunch<br />
1330–1500 PBLD <strong>and</strong> Topical Discussion Sessions<br />
PBLD 01 – Victoria Suite 1<br />
Facilitator – Dr Malcolm Hogg<br />
Implementing a Preventative Strategy in Acute Pain<br />
Topical Session 01 – Arthur Streeton Auditorium<br />
Facilitator – Dr Penny Briscoe<br />
Presenter – Dr Roman D. Jovey<br />
Office Based Pain Management – Optimising Outcome, Reducing Risk<br />
PBLD 02 – Victoria Suite 3<br />
Facilitator – Dr Chris Hayes<br />
Cessation <strong>of</strong> Established Intrathecal Analgesia in Persistent Non-Cancer Pain<br />
Topical Session 02 – Victoria Suite 2<br />
Facilitator – Assoc Pr<strong>of</strong>essor Kate Jackson<br />
Presenters – Ms Dale Long & Dr Brett Todhunter<br />
Community Management <strong>of</strong> Intrathecal Infusions for Cancer<br />
1500–1530 Afternoon Tea<br />
1530–1730 LECTURES – Arthur Streeton Auditorium<br />
Chair – Dr David Jones<br />
Dr Julia Fleming<br />
Novel Approaches to Cancer Pain<br />
Pr<strong>of</strong>essor Colin Goodchild<br />
Spinal Cord Magic Bullets – Current <strong>and</strong> Future Analgesic Developments<br />
Assoc Pr<strong>of</strong>essor Christine McDonald<br />
Opioids in Dyspnoea <strong>and</strong> Sleep Apnoea<br />
1730–1930 Welcome Cocktail Reception<br />
6<br />
2009 SPRING MEETING • FACULTY OF PAIN MEDICINE, ANZCA • ACUTE PAIN SPECIAL INTEREST GROUP OF ANZCA, ASA AND NZSA
Saturday 17 October<br />
0830–0900 Registration<br />
0900–1100 LECTURES – Arthur Streeton Auditorium<br />
Chair – Dr Jane Trinca<br />
Pr<strong>of</strong>essor Jon Currie<br />
Contemporary Approaches to Opioid Addiction<br />
Pr<strong>of</strong>essor Andrew A. Somogyi<br />
Methadone Pharmacology<br />
Assoc Pr<strong>of</strong>essor Kate Jackson<br />
Methadone Re-visited in Cancer Pain<br />
Dr Tobie Sacks<br />
Methadone in Chronic Pain<br />
1100–1130 Morning Tea<br />
1130–1300 PBLD <strong>and</strong> Topical Discussion Sessions<br />
PBLD 03 – Victoria Suite 1<br />
Facilitator – Dr Bronwen Evans<br />
Management <strong>of</strong> Ischaemic Limb Pain<br />
Topical Session 03 – Arthur Streeton Auditorium<br />
Facilitator – Assoc Pr<strong>of</strong>essor Kate Jackson<br />
Presenters – Dr Chui Chong, Pr<strong>of</strong>essor Colin Goodchild, Assoc Pr<strong>of</strong>essor Kate Jackson,<br />
Dr Odette Spruyt, Ms Jill Woods<br />
Incident/Procedural Pain Management Without an IV<br />
PBLD 04 – Victoria Suite 3<br />
Facilitator – Dr Winnie Hong<br />
A Case <strong>of</strong> Recurrent Acute on Chronic Visceral Pain - Here Pancreatitis -<br />
How to Balance Analgesia <strong>with</strong> Concerns about Appropriate Opioid Usage<br />
Topical Session 04 – Victoria Suite 2<br />
Facilitator – Dr Clayton Thomas<br />
Presenters – Dr Robert Brzozek, Dr Tobie Sacks, Dr Lisa Sherry, Dr Helen Sweeting<br />
Getting to Opioid Detoxification, Part 1. Preparing the Patient: 3 Approaches<br />
1300–1400 Lunch<br />
1400–1530 LECTURES – Arthur Streeton Auditorium<br />
Chair – Dr Chris Hayes<br />
Mr Damien Finniss<br />
Managing Placebo <strong>and</strong> Nocebo Effects – Mechanisms <strong>and</strong> Implications for Clinical Practice<br />
Dr Roman D. Jovey<br />
Pain <strong>and</strong> Addiction – Treatment Strategies<br />
7
1530–1600 Afternoon Tea<br />
1600–1730 PBLD <strong>and</strong> Topical Discussion Sessions<br />
PBLD 05 – Victoria Suite 1<br />
Facilitator – Dr Helen Sweeting<br />
Issues to Consider <strong>with</strong> Conversion to Use <strong>of</strong> Buprenorphine<br />
Topical Session 05 – room to be confirmed<br />
Facilitator – Dr Carolyn Arnold<br />
Presenters – Assoc Pr<strong>of</strong>essor Pam Macintyre & Pr<strong>of</strong>essor Barbara Workman<br />
Prescribing for Pain in the Elderly<br />
Topical Session 06 – room to be confirmed<br />
Facilitator – Dr Jane Trinca<br />
Presenters – Dr Charles Kim, Ms Cathy Senserrick, Mr Andrew Shelton, Dr Jane Trinca<br />
Acute Pain Management for Orthopaedics. Managing the Pain <strong>and</strong> Fast Tracking Rehab<br />
Topical Session 07 – room to be confirmed<br />
Facilitator – Dr Dilip Kapur<br />
Presenters – Dr Charles Brooker, Pr<strong>of</strong>essor Jon Currie, Dr Mike McDonough<br />
Detoxification Part 2. How to do it: 3 Approaches<br />
1900–2300 Conference Dinner – The Italian Restaurant, 101 Collins Street, Melbourne<br />
Sunday 18 October<br />
0900–1100 LECTURES – Arthur Streeton Auditorium<br />
Chair – Dr Clayton Thomas<br />
Dr Alex Holmes<br />
Predictors <strong>of</strong> Persistent Pain after Trauma<br />
Dr Joel Symons<br />
Procedural Pain Analgesia<br />
Dr Alex Konstantatos<br />
Psychological Adjuncts for Pain Occurring <strong>with</strong> Dressing Changes in Burns Patients<br />
1100–1130 Morning Tea<br />
1130–1230 LECTURES – Arthur Streeton Auditorium<br />
Chair – Dr Terry Lim<br />
Dr John Moloney<br />
Australia’s Worst Bushfire Disaster: The Medical Response to Victoria’s Black Saturday<br />
1235 Close<br />
Dr Chris Hayes presents the 2010 Spring Meeting<br />
8<br />
2009 SPRING MEETING • FACULTY OF PAIN MEDICINE, ANZCA • ACUTE PAIN SPECIAL INTEREST GROUP OF ANZCA, ASA AND NZSA
Summary <strong>of</strong> PBLDs <strong>and</strong> Topical Sessions<br />
PBLD 01<br />
Friday 16 October<br />
1330–1500<br />
Facilitator: Dr Malcolm Hogg<br />
Implementing a Preventative<br />
Strategy in Acute Pain<br />
Identifying patients at risk<br />
<strong>of</strong> persistent post operative<br />
<strong>pain</strong> <strong>and</strong> implementing a<br />
preventative strategy<br />
Topical Session 01<br />
Friday 16 October<br />
1330–1500<br />
Facilitator: Dr Penny Briscoe<br />
Office Based Pain<br />
Management – Optimising<br />
Outcome, Reducing Risk<br />
This session incorporates<br />
the essentials <strong>of</strong> a chronic<br />
<strong>pain</strong> assessment, including<br />
screening <strong>and</strong> risk<br />
stratification, examples <strong>of</strong><br />
a low risk patient managed<br />
<strong>with</strong> OA <strong>and</strong> discussion <strong>of</strong><br />
NSAIDS risks, <strong>and</strong> in contrast<br />
a high risk patient <strong>with</strong> back<br />
<strong>pain</strong> requiring screening for<br />
opioid risk. The concept <strong>of</strong><br />
Universal Precautions in <strong>pain</strong><br />
management to reduce risks<br />
will be discussed, <strong>and</strong> essential<br />
outcome documentation.<br />
PBLD 02<br />
Friday 16 October<br />
1330–1500<br />
Facilitator: Dr Chris Hayes<br />
Cessation <strong>of</strong> Established<br />
Intrathecal Analgesia in<br />
Persistent Non-Cancer Pain<br />
A 47 year old man has been<br />
on established intrathecal<br />
therapy <strong>with</strong> hydromorphone<br />
<strong>and</strong> clonidine for 5 years. This<br />
is directed at the management<br />
<strong>of</strong> persistent low back <strong>pain</strong><br />
previously unresponsive to<br />
3 spinal surgical procedures<br />
<strong>and</strong> oral opioids. Some<br />
modest benefits had been<br />
reported <strong>with</strong> initiation <strong>of</strong><br />
intrathecal therapy. However<br />
these benefits had not been<br />
sustained. He had undertaken<br />
a group <strong>pain</strong> management<br />
program but had not effectively<br />
engaged <strong>with</strong> the process.<br />
Where to next?<br />
Topical Session 02<br />
Friday 16 October<br />
1330–1500<br />
Facilitator: A/Pr<strong>of</strong> Kate Jackson<br />
Community Management<br />
<strong>of</strong> Intrathecal Infusions for<br />
Cancer<br />
This session will address<br />
indications, methods <strong>and</strong> drug<br />
combinations for intrathecal<br />
infusions for refractory cancer<br />
<strong>pain</strong>, plus the “nitty gritty” <strong>of</strong><br />
day to day management <strong>of</strong><br />
these infusions by domiciliary<br />
palliative care services.<br />
PBLD 03<br />
Saturday 17 October<br />
1130–1300<br />
Facilitator: Dr Bronwen Evans<br />
Management <strong>of</strong> Ischaemic<br />
Limb Pain<br />
John is a 55 year old man<br />
<strong>with</strong> Berger’s disease who<br />
is experiencing severe <strong>pain</strong><br />
in his foot in association<br />
<strong>with</strong> ischaemic ulcers <strong>and</strong><br />
is begging for more <strong>pain</strong><br />
relief; when you meet him he<br />
is rocking to <strong>and</strong> fro whilst<br />
rubbing his <strong>pain</strong>ful foot.<br />
What challenges await in the<br />
management <strong>of</strong> this man’s<br />
<strong>pain</strong> <strong>and</strong> how might one<br />
proceed?<br />
Topical Session 03<br />
Saturday 17 October<br />
1130–1300<br />
Facilitator: A/Pr<strong>of</strong> Kate Jackson<br />
Incident/Procedural Pain<br />
Management Without an IV<br />
This session will discuss<br />
the extent <strong>of</strong> this problem,<br />
<strong>and</strong> a number <strong>of</strong> different<br />
management techniques,<br />
including Intranasal<br />
Sufentanil, OTFC lozenges,<br />
methoxyflurane <strong>and</strong> ketamine<br />
lozenges.<br />
PBLD 04<br />
Saturday 17 October<br />
1130–1300<br />
Facilitator: Dr Winnie Hong<br />
A Case <strong>of</strong> Recurrent Acute on<br />
Chronic Visceral Pain- Here<br />
Pancreatitis- How to Balance<br />
Analgesia <strong>with</strong> Concerns about<br />
Opioid Usage<br />
You are asked to manage a 42<br />
year old woman <strong>with</strong> a history<br />
<strong>of</strong> chronic pancreatitis who<br />
presents <strong>with</strong> an exacerbation<br />
<strong>of</strong> abdominal <strong>pain</strong>, <strong>and</strong><br />
normal amylase. She has been<br />
admitted <strong>and</strong> treated <strong>with</strong><br />
parenteral opioid over the<br />
weekend, <strong>and</strong> is dem<strong>and</strong>ing<br />
better analgesia.<br />
Topical Session 04<br />
Saturday 17 October<br />
1130–1300<br />
Facilitator: Dr Clayton Thomas<br />
Getting to Opioid<br />
Detoxification, Part 1.<br />
Preparing the Patient: 3<br />
Approaches<br />
You have identified a patient<br />
<strong>with</strong> opioid dependence<br />
<strong>and</strong> chronic <strong>pain</strong> for whom<br />
medication reduction or<br />
even <strong>with</strong>drawal is being<br />
considered. How will you<br />
work <strong>with</strong> the patient to<br />
help them consider this<br />
option? Three experts discuss<br />
their approaches covering<br />
psychological <strong>and</strong> behavioral<br />
approaches, considerations<br />
<strong>of</strong> social factors including<br />
compensation <strong>and</strong> <strong>pain</strong><br />
management.<br />
PBLD 05<br />
Saturday 17 October<br />
1600–1730<br />
Facilitator: Dr Helen Sweeting<br />
Issues to Consider <strong>with</strong><br />
Conversion to Buprenorphine<br />
You are asked to see a young<br />
heroin injecting male, who is<br />
currently receiving parenteral<br />
opioids for <strong>pain</strong> associated<br />
<strong>with</strong> spinal osteomyelitis,<br />
<strong>and</strong> who requires ongoing<br />
analgesia.<br />
Topical Session 05<br />
Saturday 17 October<br />
1600–1730<br />
Facilitator: Dr Carolyn Arnold<br />
Prescribing for Pain in<br />
the Elderly<br />
Participants will learn how<br />
<strong>pain</strong> processing differs in<br />
older patients <strong>and</strong> appropriate<br />
selection <strong>and</strong> dosing <strong>of</strong><br />
medication. Strategies for safe<br />
<strong>and</strong> effective treatment <strong>of</strong> <strong>pain</strong><br />
in the elderly will be discussed.<br />
Topical Session 06<br />
Saturday 17 October<br />
1600–1730<br />
Facilitator: Dr Jane Trinca<br />
Acute Pain Management for<br />
Orthopaedics.<br />
Managing the Pain <strong>and</strong> Fast<br />
Tracking the Rehabilitation <strong>of</strong><br />
patients undergoing Knee or<br />
Hip Replacement<br />
Developing approaches to<br />
management <strong>of</strong> <strong>pain</strong>, which<br />
involves input from the nurse,<br />
physiotherapist, surgeon <strong>and</strong><br />
others may have important<br />
benefits for the patient <strong>and</strong><br />
healthcare system. This<br />
session aims to bring these<br />
disciplines together to develop<br />
best practice.<br />
Topical Session 07<br />
Saturday 17 October<br />
1600–1730<br />
Facilitator: Dr Dilip Kapur<br />
Detoxification Part 2. How to<br />
do it: 3 Approaches<br />
Having reached agreement<br />
<strong>with</strong> your patient to reduce<br />
or <strong>with</strong>draw the opioid for<br />
chronic <strong>pain</strong>, how will you do<br />
it? Three experts present their<br />
approaches ranging from rapid<br />
detox, detox over 1 to 2 weeks,<br />
or slower reduction.<br />
Continuing Medical Education Approvals<br />
<strong>Australian</strong> <strong>and</strong> <strong>New</strong> Zeal<strong>and</strong> College <strong>of</strong> Anaesthetists • Lecture sessions: Category 1/Level 1: 1 Credit per hour<br />
Topical sessions: Category 1/Level 2: 2 Credits per hour • PBLDs: Category 3/Level 1:2 Credits per hour • The approval number is 1440<br />
This Active Learning Module has been approved by the RACGP QA&CPD Program in the 2008 – 2010 triennium.<br />
TOTAL POINTS: 40 (Category 1)<br />
9
Opioids, Pain <strong>and</strong> Addiction –<br />
Facts vs Fiction<br />
Dr Roman D. Jovey<br />
Credit Valley Hospital, Ontario, Canada <strong>and</strong><br />
CPM Centres for Pain Management, Mississauga, Ontario, Canada<br />
EDUCATIONAL OBJECTIVES<br />
1. Update knowledge on the prevalence <strong>and</strong> neurobiology<br />
<strong>of</strong> addiction <strong>and</strong> the potential overlap <strong>with</strong> chronic <strong>pain</strong>;<br />
2. Review the appropriate definitions <strong>of</strong> addiction in<br />
patients <strong>with</strong> <strong>pain</strong> on opioid therapy;<br />
3. Describe the concepts <strong>of</strong> ‘Universal Precautions’ for<br />
optimizing the prescribing <strong>of</strong> opioids for chronic <strong>pain</strong>,<br />
including screening strategies, written agreements <strong>and</strong><br />
urine drug screening;<br />
4. Summarize current knowledge on potential “new”<br />
adverse effects <strong>of</strong> long-term opioid therapy.<br />
summary<br />
Chronic non-cancer <strong>pain</strong> (CNCP) remains a common<br />
problem affecting an estimated 20% <strong>of</strong> the adult<br />
population, <strong>with</strong> a huge burden <strong>of</strong> illness to the<br />
individual, the health care system <strong>and</strong> the economy.<br />
In spite <strong>of</strong> this impact, resources devoted to research,<br />
education <strong>and</strong> treatment <strong>of</strong> <strong>pain</strong> remain meagre<br />
compared to other chronic conditions.<br />
The use <strong>of</strong> long-term opioid (LTO) therapy for the<br />
treatment <strong>of</strong> CNCP has gradually become accepted<br />
internationally as an evidence-based component <strong>of</strong><br />
multi-modal <strong>pain</strong> management by a majority <strong>of</strong> <strong>pain</strong><br />
clinicians, <strong>pain</strong> <strong>and</strong> addiction organizations <strong>and</strong> medical<br />
regulators. This does not mean the current practice<br />
is <strong>with</strong>out ongoing controversy.<br />
The increased prescribing <strong>of</strong> opioids for <strong>pain</strong>, has<br />
coincided <strong>with</strong> an increase in misuse, addiction <strong>and</strong><br />
diversion <strong>of</strong> prescribed opioids. To reduce this risk,<br />
existing guidelines recommend that clinicians screen<br />
for addiction risk <strong>and</strong> structure treatment accordingly.<br />
As a result, there is a growing need for <strong>pain</strong> clinicians<br />
to underst<strong>and</strong> some <strong>of</strong> the essentials <strong>of</strong> addiction<br />
<strong>medicine</strong> – much as there is a need for addiction<br />
specialists to underst<strong>and</strong> something about<br />
<strong>pain</strong> <strong>medicine</strong>.<br />
Substance use disorders affect approximately 10% <strong>of</strong><br />
the general population. Patients <strong>with</strong> chronic <strong>pain</strong> either<br />
have the same or somewhat higher risk <strong>of</strong> concurrent<br />
substance abuse or addiction. The development <strong>of</strong><br />
addiction requires not only repeated exposure to a<br />
potentially addicting substance or behaviour, but an<br />
individual <strong>with</strong> a particular biopsychogenetic vulnerability<br />
living in a particular social milieu. Without the presence<br />
<strong>of</strong> these risk factors, it is unlikely that a physician can<br />
“create” an addict de novo from an opioid-naïve patient<br />
by the prescription <strong>of</strong> opioids for <strong>pain</strong>. On the other<br />
h<strong>and</strong>, physicians can certainly enable the ‘rekindling’<br />
<strong>of</strong> a previous addictive disorder by failing to screen<br />
patients for risk factors or by ignoring the early<br />
symptoms <strong>and</strong> signs <strong>of</strong> a developing addiction to<br />
prescribed opioids.<br />
There is an overlap between the neural circuitry <strong>of</strong><br />
addiction <strong>and</strong> that <strong>of</strong> chronic <strong>pain</strong>. However it is<br />
important to properly use the labels ‘misuse’, ‘abuse’<br />
‘tolerance’ <strong>and</strong> ‘addiction’ when referring to patients<br />
<strong>with</strong> <strong>pain</strong> on opioids.<br />
Gourlay et al published the concept <strong>of</strong> ‘Universal<br />
Precautions in <strong>pain</strong> <strong>medicine</strong>’, to help manage all<br />
patients in <strong>pain</strong> <strong>with</strong> a st<strong>and</strong>ardized approach in order<br />
to optimize benefit <strong>and</strong> reduce risks. This includes<br />
screening <strong>and</strong> risk stratification <strong>and</strong> the use <strong>of</strong> opioid<br />
prescribing agreements <strong>and</strong> urine drug screening in<br />
higher risk patients.<br />
Finally, our recent clinical experience <strong>with</strong> the use <strong>of</strong> LTO<br />
for chronic <strong>pain</strong> has raised the issue <strong>of</strong> some ‘new’ longterm<br />
side effects <strong>of</strong> opioids, namely opioid hyperalgesia,<br />
sex hormone disturbances, worsening sleep apnea <strong>and</strong><br />
potential immune effects. Other than opioid-induced<br />
hypogonadism, the current published data is not robust<br />
enough to allow for firm conclusions regarding these<br />
other adverse effects.<br />
10<br />
2009 SPRING MEETING • FACULTY OF PAIN MEDICINE, ANZCA • ACUTE PAIN SPECIAL INTEREST GROUP OF ANZCA, ASA AND NZSA
In the absence <strong>of</strong> other alternatives, opioids will continue<br />
to be a valuable treatment option for <strong>pain</strong> management.<br />
Genetically <strong>and</strong> psychosocially vulnerable people will<br />
continue to misuse substances for psychic effect.<br />
By incorporating some fundamental concepts from<br />
addiction <strong>medicine</strong> into a structured approach to patient<br />
assessment <strong>and</strong> treatment, the clinician can optimize<br />
the benefits <strong>and</strong> reduce the risks <strong>of</strong> chronic <strong>pain</strong><br />
management.<br />
REFERENCES<br />
1. Adin<strong>of</strong>f B. Neurobiologic processes in drug reward <strong>and</strong> addiction.<br />
Harv Rev Psychiatry. 2004 Nov-Dec;12(6):305-20. Review.<br />
2. Chou R, Ballantyne JC, Fanciullo GJ, Fine PG, Miaskowski C. Research<br />
gaps on use <strong>of</strong> opioids for chronic noncancer <strong>pain</strong>: findings from<br />
a review <strong>of</strong> the evidence for an American Pain Society <strong>and</strong> American<br />
Academy <strong>of</strong> Pain Medicine clinical practice guideline. J Pain. 2009<br />
Feb;10(2):147-59. Review.<br />
3. Chou R, Fanciullo GJ, Fine PG, Miaskowski C, Passik SD, Portenoy RK.<br />
Opioids for chronic noncancer <strong>pain</strong>: prediction <strong>and</strong> identification <strong>of</strong><br />
aberrant drug-related behaviors: a review <strong>of</strong> the evidence for<br />
an American Pain Society <strong>and</strong> American Academy <strong>of</strong> Pain Medicine<br />
clinical practice guideline. J Pain. 2009 Feb;10(2):131-46. Review.<br />
4. Fishbain DA, Cole B, Lewis JE, Gao J, Rosom<strong>of</strong>f RS. Do Opioids Induce<br />
hyperalgesia in humans? An Evidence-Based Structured Review.<br />
Pain Med. 2009 Jul 6. [Epub ahead <strong>of</strong> print]<br />
5. Fishbain DA, Cole B, Lewis J, Rosom<strong>of</strong>f HL, Rosom<strong>of</strong>f RS. What<br />
percentage <strong>of</strong> chronic nonmalignant <strong>pain</strong> patients exposed to chronic<br />
opioid analgesic therapy develop abuse/addiction <strong>and</strong>/or aberrant<br />
drug-related behaviors? A structured evidence-based review. Pain Med.<br />
2008 May-Jun;9(4):444-59. Review.<br />
6. Gourlay DL, Heit HA, Almahrezi A. Universal precautions in <strong>pain</strong><br />
<strong>medicine</strong>: a rational approach to the treatment <strong>of</strong> chronic <strong>pain</strong>.<br />
Pain Med 2005;6:107-112.<br />
7. Heit HA, Gourlay DL. Urine drug testing in <strong>pain</strong> <strong>medicine</strong>.<br />
J Pain Symptom Manage 2004;27:260-267.<br />
8. Jovey RD. Pain <strong>and</strong> Addiction: Prevalence, Neurobiology <strong>and</strong><br />
Definitions. In: Castro-Lopes J. (Ed). Pain 2008 An Updated Review<br />
(Refresher Course Syllabus) IASP Press, Seattle, 2008: 359-364.<br />
9. Koob GF. The neurobiology <strong>of</strong> addiction: a neuroadaptational review<br />
relevant for diagnosis. Addiction 2006; 101 (Suppl 1): 23-30.<br />
10. Savage SR. Assessment for addiction in <strong>pain</strong>-treatment settings.<br />
Clin J Pain 2002;18:S28-S38.<br />
11. Savage SR, Joranson DE, Covington EC, Schnoll SH, Heit HA, Gilson<br />
AM. Definitions related to the medical use <strong>of</strong> opioids: evolution<br />
towards universal agreement. J Pain Symptom Manage. 2003<br />
Jul;26(1):655-67.<br />
12. Sacerdote P. Opioid-induced immunosuppression. Curr Opin Support<br />
Palliat Care. 2008 Mar;2(1):14-8.<br />
13. Substance Abuse <strong>and</strong> Mental Health Services Administration. (2007).<br />
Results from the 2006 National Survey on Drug Use <strong>and</strong> Health:<br />
National Findings (Office <strong>of</strong> Applied Studies, NSDUH Series H-32,<br />
DHHS Publication No. SMA 07-4293). Rockville, MD. Available from:<br />
http://www.samhsa.gov Accessed Feb 1, 2003.<br />
14. Walker JM, Farney RJ. Are opioids associated <strong>with</strong> sleep apnea? A<br />
review <strong>of</strong> the evidence. Curr Pain Headache Rep. 2009 Apr;13(2):120-6.<br />
15. Webster LR, Webster RM. Predicting aberrant behaviors in opioidtreated<br />
patients: preliminary validation <strong>of</strong> the Opioid Risk Tool.<br />
Pain Med 2005;6:432-442.<br />
11
Intrathecal Analgesia – Duelling<br />
<strong>with</strong> Efficacy <strong>and</strong> Safety<br />
Dr Suellen Walker<br />
University College London <strong>and</strong> Great Ormond St Hospital, London, United Kingdom<br />
Adequate control <strong>of</strong> perioperative <strong>pain</strong> has been<br />
recognised for many years to improve acute<br />
postoperative outcomes in neonates <strong>and</strong> infants 1 <strong>and</strong><br />
may also have an impact on long-term sensory<br />
function 2, 3 . Regional anaesthesia <strong>and</strong> analgesia has an<br />
established role in postoperative <strong>pain</strong> management<br />
for children <strong>of</strong> all ages 4 . Opioid <strong>and</strong> non-opioid spinal<br />
analgesics are frequently added to local anaesthetics<br />
for single dose injection or infusion, <strong>and</strong> can improve<br />
analgesic efficacy, reduce local anaesthetic requirements,<br />
<strong>and</strong>/or prolong analgesia. However, a large range<br />
<strong>of</strong> drugs <strong>and</strong> preparations have been administered<br />
spinally 5 <strong>and</strong> there is insufficient evidence regarding the<br />
comparative efficacy, side-effect pr<strong>of</strong>ile, <strong>and</strong> potential<br />
for spinal toxicity to inform the clinical choice between<br />
different agents. Reports <strong>of</strong> neurological impairment<br />
following epidural <strong>and</strong> caudal analgesia in children are<br />
rare 6, 7 , but it has also been argued that a single case <strong>of</strong><br />
serious neurological sequelae following injection <strong>of</strong> an<br />
inadequately tested drug could bring the technique into<br />
disrepute <strong>and</strong> deny many children the benefit <strong>of</strong> regional<br />
analgesia 8 .<br />
The requirements for preclinical evaluation <strong>of</strong> the<br />
toxicity <strong>of</strong> spinal analgesics have been established in<br />
adult models, <strong>and</strong> encompass effects on both function<br />
<strong>and</strong> spinal cord morphology 9 . However, there are<br />
additional factors that require consideration in early<br />
life. Developmental age has a significant impact on<br />
nociceptive processing 10 <strong>and</strong> on analgesic efficacy<br />
following both systemic 11 <strong>and</strong> spinal 12,13 administration.<br />
In addition, reductions in neural activity at critical<br />
developmental periods may precipitate programmed<br />
cell death or neuronal apoptosis. In laboratory models,<br />
general anaesthetics <strong>with</strong> NMDA antagonist or GABA<br />
agonist activity, particularly when given in combination,<br />
have been associated <strong>with</strong> acute apoptosis <strong>and</strong> longterm<br />
deficits in learning <strong>and</strong> memory 14 . A large clinical<br />
cohort study has also shown an association between the<br />
duration <strong>and</strong> number <strong>of</strong> anaesthetic exposures in early<br />
life <strong>and</strong> an increased risk <strong>of</strong> learning difficulties during<br />
childhood 15 . While clinical studies suggest an association<br />
but cannot confirm causation (as there will be multiple<br />
confounding factors <strong>and</strong> effects <strong>of</strong> intercurrent illness,<br />
drugs, surgical factors etc.), increased utilization <strong>of</strong><br />
neuraxial techniques has been suggested as a means to<br />
reduce the potential risks related to exposure to general<br />
anaesthetic drugs 16 . Prolonged general anaesthesia<br />
has been associated <strong>with</strong> increased apoptosis in<br />
the spinal cord 17 , but the FDA has recognised that<br />
effects <strong>of</strong> spinally administered analgesics also require<br />
specific evaluation (www.fda.gov/ohrms/dockets/<br />
ac/07/minutes/2007-4285m1-Final.pdf). We have<br />
developed a preclinical model for evaluation <strong>of</strong> toxicity<br />
in neonatal rats that includes behavioural testing, acute<br />
histopathological examination <strong>of</strong> the cord, evaluation<br />
<strong>of</strong> the impact <strong>of</strong> postnatal age <strong>and</strong> intrathecal drugs on<br />
apoptosis in the spinal cord, <strong>and</strong> longterm functional<br />
outcomes 18 . As drug doses in laboratory models are<br />
not directly comparable to “clinically relevant” doses,<br />
we determined the analgesic dose <strong>and</strong> then evaluated<br />
toxicity at increasing doses to determine a therapeutic<br />
index (ratio <strong>of</strong> toxic dose to analgesic dose), which<br />
allows comparison <strong>of</strong> the relative toxicity<br />
<strong>of</strong> different drugs at different ages.<br />
Due to advances in neonatal <strong>and</strong> paediatric care,<br />
neonates are surviving at earlier gestational ages <strong>and</strong><br />
increasingly complex surgical procedures are being<br />
performed at earlier stages <strong>of</strong> development. Paediatric<br />
<strong>pain</strong> management requires a balance between multiple<br />
‘<strong>duelling</strong>’ factors. The primary requirement is to<br />
provide adequate anaesthesia <strong>and</strong> analgesia to ensure<br />
patient comfort, maintain cardiorespiratory stability,<br />
<strong>and</strong> improve postoperative outcomes. However, it is<br />
increasingly recognised that the effects <strong>of</strong> <strong>pain</strong>, injury,<br />
anaesthesia <strong>and</strong> analgesia on the developing nervous<br />
system may differ from those seen at older ages <strong>and</strong><br />
may produce long-term changes in structure <strong>and</strong><br />
function. In relation to spinal therapies, there is an<br />
ongoing ‘duel’ between efficacy <strong>and</strong> safety for patients<br />
<strong>of</strong> all ages. Preclinical spinal toxicity studies provide<br />
essential information for the evaluation <strong>of</strong> comparative<br />
risks <strong>and</strong> age-related changes in susceptibility,<br />
<strong>and</strong> can help to inform the clinical choice between<br />
different agents. Determining the most effective <strong>and</strong><br />
developmentally appropriate analgesic interventions to<br />
improve both acute <strong>and</strong> long-term outcomes is a major<br />
ongoing challenge for researchers. In clinical practice,<br />
the emphasis remains on providing adequate <strong>and</strong> safe<br />
analgesia based on currently available best evidence<br />
<strong>and</strong> an analysis <strong>of</strong> the relative benefits <strong>and</strong> risks for<br />
each individual patient.<br />
12<br />
2009 SPRING MEETING • FACULTY OF PAIN MEDICINE, ANZCA • ACUTE PAIN SPECIAL INTEREST GROUP OF ANZCA, ASA AND NZSA
REFERENCES<br />
1. An<strong>and</strong> KJ, Hickey PR. Halothane-morphine compared <strong>with</strong> high-dose<br />
sufentanil for anesthesia <strong>and</strong> postoperative analgesia in neonatal<br />
cardiac surgery. N Engl J Med. 1992 Jan 2;326(1):1-9.<br />
2. Walker SM, Franck LS, Fitzgerald M, Myles J, Stocks J, Marlow N.<br />
Long-term impact <strong>of</strong> neonatal intensive care <strong>and</strong> surgery on<br />
somatosensory perception in children born extremely preterm.<br />
Pain. 2009 Jan;141(1-2):79-87.<br />
3. Walker SM, Tochiki KK, Fitzgerald M. Hindpaw incision in early life<br />
increases the hyperalgesic response to repeat surgical injury: critical<br />
period <strong>and</strong> dependence on initial afferent activity. (submitted).<br />
4. Howard RF, Carter B, Curry J, Morton N, Rivett K, Rose M, et al.<br />
Association <strong>of</strong> Paediatric Anaesthetists: Good Practice in Postoperative<br />
<strong>and</strong> Procedural Pain. Pediatric Anesthesia. 2008;18 (Suppl. 1):1-81.<br />
5. Williams DG, Howard RF. Epidural analgesia in children. A survey <strong>of</strong><br />
current opinions <strong>and</strong> practices amongst UK paediatric anaesthetists.<br />
Paediatr Anaesth. 2003 Nov;13(9):769-76.<br />
6. Llewellyn N, Moriarty A. The national pediatric epidural audit.<br />
Paediatr Anaesth. 2007 Jun;17(6):520-33.<br />
7. Royal College <strong>of</strong> Anaesthetists. Major Complications <strong>of</strong> Central Neural<br />
Blockade in the United Kingdom. 2009 Available from:<br />
www.rcoa.ac.uk/index.asp?PageID=717.<br />
8. Lonnqvist PA. Adjuncts to caudal block in children--Quo vadis?<br />
Br J Anaesth. 2005 Oct;95(4):431-3.<br />
9. Yaksh TL RM, Provencher JC. . Preclinical safety evaluation for spinal<br />
drugs. . In: Yaksh TL, editor. Spinal Drug Delivery. Amsterdam:<br />
Elsevier Science B.V.; 1999. p. 417-37.<br />
10. Fitzgerald M, Walker SM. Infant <strong>pain</strong> management: a developmental<br />
neurobiological approach. Nat Clin Pract Neurol. 2009 Jan;5(1):35-50.<br />
11. N<strong>and</strong>i R, Beacham D, Middleton J, Koltzenburg M, Howard RF,<br />
Fitzgerald M. The functional expression <strong>of</strong> mu opioid receptors on<br />
sensory neurons is developmentally regulated; morphine analgesia<br />
is less selective in the neonate. Pain. 2004 Sep;111(1-2):38-50.<br />
12. Walker SM, Howard RF, Keay KA, Fitzgerald M. Developmental age<br />
influences the effect <strong>of</strong> epidural dexmedetomidine on inflammatory<br />
hyperalgesia in rat pups. Anesthesiology. 2005 Jun;102(6):1226-34.<br />
13. Walker SM, Fitzgerald M. Characterization <strong>of</strong> spinal alpha-adrenergic<br />
modulation <strong>of</strong> nociceptive transmission <strong>and</strong> hyperalgesia throughout<br />
postnatal development in rats.<br />
Br J Pharmacol. 2007 Aug;151(8):1334-42.<br />
14. Loepke AW, Soriano SG. An assessment <strong>of</strong> the effects <strong>of</strong> general<br />
anesthetics on developing brain structure <strong>and</strong> neurocognitive function.<br />
Anesth Analg. 2008 Jun;106(6):1681-707.<br />
15. Wilder RT, Flick RP, Sprung J, Katusic SK, Barbaresi WJ, Mickelson C,<br />
et al. Early exposure to anesthesia <strong>and</strong> learning disabilities<br />
in a population-based birth cohort.<br />
Anesthesiology. 2009 Apr;110(4):796-804.<br />
16. McGowan FX, Jr., Davis PJ. Anesthetic-related neurotoxicity in the<br />
developing infant: <strong>of</strong> mice, rats, monkeys <strong>and</strong>, possibly, humans.<br />
Anesth Analg. 2008 Jun;106(6):1599-602.<br />
17. S<strong>and</strong>ers RD, Xu J, Shu Y, Fidalgo A, Ma D, Maze M. General<br />
anesthetics induce apoptotic neurodegeneration in the neonatal rat<br />
spinal cord. Anesth Analg. 2008 Jun;106(6):1708-11.<br />
18. Westin BD, Walker SM, Grafe M, Yaksh TL. Intrathecal morphine in<br />
the neonatal rat: analgesic efficacy <strong>and</strong> preclinical evaluation <strong>of</strong> safety.<br />
Anesth Analg 2009;108:S235.<br />
13
Non Neuronal Opioid Actions<br />
Pr<strong>of</strong>essor Andrew A. Somogyi<br />
University <strong>of</strong> Adelaide, SA<br />
Mark R Hutchinson<br />
University <strong>of</strong> Adelaide, SA<br />
More than 30 opioids are marketed worldwide for the<br />
treatment <strong>of</strong> acute <strong>and</strong> persistent moderate to severe<br />
<strong>pain</strong>. The traditional view regarding the mechanism <strong>of</strong><br />
action <strong>of</strong> the opioids is that they bind to the G-protein<br />
coupled mu opioid receptor on pre- <strong>and</strong> post synaptic<br />
neurons causing the closing <strong>of</strong> voltage gated Ca++<br />
channels (presynaptic) <strong>and</strong> opening <strong>of</strong> K+ channels<br />
(postsynaptic). This results in a reduction in transmitter<br />
release <strong>and</strong> hyperpolarisation <strong>and</strong> the beneficial clinical<br />
effects <strong>of</strong> analgesia. It is generally accepted that the<br />
same mechanisms are responsible for the adverse<br />
effects <strong>of</strong> opioids, such as respiratory depression,<br />
tolerance, dependence <strong>and</strong> neurotoxicity. However recent<br />
in vitro <strong>and</strong> animal findings indicate a role for opioidinduced<br />
glial activation. Glia are immune-like cells in the<br />
brain <strong>and</strong> spinal cord <strong>and</strong> express the innate immune<br />
receptor toll-like receptor 4 (TLR4) through which<br />
opioids cause signaling activation. Importantly, the rank<br />
order <strong>of</strong> effect at TLR4 by opioids is completely different<br />
compared to the classical neuronal mu receptor. For<br />
example, the non-opioid receptor active morphine<br />
metabolite, morphine-3-glucuronide, possesses<br />
significant TLR4 activity, whilst the potent morphine<br />
metabolite, morphine-6-glucuronide, has minimal<br />
activity. Opioids also target TLR4 in a nonstereoselective<br />
manner (in contrast to binding at the mu receptor);<br />
for example, the non-opioid S-methadone is as active at<br />
TLR4 as the opioid active R-methadone. Thus, opioids<br />
possess TLR4 signaling activation activity resulting in<br />
pro-inflammatory glial activation. This causes the release<br />
<strong>of</strong> neuroexcitatory pro-inflammatory cytokines such as<br />
IL-1 that can act on pre- <strong>and</strong> post-synaptic neurons to<br />
enhance <strong>pain</strong>, decrease analgesia <strong>and</strong> increase tolerance<br />
<strong>and</strong> dependence. Moreover, glial activation has also been<br />
linked to elevated morphine-induced dopamine release<br />
<strong>with</strong>in the nucleus accumbens, suggesting an important<br />
role in modifying opioid reward. Chronic administration<br />
<strong>of</strong> opioids causes enhanced cytokine release from glia.<br />
Suppressing opioid-induced glial activation by targeting<br />
TLR4 or generally attenuating glial activation potentiates<br />
acute opioid analgesia, reduces the development<br />
<strong>of</strong> tolerance, opioid-induced hyperalgesia, reward,<br />
dependence <strong>and</strong> <strong>with</strong>drawal, <strong>and</strong> reduces respiratory<br />
depression. Thus the beneficial <strong>and</strong> detrimental effects<br />
<strong>of</strong> opioids might be able to be separated by targeting<br />
<strong>and</strong> inhibiting opioid-induced glial activation.<br />
In animal studies, the antibiotic minocycline is an<br />
effective attenuator <strong>of</strong> opioid-induced glial activation.<br />
Whilst acutely potentiating morphine analgesia,<br />
it suppresses opioid dependence <strong>and</strong> respiratory<br />
depression. TLR4 signaling inhibitors such as the mu<br />
opioid inactive isomers <strong>of</strong> naloxone <strong>and</strong> naltrexone<br />
behave similarly <strong>and</strong> result in the separation <strong>of</strong> the<br />
wanted <strong>and</strong> unwanted actions <strong>of</strong> opioids.<br />
In conclusion, a new paradigm shift in our<br />
underst<strong>and</strong>ing <strong>of</strong> the mechanisms <strong>of</strong> action <strong>of</strong> the<br />
opioids is evolving. Consideration now needs to be<br />
given to the potentially important contribution <strong>of</strong><br />
immune signalling in the central nervous system to the<br />
efficacy <strong>and</strong> toxicity <strong>of</strong> the opioids. Translation <strong>of</strong> these<br />
promising preclinical results into the clinical setting is<br />
required but contingent upon the development <strong>of</strong> newer<br />
<strong>and</strong> more selective TLR4 opioid binding site inhibitors.<br />
REFERENCES<br />
1. Hutchinson MR et al. Opioid-induced glial activation: mechanisms<br />
<strong>of</strong> activation <strong>and</strong> implications for opioid analgesia, dependence <strong>and</strong><br />
reward. Sci World J 7: 98-111, 2007<br />
2. Hutchinson MR et al. Minocycline suppresses morphine-induced<br />
respiratory depression, suppresses morphine-induced <strong>with</strong>drawal <strong>and</strong><br />
enhances systemic morphine-induced analgesia. Brain Behav Immun<br />
22: 1248-56, 2008<br />
3. Milligan ED, Watkins LR. Pathological <strong>and</strong> protective roles <strong>of</strong> glia in<br />
chronic <strong>pain</strong>. Nature Rev Neurosci 10: 23-36, 2009.<br />
14<br />
2009 SPRING MEETING • FACULTY OF PAIN MEDICINE, ANZCA • ACUTE PAIN SPECIAL INTEREST GROUP OF ANZCA, ASA AND NZSA
Novel Approaches to Cancer Pain<br />
Pr<strong>of</strong>essor Julia Fleming<br />
Royal Brisbane Hospital, QLD<br />
Not available at time <strong>of</strong> printing<br />
Spinal Cord Magic Bullets –<br />
Current <strong>and</strong> Future Analgesic Developments<br />
Pr<strong>of</strong>essor Colin Goodchild<br />
Monash University, VIC<br />
The holy grail <strong>of</strong> modern <strong>medicine</strong> is to find treatments<br />
that eradicate disease <strong>with</strong> no other effect on the host.<br />
Paul Ehrlich used the expression ‘magic bullet’ for the<br />
first time in 1908 in his Harben Lectures 1 . Ehrlich’s first<br />
magic bullet was Salvarsan, discovered in 1909, which<br />
provided the first cure for syphilis. The rational approach<br />
to modern therapeutics h<strong>and</strong>ed down by Ehrlich is<br />
first to identify a disease-specific target <strong>and</strong> then find a<br />
therapy selective for that compared <strong>with</strong> the rest <strong>of</strong> the<br />
host organism. This is not easy in <strong>pain</strong> <strong>medicine</strong>.<br />
The first target hailed as the ‘<strong>pain</strong> transmitter’ was<br />
Substance P 2,3 . This compound fulfilled the Dale criteria<br />
in being present at the correct site (C fibres), released<br />
physiologically during nociception, <strong>and</strong> exogenous<br />
Substance P caused <strong>pain</strong> behaviours in animals when<br />
administered intrathecally. A target was identified<br />
(NK1 receptors) <strong>and</strong> highly selective magic bullets were<br />
synthesised. Glutamate acting at NMDA receptors <strong>and</strong><br />
subsequent NMDA antagonist development followed<br />
the same pattern 4 . NK1 <strong>and</strong> NMDA antagonists showed<br />
efficacy in animal <strong>pain</strong> models but were abysmal failures<br />
in the treatment <strong>of</strong> human clinical <strong>pain</strong> states. This<br />
was not the fault <strong>of</strong> the selectivity <strong>of</strong> the magic bullets<br />
but <strong>of</strong> our limited underst<strong>and</strong>ing <strong>of</strong> the physiology <strong>of</strong><br />
<strong>pain</strong>. Valuable lessons were learned <strong>with</strong> respect to<br />
proper careful use <strong>of</strong> animal models <strong>and</strong> an awareness<br />
<strong>of</strong> the complex nature <strong>of</strong> the nervous system. Pain<br />
perception is the result <strong>of</strong> a complex process <strong>of</strong> multiple<br />
parallel pathways <strong>with</strong> changing inter-relationships<br />
(plasticity). Receptor targets are rarely, if at all, confined<br />
to nociception <strong>and</strong> <strong>pain</strong>, so a magic bullet for one<br />
such target is likely to cause harm to the organism by<br />
interactions, albeit selective, <strong>with</strong> the same receptor<br />
involved <strong>with</strong> systems other than <strong>pain</strong> <strong>and</strong> nociception.<br />
A more sensible approach is to administer two or more<br />
such compounds interfering <strong>with</strong> complementary<br />
pathways involved <strong>with</strong> <strong>pain</strong> <strong>and</strong> nociception –<br />
multimodal analgesia.<br />
There are many current targets that are the focus for<br />
drug development because they have been identified as<br />
being involved <strong>with</strong> peripheral nerves <strong>and</strong> spinal cord<br />
h<strong>and</strong>ling <strong>of</strong> nociceptive information. These include<br />
lig<strong>and</strong>-gated receptors, transporter mechanisms <strong>and</strong><br />
voltage-gated calcium, potassium <strong>and</strong> sodium channels.<br />
Examples <strong>of</strong> some <strong>of</strong> these will be discussed. It remains<br />
to be seen which <strong>of</strong> the systems will lead to a true magic<br />
bullet unimodal therapy, <strong>and</strong> which will be useful as part<br />
<strong>of</strong> a multimodal approach.<br />
REFERENCES<br />
1. Royal Institute <strong>of</strong> Public Health (London: Lewis, 1908). Experimental<br />
Researches on Specific Therapy. On Immunity <strong>with</strong> special Reference<br />
to the Relationship between Distribution <strong>and</strong> Action <strong>of</strong> Antigens. 107<br />
2. Brain peptides: is substance P a transmitter <strong>of</strong> <strong>pain</strong> signals? Marx JL.<br />
Science. 1979, 205(4409):886-9.<br />
3. Pharmacology <strong>of</strong> <strong>pain</strong> <strong>and</strong> analgesia. Wilson PR, Yaksh TL.<br />
Anaesth Intensive Care. 1980 (3):248-56<br />
4. Spinal pharmacology <strong>of</strong> thermal hyperesthesia induced by constriction<br />
injury <strong>of</strong> sciatic nerve. Excitatory amino acid antagonists.Yamamoto T,<br />
Yaksh TL. Pain. 1992 Apr;49(1):121-8.<br />
15
Opioids in Dyspnoea <strong>and</strong> Sleep<br />
Apnoea<br />
Assoc Pr<strong>of</strong>essor Christine McDonald<br />
Austin Health, VIC<br />
Breathlessness is a common symptom in patients <strong>with</strong><br />
a variety <strong>of</strong> advanced diseases. Opioids are frequently<br />
used to treat severe breathlessness <strong>and</strong> the efficacy <strong>of</strong><br />
both oral <strong>and</strong> parenteral opioids has been confirmed 1 .<br />
Chronic obstructive pulmonary disease guidelines<br />
support the use <strong>of</strong> opioids in treating intractable<br />
breathlessness if disease specific therapy has been<br />
maximised but their use is limited, probably because<br />
<strong>of</strong> concerns about respiratory depression, hypercapnia<br />
<strong>and</strong> other adverse effects. Opioids are an effective tool<br />
in the management <strong>of</strong> severe, acute <strong>pain</strong> <strong>and</strong> <strong>pain</strong><br />
associated <strong>with</strong> malignancy. They have also become<br />
increasingly used long-term for treating patients <strong>with</strong><br />
chronic non-malignant <strong>pain</strong>. Although the potential for<br />
adverse respiratory effects is well-known, there are only<br />
relatively few studies examining sleep <strong>and</strong> breathing in<br />
patients receiving long-term opioid therapy. Methadone<br />
administration has been demonstrated to increase the<br />
risk for both obstructive <strong>and</strong> central sleep apnoea in<br />
patients receiving methadone either for chronic <strong>pain</strong><br />
or as part <strong>of</strong> management for drug dependency. In a<br />
cohort <strong>of</strong> such patients receiving methadone through<br />
a maintenance program the presence <strong>of</strong> central sleep<br />
apnoea did not correlate <strong>with</strong> symptoms <strong>of</strong> excessive<br />
daytime somnolence 2 . Prospective studies before <strong>and</strong><br />
after chronic opioid administration are needed to allow<br />
definitive conclusions to be drawn about the aetiological<br />
relationship between opioids <strong>and</strong> sleep apnoea 3 . It is<br />
estimated that a large proportion <strong>of</strong> people <strong>with</strong> sleep<br />
disordered breathing remain undiagnosed. Patients<br />
<strong>with</strong> undiagnosed obstructive sleep may be at risk <strong>of</strong><br />
increased perioperative complications. The perioperative<br />
risk <strong>of</strong> patients <strong>with</strong> obstructive sleep apnoea may be<br />
reduced by appropriate screening to detect undiagnosed<br />
obstructive sleep apnoea.<br />
REFERENCES<br />
1. Jennings Al, Davies AN, Higgins JP, et al. (2002). A systematic review<br />
<strong>of</strong> the use <strong>of</strong> opioids in the management <strong>of</strong> dyspnoea.<br />
Thorax 57, 939-44<br />
2. Wang D, Teichtahl H, Goodman C et al. (2008)<br />
J Clin Sleep Med 15, 557-62<br />
3. Walker JM, Farney RJ. (2009) Are opioids associated <strong>with</strong> sleep apnea?<br />
A review <strong>of</strong> the evidence. Curr Pain Headache Rep13,120-126<br />
Contemporary Approaches to<br />
Opioid Addiction<br />
Pr<strong>of</strong>essor Jon Currie<br />
St Vincent’s Hospital, VIC<br />
Dramatic advances in the neurosciences over the past<br />
two decades have revolutionised our underst<strong>and</strong>ing <strong>of</strong><br />
drug abuse <strong>and</strong> addiction, <strong>with</strong> clear evidence emerging<br />
that drug addiction is a chronic relapsing brain disease.<br />
However, as Alan Leshner, former Director <strong>of</strong> the<br />
National Institute on Drug Abuse, wrote in a seminal<br />
article entitled ‘Addiction is a Brain Disease – <strong>and</strong> it<br />
Matters!’ (Science 1997; 278:45-47), despite this scientific<br />
knowledge, the concept <strong>of</strong> addiction as a chronic<br />
relapsing brain disease remains totally new for most <strong>of</strong><br />
the general public, for many policy makers <strong>and</strong> sadly, for<br />
many health care pr<strong>of</strong>essionals as well. Unfortunately<br />
little has changed in the subsequent 12 years.<br />
This presentation will explore some <strong>of</strong> the implications<br />
<strong>and</strong> opportunities that the neurobiological revolution<br />
now provides for the modern treatment <strong>and</strong> prevention<br />
<strong>of</strong> drug addiction in general, <strong>and</strong> for opioid dependence<br />
in particular.<br />
16<br />
2009 SPRING MEETING • FACULTY OF PAIN MEDICINE, ANZCA • ACUTE PAIN SPECIAL INTEREST GROUP OF ANZCA, ASA AND NZSA
Methadone Pharmacology<br />
Dr Andrew A. Somogyi<br />
University <strong>of</strong> Adelaide, SA<br />
INTRODUCTION<br />
Developed over 60 years ago, the use <strong>of</strong> methadone<br />
for severe persistent <strong>pain</strong> has steadily increased over<br />
the past 10 years. However it remains a difficult opioid<br />
to use because <strong>of</strong> concerns regarding toxicity due to<br />
excessive accumulation, cardiac rhythm disturbances<br />
<strong>and</strong> the diversity in reported dosage conversion ratios.<br />
BASIC PHARMACOLOGY<br />
Methadone is administered as a racemic mixture <strong>of</strong><br />
2 enantiomers, the opioid-active R-methadone which<br />
has a much higher affinity for the mu opioid receptor<br />
than the ‘inactive’ S-methadone. Although methadone<br />
does not bind to the other opioid receptors, it does<br />
have very weak serotonin reuptake transporter blocking<br />
effects <strong>and</strong> is a noncompetitive NMDA antagonist;<br />
the clinical effects <strong>of</strong> such antagonism, if they occur<br />
at all, are unlikely to be important. Both enantiomers<br />
have immune suppressant <strong>and</strong> pro-inflammatory glial<br />
activation effects through TLR4 signaling activation <strong>and</strong>,<br />
prolong the QT interval by binding to the cardiac<br />
hERG potassium channel; in both cases, S-methadone<br />
is more active than R-methadone.<br />
CLINICAL PHARMACOLOGY<br />
Methadone has a high oral bioavailability <strong>and</strong><br />
is mainly eliminated by metabolism via CYP3A4<br />
(nonstereoselective <strong>and</strong> subject to environmental<br />
influences) <strong>and</strong> CYP2B6 (stereoselective <strong>and</strong> subject<br />
also to genetic influences). Uptake into the brain is<br />
opposed by the efflux transporter p-glycoprotein which<br />
is influenced by genetic <strong>and</strong> environmental factors.<br />
Methadone has the longest half life <strong>of</strong> all the opioids,<br />
typically ranging from 15 to 90 hours <strong>with</strong> R-methadone<br />
being 60% longer than the S-enantiomer. A 6-fold<br />
difference in half life between patients results in a<br />
6-fold difference in accumulation on chronic dosing.<br />
In addition, it also means that steady-state for the<br />
opioid active R-methadone is not reached until about<br />
10 days <strong>and</strong>, the long half life calls into question<br />
dosing more frequently than twice daily. Its very steep<br />
dose- <strong>and</strong> plasma concentration–response relationship<br />
necessitates that monitoring is required in the two<br />
weeks following initiation <strong>of</strong> dosing to avoid <strong>and</strong><br />
attend to any excessive accumulation as evidenced by<br />
sedation-respiratory depression. The cardiac effects <strong>of</strong><br />
methadone have been somewhat over emphasized as<br />
long as dosage rates are kept to the minimum required<br />
for <strong>pain</strong> relief (usually < 50 mg/day) <strong>and</strong> the patient does<br />
not have any clinical or genetic factors that predispose<br />
to torsades de pointes. Many drugs may inhibit the<br />
metabolism <strong>of</strong> methadone mainly via CYP3A4 inhibition<br />
leading to toxicity <strong>and</strong> specific drug metabolism<br />
inducers may cause reduced analgesia. Since it has<br />
no active metabolites, methadone has advantages<br />
over some other opioids especially for the patient <strong>with</strong><br />
renal impairment. The clinical effects <strong>of</strong> genetic factors<br />
in the metabolism (CYP2B6), brain efflux transport<br />
(ABCB1) <strong>and</strong> mu opioid receptor (OPRM1) binding <strong>of</strong><br />
methadone are unclear but may be important in certain<br />
individuals. Whereas the single dose analgesia potency<br />
ratio <strong>of</strong> methadone to morphine IV is about unity, on<br />
chronic oral dosing the ratio is about 10 due to greater<br />
accumulation <strong>and</strong> incomplete cross tolerance.<br />
CONCLUSION<br />
Methadone is now regarded as an important <strong>and</strong><br />
inexpensive back-up opioid for severe persistent <strong>pain</strong><br />
especially that due to malignancies. Dosing guidelines<br />
have been promulgated to allow for supposedly “easier”<br />
transition from morphine <strong>and</strong> other commonly used<br />
opioids to oral methadone. An underst<strong>and</strong>ing <strong>of</strong><br />
methadone’s ‘different’ pharmacological properties<br />
together <strong>with</strong> clinical <strong>and</strong> genetic factors that might<br />
contribute to toxicity should allow for greater confidence<br />
by <strong>pain</strong> physicians in adding methadone to their<br />
pharmaceutical armamentarium.<br />
REFERENCES<br />
1. Auret K et al. Pharmacokinetics <strong>and</strong> pharmacodynamics <strong>of</strong> methadone<br />
enantiomers in hospice patients <strong>with</strong> cancer <strong>pain</strong>. Ther Drug Monit 28:<br />
359-66, 2006<br />
2. Coller JK, Christrup LL, Somogyi AA. Role <strong>of</strong> active metabolites in the<br />
use <strong>of</strong> opioids. Eur J Clin Pharmacol 65: 121-39, 2009<br />
3. Eap CB et al. Stereoselective block <strong>of</strong> hERG channel by (S)-methadone<br />
<strong>and</strong> QT interval prolongation in CYP2B6 slow metabolisers.<br />
Clin Pharmacol Ther 81: 719-28, 2007<br />
4. Leppert W. The role <strong>of</strong> methadone in cancer <strong>pain</strong> treatment – a review.<br />
Int J Clin Prac 63: 1095-1109, 2009<br />
17
Methadone Re-visited in<br />
Cancer Pain<br />
Assoc Pr<strong>of</strong>essor Kate Jackson<br />
Southern Health <strong>and</strong> Monash University, VIC<br />
INTRODUCTION<br />
Methadone has been around for more than 50 years,<br />
but until recently, in Australia <strong>and</strong> many other countries,<br />
it has been stigmatised by both the medical pr<strong>of</strong>ession<br />
<strong>and</strong> the lay public as ‘the heroin addicts drug’. However<br />
due to a number <strong>of</strong> significant differences to other<br />
opioids its use is being revisited for both cancer <strong>and</strong><br />
non cancer <strong>pain</strong>. 1 This has been bolstered by the better<br />
underst<strong>and</strong>ing <strong>of</strong> methadone’s pharmacokinetics, <strong>and</strong><br />
the development <strong>of</strong> a number <strong>of</strong> newer <strong>and</strong> perceived<br />
safer dosing guidelines.<br />
We elected to audit McCulloch House’s (a level III<br />
inpatient hospice unit) methadone conversions for 2<br />
years using the Royal Perth Hospital’s protocol. 2 This<br />
protocol acknowledges the apparent paradox whereby<br />
the equi-analgesic dose <strong>of</strong> methadone is much lower<br />
in patients currently on high doses <strong>of</strong> morphine or<br />
other opioids.<br />
AIMS<br />
To prospectively audit all conversions over a<br />
2 year period 2005/2006, from another opioid to<br />
methadone for:<br />
• Indication for conversion<br />
• Efficacy <strong>and</strong> safety <strong>of</strong> the RPH conversion protocol<br />
• Pain control outcome<br />
• Retrospective cost comparison.<br />
METHODS<br />
All conversions were converted during an inpatient<br />
admission <strong>and</strong> used the RPH conversion protocol. 2<br />
This involves the calculation <strong>of</strong> the predicted daily<br />
methadone dose by determining the approximate daily<br />
oral morphine dose equivalent <strong>and</strong> using a conversion<br />
ratio in the table below:<br />
Daily Oral Morphine<br />
< 100 mg 3:1<br />
101 – 300 mg 5:1<br />
301 – 600 mg 10:1<br />
601 – 800 mg 12:1<br />
801 – 1000 mg 15:1<br />
RESULTS<br />
• From January 2005 to November 2006 24 pts <strong>of</strong> which<br />
23/24 had cancer related <strong>pain</strong>.<br />
• Age 40-78 yrs: mean 56, median 61.<br />
• Major <strong>pain</strong> mechanism/s:<br />
– Neuropathic + incident (vertebral mets) - 17<br />
– Neuropathic - 6<br />
– Digital Ischaemia (<strong>and</strong> renal failure) - 1<br />
• Indications:<br />
– Step down after response to “burst” ketamine in<br />
patients <strong>with</strong> refractory cancer <strong>pain</strong> 3 -15<br />
– Opioid rotation ie. for inefficacy (poor <strong>pain</strong> control) - 6<br />
– Opioid substitution ie. for opioid adverse effects - 3<br />
• Prior opioid – a wide range <strong>of</strong> different opioids/<br />
formulations at relatively high doses (converted to oral<br />
morphine equivalents):<br />
– Range 150–1320 mg/24 hrs: mean 540mg/24 hrs,<br />
median 360mg/24 hrs<br />
CONCLUSIONS<br />
• Apparent support for the use <strong>of</strong> methadone:<br />
– For neuropathic <strong>and</strong> incident <strong>pain</strong><br />
– As a step down from “burst” ketamine<br />
• Support for the RPH conversion protocol<br />
• Methadone demonstrated a significant cost advantage<br />
REFERENCES<br />
1. Bruera E <strong>and</strong> Sweeney C, Methadone Use in Cancer Patients <strong>with</strong> Pain:<br />
A review. Journal <strong>of</strong> Palliative Medicine 2002; 5(1): 127-138.<br />
2. Ayonrinde OT, Bridge TD. The rediscovery <strong>of</strong> methadone for cancer<br />
<strong>pain</strong> management. MJA 2000: 173; 536-540.<br />
3. Jackson K, Ashby M, Martin P, Pisasale M, Brumley D <strong>and</strong> Hayes B.<br />
‘Burst’ ketamine for refractory cancer <strong>pain</strong>: An open-label audit <strong>of</strong> 39<br />
patients. JPSM 2001; 22(4): 834-842.<br />
OUTCOMES<br />
• 22/24 good <strong>pain</strong> control.<br />
• 2 pts adequate analgesia not attained:<br />
– Further RT <strong>and</strong> lignocaine CSCI<br />
– Spinal decompression <strong>and</strong> internal fixation<br />
• Minimal Adverse Effects:<br />
– 2 pts drowsy <strong>and</strong> methadone reduced<br />
• 5 pts methadone increased after 3/7 due to inadequate<br />
analgesia<br />
• 3 pts repeated “burst” ketamine on subsequent<br />
admissions <strong>with</strong> 1 pt 3 “bursts” over 8/12<br />
19
Methadone in Chronic Pain<br />
Dr Tobie Sacks<br />
St Vincent’s Hospital, VIC<br />
Methadone is a synthetic opioid <strong>with</strong> potent analgesic<br />
effects. Although commonly associated <strong>with</strong> the<br />
treatment <strong>of</strong> opioid addiction, it is, as a result <strong>of</strong> its<br />
unique pharmacokinetics <strong>and</strong> pharmacodynamics,<br />
a valuable option in the treatment <strong>of</strong> Chronic Nonmalignant<br />
Pain:<br />
A highly lipophilic molecule <strong>with</strong> >80% bioavailability,<br />
it is rapidly absorbed from the stomach <strong>and</strong> distributed<br />
to the liver <strong>and</strong> other tissues that then act as a natural<br />
peripheral reservoir. Consequently, its extended<br />
elimination half-life, while variable between patients,<br />
generally provides stable analgesia <strong>with</strong> daily or twice<br />
daily dosing – reducing the salience <strong>of</strong> drug use.<br />
Methadone is a mu-opioid agonist <strong>with</strong> receptor<br />
affinity similar to morphine but, <strong>with</strong> repeated dosing,<br />
its efficacy is greater than that <strong>of</strong> morphine. It is also<br />
a NMDA receptor antagonist, potentially decreasing<br />
tolerance <strong>and</strong> craving for opioids <strong>and</strong> modulating<br />
the development <strong>of</strong> central sensitization. Although<br />
methadone also inhibits reuptake <strong>of</strong> monoamines<br />
(e.g., serotonin, noradrenaline), potentially augmenting<br />
the effects <strong>of</strong> antidepressants, its weak euphorigenic<br />
effects reduce the risk <strong>of</strong> it being abused<br />
Other potential benefits include low cost – <strong>and</strong> <strong>with</strong><br />
regard to risk <strong>of</strong> diversion into the blackmarket, low<br />
street value compared to other prescribed opioids.<br />
Methadone does, however, have a number <strong>of</strong><br />
disadvantages: Like other opioids, it is <strong>of</strong>ten associated<br />
<strong>with</strong> constipation <strong>and</strong> other GI symptoms, <strong>and</strong> in high<br />
doses, sleep-disordered breathing <strong>and</strong> arrhythmias.<br />
Its interactions <strong>with</strong> other medications, particularly<br />
benzodiazepines <strong>and</strong> antidepressant drugs, initiation<br />
<strong>and</strong> maintenance dosage regimens will also be<br />
discussed.<br />
20<br />
2009 SPRING MEETING • FACULTY OF PAIN MEDICINE, ANZCA • ACUTE PAIN SPECIAL INTEREST GROUP OF ANZCA, ASA AND NZSA
Managing Placebo<br />
<strong>and</strong> Nocebo Effects –<br />
Mechanisms <strong>and</strong><br />
Implications for Clinical Practice<br />
Mr Damien Finniss<br />
University <strong>of</strong> Sydney, NSW<br />
The placebo effect is a term that has been widely used<br />
in health literature <strong>and</strong> its nature has been the focus <strong>of</strong><br />
increasing research in recent years. A key conclusion<br />
<strong>of</strong> recent research is that there is not one placebo<br />
effect, but many, <strong>and</strong> that these effects are mediated by<br />
different psychological <strong>and</strong> neurobiological mechanisms.<br />
Less research has been devoted to the nocebo effect,<br />
a phenomenon that is opposite to the placebo effect,<br />
<strong>and</strong> despite the limited amount <strong>of</strong> research, several<br />
important mechanisms <strong>of</strong> nocebo effects have been<br />
identified.<br />
In the case <strong>of</strong> placebo analgesia, several effects<br />
have been identified <strong>and</strong> it is argued that by better<br />
underst<strong>and</strong>ing how they work, it might be possible for<br />
clinicians to ethically augment treatment effects, even<br />
when a placebo is not given. Several effects have also<br />
been identified in the case <strong>of</strong> nocebo hyperalgesia, <strong>and</strong><br />
a better underst<strong>and</strong>ing <strong>of</strong> these effects may lead to<br />
managing them in routine care.<br />
This presentation will review placebo effects <strong>and</strong> nocebo<br />
effects at a conceptual level <strong>with</strong> a view to promoting a<br />
reconceptualisation <strong>of</strong> these phenomenons. A synthesis<br />
<strong>of</strong> the mechanistic literature will be provided both from<br />
psychological <strong>and</strong> neurobiological viewpoints. The<br />
implications for clinical practice will be presented based<br />
on analysis <strong>of</strong> mechanistic trials, clinical trials <strong>and</strong> review<br />
papers <strong>with</strong> a view to presenting some conclusions<br />
on how these effects may be managed to improve<br />
clinical care.<br />
references<br />
1. Benedetti, F., M. Lanotte, et al. (2007). “When words are <strong>pain</strong>ful:<br />
unravelling the mechanisms <strong>of</strong> the nocebo effect.” Neuroscience<br />
147(2): 260-71.<br />
2. Finniss, D. G. <strong>and</strong> F. Benedetti (2005). “Mechanisms <strong>of</strong> the placebo<br />
response <strong>and</strong> their impact on clinical trials <strong>and</strong> clinical practice.”<br />
Pain 114: 3-6.<br />
3. Kaptchuk, T. J., W. B. Stason, et al. (2006). “Sham device v inert pill:<br />
r<strong>and</strong>omised controlled trial <strong>of</strong> two placebo treatments.”<br />
BMJ 332(7538): 391-7.<br />
4. Kaptchuk, T. J., J. M. Kelley, et al. (2008). “Components <strong>of</strong> placebo<br />
effect: r<strong>and</strong>omised controlled trial in patients <strong>with</strong> irritable bowel<br />
syndrome.” BMJ 336(7651): 999-1003.<br />
5. Price, D. D., D. G. Finniss, et al. (2008). “A comprehensive review<br />
<strong>of</strong> the placebo effect: recent advances <strong>and</strong> current thought.”<br />
Annual Review <strong>of</strong> Psychology 59: 565-90.<br />
21
Pain <strong>and</strong> Addiction –<br />
Treatment Strategies<br />
Dr Roman D. Jovey<br />
Credit Valley Hospital, Ontario, Canada <strong>and</strong><br />
CPM Centres for Pain Management, Mississauga, Ontario, Canada<br />
EDUCATIONAL OBJECTIVES<br />
1. Review the prevalence <strong>of</strong> chronic <strong>pain</strong> in patients <strong>with</strong><br />
addiction <strong>and</strong> the prevalence <strong>of</strong> addiction in patients<br />
<strong>with</strong> chronic <strong>pain</strong><br />
2. Operationalize <strong>and</strong> illustrate the concepts <strong>of</strong> Universal<br />
Precautions in the management <strong>of</strong> high risk patients<br />
<strong>with</strong> <strong>pain</strong><br />
3. Describe an approach to managing acute <strong>pain</strong> in the<br />
patient on Opioid Agonist Treatment (OAT) for addiction<br />
SUMMARY<br />
The needs <strong>of</strong> patients <strong>with</strong> both <strong>pain</strong> <strong>and</strong> addiction are<br />
not well served in most countries. Pain clinicians are<br />
reluctant to prescribe opioids to high risk patients due<br />
to concerns regarding misuse <strong>and</strong> diversion. Addiction<br />
pr<strong>of</strong>essionals are reluctant to manage <strong>pain</strong> due to<br />
regulatory limitations <strong>and</strong> lack <strong>of</strong> knowledge. There is a<br />
growing need for <strong>pain</strong> clinicians to underst<strong>and</strong> essential<br />
prinicples <strong>of</strong> addiction <strong>medicine</strong> – much as there is a<br />
need for addiction specialists to underst<strong>and</strong> something<br />
about <strong>pain</strong> <strong>medicine</strong>.<br />
It is important to properly use the labels ‘misuse’,<br />
‘abuse,’ ‘tolerance,’ ‘dependence,’ <strong>and</strong> ‘addiction’ when<br />
referring to patients <strong>with</strong> <strong>pain</strong> on opioids. Some patients<br />
are mislabelled <strong>and</strong> referred to detox facilities or OAT<br />
programs when they are simply physically dependent<br />
on opioid analgesics. In some regions, the only place<br />
that patients can access opioid therapy for <strong>pain</strong> is in<br />
an OAT program. Some patients in <strong>pain</strong> programs are<br />
benefitting from opioids but have difficulty managing<br />
their dosage due to inadequate <strong>pain</strong> relief or tolerance<br />
development.<br />
The concept <strong>of</strong> ‘Universal Precautions’ presents a<br />
st<strong>and</strong>ardized approach to assessment <strong>and</strong> treatment in<br />
order to optimize benefits <strong>and</strong> reduce risks, but may be<br />
difficult to implement due to limited local availability <strong>of</strong><br />
multi-modal treatment resources. Some clinicians have<br />
successfully demonstrated these principles in novel<br />
approaches to managing patients <strong>with</strong> aberrant drugrelated<br />
behaviours.<br />
Brief screening tools for risk stratification have<br />
been published but have limited evidence due to<br />
methodological limitations <strong>of</strong> the research. Written<br />
opioid prescribing agreements are universally<br />
recommended but not all clinicians agree <strong>with</strong> their use<br />
<strong>and</strong> most published examples are written in language<br />
that is too high a reading level for a number <strong>of</strong> patients.<br />
Likewise, periodic urine drug testing is recommended as<br />
a monitoring technique, but urine is not the ideal testing<br />
substance due to technical lab issues <strong>and</strong> the increased<br />
susceptibility to tampering.<br />
Patients on OAT for addiction will periodically develop<br />
acutely <strong>pain</strong>ful conditions which require treatment.<br />
Undertreated acute <strong>pain</strong> is a stressor which can trigger<br />
a return to substance misuse behaviour. On the other<br />
h<strong>and</strong>, patients in good recovery from addiction may<br />
be fearful <strong>of</strong> exposure to opioids for <strong>pain</strong>. A careful<br />
approach to assessment <strong>and</strong> treatment along <strong>with</strong> good<br />
communication can provide humane treatment for <strong>pain</strong><br />
along <strong>with</strong> reduced risk for relapse.<br />
By incorporating fundamental concepts from addiction<br />
<strong>medicine</strong> into a structured approach to patient<br />
assessment <strong>and</strong> treatment, the clinician can optimize<br />
the benefits <strong>and</strong> reduce the risks <strong>of</strong> chronic <strong>pain</strong><br />
management, even in high risk individuals.<br />
22<br />
2009 SPRING MEETING • FACULTY OF PAIN MEDICINE, ANZCA • ACUTE PAIN SPECIAL INTEREST GROUP OF ANZCA, ASA AND NZSA
REFERENCES<br />
1. Arnold RM, Han PK, Seltzer D. Opioid contracts in chronic<br />
nonmalignant <strong>pain</strong> management: objectives <strong>and</strong> uncertainties. Am J<br />
Med. 2006 Apr;119(4):292-6.<br />
2. Blinderman CD, Sekine R, Zhang B, Nillson M, Shaiova L. Methadone<br />
as an analgesic for patients <strong>with</strong> chronic <strong>pain</strong> in methadone<br />
maintenance treatment programs (MMTPs). J Opioid Manag. 2009<br />
Mar-Apr;5(2):107-14.<br />
3. Chou R, Fanciullo GJ, Fine PG, Miaskowski C, Passik SD, Portenoy<br />
RK. Opioids for chronic noncancer <strong>pain</strong>: prediction <strong>and</strong> identification<br />
<strong>of</strong> aberrant drug-related behaviors: a review <strong>of</strong> the evidence for an<br />
American Pain Society <strong>and</strong> American Academy <strong>of</strong> Pain Medicine<br />
clinical practice guideline. J Pain. 2009 Feb;10(2):131-46. Review.<br />
4. Gourlay DL, Heit HA, Almahrezi A. Universal precautions in <strong>pain</strong><br />
<strong>medicine</strong>: a rational approach to the treatment <strong>of</strong> chronic <strong>pain</strong>.<br />
Pain Med 2005;6:107-112.<br />
5. Jovey RD. Managing acute <strong>pain</strong> in the opioid-dependent patient.<br />
Proceedings <strong>of</strong> the 11th World Congress on Pain, edited by Herta Flor,<br />
Eija Kalso, <strong>and</strong> Jonathan O. Dostrovsy, IASP Press, Seattle, 2006<br />
6. Meghani SH, Wiedemer NL, Becker WC, Gracely EJ, Gallagher RM.<br />
Predictors <strong>of</strong> Resolution <strong>of</strong> Aberrant Drug Behavior in Chronic Pain<br />
Patients Treated in a Structured Opioid Risk Management Program.<br />
Pain Med. 2009 Jun 11. [Epub ahead <strong>of</strong> print]<br />
7. Manchikanti L, Atluri S, Trescot AM, Giordano J. Monitoring opioid<br />
adherence in chronic <strong>pain</strong> patients: tools, techniques, <strong>and</strong> utility. Pain<br />
Physician. 2008 Mar;11(2 Suppl):S155-80.<br />
8. Nafziger AN, Bertino JS Jr. Utility <strong>and</strong> application <strong>of</strong> urine drug<br />
testing in chronic <strong>pain</strong> management <strong>with</strong> opioids. Clin J Pain. 2009<br />
Jan;25(1):73-9.<br />
9. Passik SD. Issues in long-term opioid therapy: unmet needs, risks, <strong>and</strong><br />
solutions. Mayo Clin Proc. 2009 Jul;84(7):593-601.<br />
10. Rosenblum A, Joseph H, Fong C, Kipnis S, Clel<strong>and</strong> C, Portenoy RK.<br />
Prevalence <strong>and</strong> characteristics <strong>of</strong> chronic <strong>pain</strong> among chemically<br />
dependent patients in methadone maintenance <strong>and</strong> residential<br />
treatment facilities. JAMA. 2003 May 14;289(18):2370-8.<br />
11. Roskos SE, Keenum AJ, <strong>New</strong>man LM, Wallace LS. Literacy dem<strong>and</strong>s<br />
<strong>and</strong> formatting characteristics <strong>of</strong> opioid contracts in chronic<br />
nonmalignant <strong>pain</strong> management. J Pain. 2007 Oct;8(10):753-8.<br />
12. Savage SR, Joranson DE, Covington EC, Schnoll SH, Heit HA, Gilson<br />
AM. Definitions related to the medical use <strong>of</strong> opioids: evolution<br />
towards universal agreement.<br />
J Pain Symptom Manage. 2003 Jul;26(1):655-67.<br />
13. Savage SR, Kirsh KL, Passik SD. Challenges in using opioids to treat<br />
<strong>pain</strong> in persons <strong>with</strong> substance use disorders. Addict Sci Clin Pract<br />
June 2008 pp 4-25.<br />
14. Wallace LS, Keenum AJ, Roskos SE, McDaniel KS. Development <strong>and</strong><br />
validation <strong>of</strong> a low-literacy opioid contract. J Pain. 2007 Oct;8(10):759-<br />
66. Epub 2007 Jun 13.<br />
15. Wiedemer NL, Harden PS, Arndt IO, Gallagher RM. The opioid<br />
renewal clinic: a primary care, managed approach to opioid therapy<br />
in chronic <strong>pain</strong> patients at risk for substance abuse. Pain Med. 2007<br />
Oct-Nov;8(7):573-84.<br />
23
Predictors <strong>of</strong> Persistent Pain<br />
after Trauma<br />
Dr Alex Holmes<br />
Royal Melbourne Hospital, VIC<br />
The emergence <strong>of</strong> persistent <strong>pain</strong> after serious injury<br />
provides an opportunity for the triage <strong>of</strong> high risk<br />
patients to early intervention programs in order to<br />
improve long term outcomes. In order for triage to<br />
occur, a method is required for identifying high risk<br />
patients using measures available at or around the time<br />
<strong>of</strong> injury. To date, although range possible risk factors<br />
for persistent <strong>pain</strong> have been identified, no prospective<br />
studies have tested these factors concurrently. In order<br />
to determine the degree to which persistent <strong>pain</strong> can<br />
be predicted at the time <strong>of</strong> injury <strong>and</strong> to identify the<br />
individual risk factors a 12 month prospective cohort<br />
study <strong>of</strong> patients following serious injury was conducted.<br />
METHOD<br />
The study recruited patients admitted to RMH <strong>and</strong> Alfred<br />
Hospitals <strong>with</strong> injury between Oct 2006 <strong>and</strong> March<br />
2008. Eligible patients underwent a comprehensive<br />
physical <strong>and</strong> psychological assessment <strong>and</strong> were<br />
followed up at 3 <strong>and</strong> 12 months.<br />
RESULTS<br />
Two hundred ninety patients were recruited <strong>and</strong> 233<br />
patients followed up at twelve months. At 12 months<br />
the majority <strong>of</strong> patients (71.2%) reported some <strong>pain</strong>,<br />
<strong>and</strong> 14.6% reported moderate or severe <strong>pain</strong>. Five<br />
independent factors predicted the presence <strong>of</strong> moderate<br />
or severe <strong>pain</strong> at 12 months:<br />
• Not working at time <strong>of</strong> injury<br />
• Pain at initial assessment<br />
• Injury severity - AIS total<br />
• Initial <strong>pain</strong> control cognitions<br />
• Compensable injury.<br />
These factors combined to be able to predict <strong>of</strong> most<br />
(80%) <strong>of</strong> patients <strong>with</strong> moderate or severe <strong>pain</strong> <strong>with</strong><br />
a specificity <strong>of</strong> 70%.<br />
CONCLUSIONS<br />
Injury leading to admission to a trauma hospital is<br />
associated <strong>with</strong> significant <strong>pain</strong> at 12 months. The<br />
presence <strong>of</strong> moderate or severe <strong>pain</strong> at 12 months can<br />
be predicated by 5 factors. The application <strong>of</strong> these<br />
factors allows for the division <strong>of</strong> injured patients into<br />
a low risk group <strong>and</strong> a high risk groups. A third <strong>of</strong> the<br />
high risk group will go on to develop persistent <strong>pain</strong>.<br />
The identification <strong>of</strong> a high risk group provides the<br />
opportunity <strong>of</strong> targeted early intervention to reduce<br />
chronic <strong>pain</strong>.<br />
24<br />
2009 SPRING MEETING • FACULTY OF PAIN MEDICINE, ANZCA • ACUTE PAIN SPECIAL INTEREST GROUP OF ANZCA, ASA AND NZSA
Procedural Pain Analgesia<br />
Dr Joel Symons<br />
Alfred Hospital, VIC<br />
INTRODUCTION<br />
Procedural <strong>pain</strong> may be difficult to manage, especially<br />
in burns patients where there is a period <strong>of</strong> an<br />
intensely <strong>pain</strong>ful stimulus over <strong>and</strong> above the patient’s<br />
background <strong>pain</strong>. This period may also continue into<br />
the post-procedure period. Adequate <strong>and</strong> effective<br />
management <strong>of</strong> analgesia in this period is essential in<br />
order to prevent wind up <strong>and</strong> the psychological stress<br />
that may accompany poorly managed analgesia.<br />
SCOPE OF PRESENTATION<br />
This presentation will focus mainly on the treatment<br />
<strong>of</strong> procedural <strong>pain</strong> related to burns patients. Most <strong>of</strong> the<br />
content will deal <strong>with</strong> our experience from managing<br />
burns patients from the Black Saturday fires in<br />
February 2009.<br />
Procedural <strong>pain</strong> is <strong>of</strong>ten undertreated <strong>with</strong> a large<br />
percentage <strong>of</strong> burns patients reporting severe <strong>pain</strong><br />
during the procedure 1 . Effective analgesia is required<br />
to facilitate burns dressings changes, staple removal,<br />
physiotherapy <strong>and</strong> occupational therapy as well as<br />
to reduce anxiety during the procedure. This should<br />
be achieved <strong>with</strong>out producing excessive respiratory<br />
depression. Analgesia should be administered by<br />
a practitioner who is skilled in dealing <strong>with</strong> the<br />
consequences which can occur (eg airway obstruction)<br />
after administration <strong>of</strong> these drugs.<br />
Analgesia should also cover the post procedure period.<br />
Maintaining continuity <strong>of</strong> a successful procedural<br />
analgesic plan amongst anaesthetists <strong>and</strong> nursing staff<br />
is essential.<br />
In our institution, analgesia for burns dressings changes<br />
is administered either by nursing staff (in ICU or<br />
on the burns ward), or by an anaesthetist when the<br />
analgesic requirement requires much larger doses<br />
<strong>of</strong> analgesics to be administered. When analgesia is<br />
administered by nursing staff, a prior analgesic plan is<br />
drawn up in consultation <strong>with</strong> the Acute Pain Service.<br />
Our <strong>pain</strong> service has well established protocols<br />
for management <strong>of</strong> procedural analgesia for burns<br />
patients. Patients are administered a loading dose <strong>of</strong><br />
intravenous morphine or oral oxycodone fifteen or<br />
thirty minutes respectively prior to the commencement<br />
<strong>of</strong> the procedure. This dose is based on the patient’s<br />
background analgesic requirements.<br />
During the procedure, intravenous opioid therapy<br />
administered by anaesthetic or nursing staff remains<br />
the mainstay <strong>of</strong> analgesia 2 . This is supplemented <strong>with</strong><br />
a ketamine/midazolam combination <strong>and</strong> prop<strong>of</strong>ol<br />
in order to minimize opioid requirements <strong>and</strong> to<br />
provide sedation 3 . When the abovementioned regime<br />
is suboptimal, we have found that an intravenous<br />
lignocaine infusion 4 commenced 1 hour prior to the<br />
procedure <strong>and</strong> continued for 4 hours post procedure<br />
has been effective despite a Cochrane review suggesting<br />
that more trials are required to determine the efficacy<br />
<strong>of</strong> this drug 5 <strong>and</strong> a recent trial possibly refuting its use<br />
for this purpose 6 .<br />
Breakthrough analgesia after the procedure is provided<br />
<strong>with</strong> morphine boluses <strong>and</strong> ketamine when required.<br />
Patients who have dressings changes as outpatients<br />
are <strong>of</strong>ten administered inhaled Penthrane (Penthrox ® )<br />
by nursing staff.<br />
The evidence for the use <strong>of</strong> the above agents as<br />
well as alternative methods <strong>of</strong> administration (PCA,<br />
intranasal, topical routes), will be reviewed. The use <strong>of</strong><br />
other agents such as nitrous oxide, dexmedetomidine,<br />
hydromorphone, ketamine lozenges <strong>and</strong> regional<br />
anaesthesia will also be covered.<br />
CONCLUSIONS<br />
Effective management <strong>of</strong> procedural <strong>pain</strong> analgesia<br />
requires a multimodal <strong>and</strong> multidisciplinary approach<br />
in order to obtain the best patient outcomes.<br />
REFERENCES<br />
1. Ashburn MA (1995) Burn <strong>pain</strong>: the management <strong>of</strong> procedure-related<br />
<strong>pain</strong>. J Burn care Rehabil 16(3 pt 2):365-71<br />
2. Linneman PK et al (2000) The efficacy <strong>and</strong> safety <strong>of</strong> fentanyl for the<br />
management <strong>of</strong> severe procedural <strong>pain</strong> in patients <strong>with</strong> burn injuries.<br />
J Burn Care Rehabil 21(6):519-22<br />
3. Gregoretti C et al. (2008) Analgo-sedation <strong>of</strong> patients <strong>with</strong> burns<br />
outside the operating room. Drugs 68(17):2427-43<br />
4. Jonsson A et al. (1991) Inhibition <strong>of</strong> burn <strong>pain</strong> by intravenous<br />
lignocaine infusion. Lancet 338 (8760):151-2<br />
5. Wasiak J et al. (2007) Lidocaine for <strong>pain</strong> relief in burn injured patients.<br />
Cochrane Database Syst Rev (3):CD005622<br />
6. Wasiak J (2009). Personal communication<br />
25
Psychological Adjuncts for Pain<br />
Occurring <strong>with</strong> Dressing Changes<br />
in Burns Patients<br />
Dr Alex Konstantatos<br />
Alfred Hospital, VIC<br />
Burns injuries have wide ranging ramifications, which<br />
include the potential for severe <strong>and</strong> persistent <strong>pain</strong> <strong>and</strong><br />
psychological sequelae.<br />
The prospect <strong>of</strong> multiple burns dressings changes can<br />
heighten <strong>pain</strong> through repeated stimulation <strong>of</strong> <strong>pain</strong><br />
pathways <strong>and</strong> add to existing anxiety. Post traumatic<br />
stress disorder is a common accompaniment to burns<br />
injury <strong>with</strong> a prevalence <strong>of</strong> 11-50% 1 .<br />
Adjunctive psychological therapies are a logical<br />
accompaniment to analgesic therapies in the setting<br />
<strong>of</strong> burns dressings changes. Such therapies include<br />
pharmacological management <strong>with</strong> benzodiazepines<br />
or reliance on the sedating effects <strong>of</strong> opioids or a<br />
range <strong>of</strong> nonpharmacological therapies. These include<br />
cognitive techniques to provide distraction or redirect<br />
patient attention to more relaxing themes, behavioural<br />
techniques modelled on principles <strong>of</strong> conditioning or<br />
autonomic feedback, detailed education to help patients<br />
anticipate potentially stressful moments, alternative<br />
<strong>medicine</strong> <strong>and</strong> hypnosis 2 . Recent developments<br />
have made it possible for virtual reality technology<br />
to incorporate themes <strong>of</strong> relaxation, hypnosis <strong>and</strong><br />
distraction allowing for potent visual <strong>and</strong> auditory<br />
cues to guide therapies.<br />
Current research examining the role for psychological<br />
interventions is currently dominated by case reports<br />
attesting to improved <strong>pain</strong> scores 3,4,5,6,7,8 . Larger studies<br />
which include some r<strong>and</strong>omized controlled trials have<br />
provided more conflicting results 9,10 .<br />
Clearly the potential for psychological therapies to<br />
improve patient outcome is not questioned, but the ideal<br />
indications <strong>and</strong> best timimg still need to be resolved<br />
<strong>and</strong> confirmed scientifically.<br />
REFERENCES<br />
1. Bauer KM, Hardy PE, Van Dorsten B. Posttraumatic stress disorder in<br />
burn populations. A critical review <strong>of</strong> the literature. J Burn Care Rehabil<br />
19: 230-240, 1998<br />
2. Summer GJ, Puntillo KA, Miaskowski C, Green PG, Levine JD.<br />
Burn injury <strong>pain</strong>: The continuing challenge. J Pain 8(7): 533-548, 2007.<br />
3. Edwin DM. Emergency room hypnosis for the burned patient.<br />
Am J Clin Hypn 29(1): 7-12, 1986.<br />
4. Edwin DM. Emergency room hypnosis for the burned patient.<br />
Am J Clin Hypn. 26(1); 5-8, 1983<br />
5. Hammond DC, Keye WR, Grnat CWJr. Hypnotic analgesia <strong>with</strong> burns:<br />
an initial study. Am J Clin Hypn 26(1): 9-15, 1983.<br />
6. Margolis CG, Domangue BB, Ehleben C, Shrier L. Hypnosis in the<br />
early treatment <strong>of</strong> burns: a pilot study. Am J Clin Hypn 26(1): 9-15.<br />
7. Patterson DR, Everett JJ, Burns GL, Marvin JA. Hypnosis for the<br />
treatment <strong>of</strong> burn <strong>pain</strong>. J Consult Clin Psychol 60(5): 713-717, 1992.<br />
8. Wright BR, Drummond PD, Rapid induction analgesia for the<br />
alleviation <strong>of</strong> procedural <strong>pain</strong> during burn care.<br />
Burns 26: 275-282, 2000.<br />
9. Frenay M, Faymonville M, Devlieger S, Albert A, V<strong>and</strong>erkelen A.<br />
Psychological approaches during dressings changes <strong>of</strong> burned<br />
patients: a prospective r<strong>and</strong>omized study comparing hypnosis against<br />
stress reducing strategy. Burns 27(8): 793-799, 2001.<br />
10. Konstantatos AH, Angliss M, Costello V, Clel<strong>and</strong> H, Stafrace S.<br />
Predicting the effectiveness <strong>of</strong> Virtual Reality relaxation on <strong>pain</strong><br />
<strong>and</strong> anxiety when added to PCA Morphine in patients having burns<br />
dressings Changes. Burns (35) 491-499, 2009<br />
26<br />
2009 SPRING MEETING • FACULTY OF PAIN MEDICINE, ANZCA • ACUTE PAIN SPECIAL INTEREST GROUP OF ANZCA, ASA AND NZSA
Australia’s Worst Bushfire Disaster:<br />
The Medical Response<br />
to Victoria’s Black Saturday<br />
Dr John Moloney<br />
Alfred Hospital, VIC<br />
“The rich plains, denied their beneficent rains, lay bare<br />
<strong>and</strong> baking; <strong>and</strong> the forests, from the foothills to the alpine<br />
heights, were tinder. The s<strong>of</strong>t carpet <strong>of</strong> the forest floor was<br />
gone; the bone-dry litter crackled underfoot; dry heat <strong>and</strong><br />
hot dry winds worked upon a l<strong>and</strong> already dry, to suck<br />
from it the last, least drop <strong>of</strong> moisture.”<br />
After years <strong>of</strong> drought, south-eastern Australia suffered<br />
under days <strong>of</strong> record heat during January, 2009. A day<br />
<strong>of</strong> unprecedented weather was predicted for February<br />
7th. The premier was warning <strong>of</strong> the ‘worst day in<br />
Victoria’s history’.<br />
The worst bushfires in Australia’s history took place<br />
that day – Black Saturday. 172 people were killed, <strong>and</strong><br />
a firefighter was fatally injured in the subsequent weeks.<br />
The extreme weather conditions played havoc <strong>with</strong><br />
‘normal’ aeromedical work. With ambulance planes<br />
<strong>and</strong> helicopters unable to fly, critically ill patients were<br />
unable to be readily evacuated to Melbourne’s intensive<br />
care units. As fires threatened <strong>and</strong> then closed major<br />
highways to the North <strong>and</strong> East, road transport was<br />
removed as an option. Then a major regional hospital<br />
had fires only 2km away.<br />
With the evening approaching, it was becoming clear<br />
that not only were major parts <strong>of</strong> the state ablaze,<br />
but that many <strong>of</strong> these were in areas <strong>with</strong> significant<br />
populations. Small townships on the urban fringe were<br />
under threat, or had in fact already been attacked. The<br />
Coordinator for the Field Emergency Medical Officer<br />
Program, part <strong>of</strong> the State Health Emergency Response<br />
Plan, was activated, subsequently arranging for disaster<br />
<strong>medicine</strong> specialists to be in the field the night <strong>of</strong><br />
Black Saturday. These doctors worked <strong>with</strong> ambulance<br />
paramedics, first aid organisations <strong>and</strong> other volunteers.<br />
The flow <strong>of</strong> information was chaotic, hindered by the<br />
speed <strong>with</strong> which events were unfolding <strong>and</strong> the loss<br />
<strong>of</strong> communications infrastructure.<br />
The Alfred houses Victoria’s Adult Burns Unit, <strong>and</strong> is<br />
one <strong>of</strong> two adult major trauma centers. The Alfred didn’t<br />
have any information on potentially how many burns<br />
patients there would be, so the plan was to basically<br />
take all patients <strong>with</strong> more than 30 percent burns <strong>and</strong><br />
anything that wasn’t quite so severe went to one <strong>of</strong> the<br />
other major hospitals. Another procedure that was put<br />
in place was for the Alfred to only receive burns patients<br />
<strong>and</strong> the Royal Melbourne Hospital to receive all other<br />
trauma patients. Other adult hospitals in Melbourne<br />
were planned to receive everything else.<br />
The Alfred staff coped fairly well <strong>with</strong> the burns crisis.<br />
One intensivist said it was actually easier than some<br />
Saturday nights. The Alfred put 10 patients through<br />
ICU <strong>and</strong> about another 10 into wards, <strong>and</strong> yet still had<br />
ICU bed capacity by Monday morning. Within 36 hours,<br />
despite the influx <strong>of</strong> major burns, they had created<br />
ICU capacity.<br />
Extra staff were called in <strong>and</strong> The Alfred basically ran<br />
two burns theatres all day Sunday, Monday <strong>and</strong> Tuesday<br />
<strong>and</strong> then ran one burns theatre for the rest <strong>of</strong> the week.<br />
Normally there would have burns theatres running for<br />
only three half days a week.<br />
The Burns Unit had the experience <strong>of</strong> dealing <strong>with</strong><br />
some <strong>of</strong> the survivors <strong>of</strong> the Bali Bombings. They paced<br />
themselves a bit more, so they didn’t run themselves<br />
into the ground. The great thing was that everyone was<br />
willing to help. Every department went out <strong>of</strong> its way to<br />
work extraordinarily well together <strong>and</strong> show good will.<br />
As the initial response moved from the field to hospitals,<br />
<strong>and</strong> although the bushfires had subsided, it was thought<br />
people from isolated areas would start presenting <strong>with</strong><br />
injuries. A medical presence was needed.<br />
Some aspects <strong>of</strong> the extended response weren’t as<br />
considered. If there was a need, it was met, but some <strong>of</strong><br />
it wasn’t explicitly planned for. To have so many people<br />
affected <strong>and</strong> the destruction <strong>of</strong> infrastructure over<br />
such a large area was unimaginable. The general practice<br />
in Marysville was burnt out <strong>and</strong> the whole town was<br />
basically inaccessible. The pharmacist in Yea was busy<br />
defending his house <strong>and</strong> in Alex<strong>and</strong>ra, one <strong>of</strong> the GPs<br />
was defending his house while another was missing for<br />
a period <strong>of</strong> time. So instead <strong>of</strong> having four GPs they were<br />
down to one. Medical teams supported communities<br />
including Kinglake, Alex<strong>and</strong>ra, Eildon, Flowerdale, Buxton<br />
<strong>and</strong> Narbethong. This was facilitated by DHS, RWAV <strong>and</strong><br />
RDNS, <strong>and</strong> also included medical <strong>and</strong> nursing staff from<br />
many metropolitan <strong>and</strong> regional hospitals.<br />
Black Saturday wasn’t specifically a burns response but<br />
a mass casualty incident <strong>with</strong> multiple victims that<br />
needed people <strong>with</strong> expertise <strong>and</strong> experience in dealing<br />
<strong>with</strong> multiple patients at the same time.<br />
“These dreadful expectations were matched by the<br />
calamity that resulted on 7 February.”<br />
REFERENCES<br />
1. Interim Report, 2009 Victorian Bushfires Royal Commission<br />
2. Judge Stretton, 1939 Royal Commission<br />
27
PBLD 01<br />
Implementing a Preventative Strategy<br />
in Acute Pain<br />
Dr Malcolm Hogg<br />
Royal Melbourne Hospital, VIC<br />
CASE PRESENTATION<br />
30 yr female <strong>with</strong> persistent wrist <strong>and</strong> h<strong>and</strong> <strong>pain</strong><br />
presents for carpel tunnel release <strong>and</strong> removal <strong>of</strong><br />
hardware. She describes a history <strong>of</strong> a MVA <strong>with</strong> open<br />
radial fracture, requiring an ORIF one year previously.<br />
This surgery was complicated by severe post<br />
operative <strong>pain</strong> <strong>and</strong> oedema, requiring POP split, <strong>and</strong><br />
slow subsequent rehabilitation. Current medications<br />
included Oxycontin 40 mg BD <strong>and</strong> Gabapentin<br />
300 mg bd.<br />
REFERENCES<br />
1. Brill S et al. Perioperative management <strong>of</strong> chronic <strong>pain</strong> patients <strong>with</strong><br />
opioid dependency. Current Opin Anaesth 2006; 19: 325<br />
2. Janig W & Baron R. Complex regional <strong>pain</strong> syndrome: mystery<br />
explained? The Lancet Neruology 2003; 2: 687<br />
3. Kehlet H, Jensen T & Woolf C. Persistent postsurgical <strong>pain</strong>: risk factors<br />
<strong>and</strong> prevention. The Lancet 2006; 367: 1618<br />
4. Tippana E et al. Do surgical patients benefit form perioperative<br />
gabapentin/Pregabalin? Anesth Analg 2007; 104: 1545<br />
5. White P. Multimodal analgesia: its role in preventing postoperative<br />
<strong>pain</strong>. Current Opin Investigational Drugs 2008; 9: 76<br />
OBJECTIVES<br />
At the conclusion <strong>of</strong> the PBLD, the participant should<br />
be able to:<br />
• Accurately identify <strong>and</strong> assess patients pre-operatively<br />
<strong>with</strong> regards to their potential to have poorly controlled<br />
post operative <strong>pain</strong> or persistent <strong>pain</strong><br />
• Underst<strong>and</strong> pertinent issues <strong>with</strong> regards to chronic<br />
opioid use<br />
• Design <strong>and</strong> implement a persistent <strong>pain</strong> “preventative”<br />
strategy<br />
• Have a clearer underst<strong>and</strong>ing <strong>of</strong> CRPS<br />
28<br />
2009 SPRING MEETING • FACULTY OF PAIN MEDICINE, ANZCA • ACUTE PAIN SPECIAL INTEREST GROUP OF ANZCA, ASA AND NZSA
Topical Session 01<br />
Office Based Pain Management –<br />
Optimising Outcome, Reducing Risk<br />
Dr Roman D. Jovey<br />
Credit Valley Hospital, Ontario, Canada <strong>and</strong><br />
CPM Centres for Pain Management, Mississauga, Ontario, Canada<br />
TOPIC SUMMARY<br />
This topical session will review the practical aspects<br />
<strong>of</strong> an <strong>of</strong>fice-based chronic <strong>pain</strong> assessment, including<br />
screening <strong>and</strong> risk stratification, using st<strong>and</strong>ardized<br />
tools, to develop a risk-based treatment plan. The needs<br />
<strong>of</strong> a low risk older patient <strong>with</strong> osteoarthritis <strong>and</strong> a<br />
high risk patient <strong>with</strong> back <strong>pain</strong> will be compared <strong>and</strong><br />
contrasted. The concepts <strong>of</strong> ‘Universal Precautions’ will<br />
be applied <strong>and</strong> time efficient strategies for essential<br />
outcome documentation illustrated.<br />
EDUCATIONAL OBJECTIVES<br />
Using case vignettes, participants will discuss practical<br />
assessment <strong>and</strong> treatment issues in chronic <strong>pain</strong><br />
management that:<br />
1. define a st<strong>and</strong>ardized approach to assessment using<br />
validated tools;<br />
2. optimize <strong>pain</strong> management outcomes;<br />
3. reduce <strong>pain</strong> management risk;<br />
4. ensure essential documentation<br />
REFERENCES<br />
1. Chou R, Fanciullo GJ, Fine PG, Adler JA, Ballantyne JC, et al. American<br />
Pain Society-American Academy <strong>of</strong> Pain Medicine Opioids Guidelines<br />
Panel. Clinical guidelines for the use <strong>of</strong> chronic opioid therapy in<br />
chronic noncancer <strong>pain</strong>. J Pain. 2009 Feb;10(2):113-30.<br />
2. Gourlay DL, Heit HA, Almahrezi A. Universal precautions in <strong>pain</strong><br />
<strong>medicine</strong>: a rational approach to the treatment <strong>of</strong> chronic <strong>pain</strong>.<br />
Pain Med 2005;6:107-112.<br />
3. Smith HS, Kirsh KL. Documentation <strong>and</strong> potential tools in long-term<br />
opioid therapy for <strong>pain</strong>. Anesthesiol Clin. 2007 Dec;25(4):809-23, vii.<br />
4. The Royal Australasian <strong>of</strong> Physicians. Prescription Opioid Policy.<br />
Improving management <strong>of</strong> chronic non-malignant <strong>pain</strong> <strong>and</strong> prevention<br />
<strong>of</strong> problems associated <strong>with</strong> prescription opioid use.<br />
Sydney April 2009.<br />
29
PBLD 02<br />
Cessation <strong>of</strong> Established Intrathecal<br />
Analgesia in Persistent Non-Cancer Pain<br />
Dr Chris Hayes<br />
Hunter Integrated Pain Service, NSW<br />
OBJECTIVES<br />
1. To analyse the evidence in regard to effectiveness<br />
<strong>of</strong> intrathecal therapy in persistent non cancer <strong>pain</strong>.<br />
2. To weigh potential benefit <strong>and</strong> harm from<br />
intrathecal therapy.<br />
3. To discuss the feasibility <strong>of</strong> ceasing established<br />
intrathecal therapy.<br />
4. To formulate a broad based management plan<br />
appropriate to the care <strong>of</strong> a patient undergoing<br />
intrathecal cessation.<br />
BRIEF CASE OUTLINE<br />
A 47 year old man has been on established intrathecal<br />
therapy <strong>with</strong> hydromorphone <strong>and</strong> clonidine for 5 years.<br />
This is directed at the management <strong>of</strong> persistent low<br />
back <strong>pain</strong> previously unresponsive to 3 spinal surgical<br />
procedures <strong>and</strong> oral opioids. Some modest benefits<br />
had been reported <strong>with</strong> initiation <strong>of</strong> intrathecal therapy.<br />
However these benefits had not been sustained.<br />
He had undertaken a group <strong>pain</strong> management program<br />
but had not effectively engaged <strong>with</strong> the process.<br />
Where to next? At a team case discussion a number <strong>of</strong><br />
options were debated including escalating the intrathecal<br />
dose or alternatively working toward cessation <strong>of</strong><br />
intrathecal therapy altogether. What view would you<br />
express if you were in attendance at this meeting?<br />
QUESTIONS<br />
1. What benefit is to be expected from intrathecal therapy<br />
for persistent non cancer <strong>pain</strong>?<br />
2. What harm can occur from intrathecal therapy? What<br />
mechanisms are involved?<br />
3. Is cessation <strong>of</strong> intrathecal therapy feasible? How would<br />
you go about this process?<br />
4. Can intrathecal cessation be used to motivate greater<br />
engagement <strong>with</strong> active management?<br />
REFERENCES<br />
1. Turner JA, Sears JM, Loeser JD. Programmable intrathecal opioid<br />
delivery systems for chronic noncancer <strong>pain</strong>: a systematic review<br />
<strong>of</strong> effectiveness <strong>and</strong> complications. Clin J Pain 2007;23(2):180-194<br />
2. Molloy AR, Nicholas MK et al. Does a combination <strong>of</strong> intensive<br />
cognitive-behavioral <strong>pain</strong> management <strong>and</strong> a spinal implantable<br />
device confer any advantage? A preliminary examination. Pain Pract.<br />
2006;6(2):96-103<br />
3. Hutchinson MR, Watkins L et al. Opioid-induced glial activation:<br />
mechanisms <strong>of</strong> activation <strong>and</strong> implications for opioid analgesia,<br />
dependence, <strong>and</strong> reward. Scientific World Journal 2007;7:98-111<br />
30<br />
2009 SPRING MEETING • FACULTY OF PAIN MEDICINE, ANZCA • ACUTE PAIN SPECIAL INTEREST GROUP OF ANZCA, ASA AND NZSA
Topical Session 02<br />
Community Management <strong>of</strong> Intrathecal<br />
Infusions for Cancer<br />
Ms Dale Long<br />
Peter MacCallum Cancer Centre, VIC<br />
Dr Brett Todhunter<br />
Wodonga Regional Health Service, VIC<br />
80-90% <strong>of</strong> cancer <strong>pain</strong> can be controlled <strong>with</strong>out the<br />
need for an interventional technique.<br />
There are however a significant number <strong>of</strong> patients who<br />
require an interventional technique, the commonest<br />
<strong>of</strong> which is an intrathecal infusion. This technique should<br />
be considered before patients are escalated to industrial<br />
but ineffective doses <strong>of</strong> opioids <strong>and</strong> other medications<br />
<strong>and</strong>/or are showing obvious signs <strong>of</strong> drug toxicity.<br />
This session will discuss Intrathecal Infusions,<br />
in particular their management in the community.<br />
At the conclusion <strong>of</strong> what will be an interactive<br />
session, participants will:<br />
1. know when to consider intrathecal infusions.<br />
2. be aware <strong>of</strong> the indications/contraindications <strong>and</strong><br />
risk vs benefit issues.<br />
3. be able to participate in the multidisciplinary<br />
(<strong>pain</strong> physician/neurosurgeon, domiciliary palliative<br />
care service, GP, patient <strong>and</strong> family) management<br />
<strong>of</strong> intrathecal infusions.<br />
4. Have a clear concept <strong>of</strong> the possible techniques,<br />
equipment <strong>and</strong> drugs used.<br />
5. Be able to identify any problems encountered in the<br />
community <strong>and</strong> their management including when<br />
to seek advise, <strong>and</strong><br />
6. Be able to apply the knowledge learnt towards<br />
developing a comprehensive policy for the management<br />
<strong>of</strong> intrathecal infusions in the community.<br />
REFERENCES<br />
1. Peter S Staats. “Complications <strong>of</strong> Intrathecal Therapy”. Pain Medicine.<br />
Vol 9 Number S1. 2008 pp 102-107.<br />
2. D. Kedlaya, L. Reynolds, S. Waldman. “Epidural <strong>and</strong> Intrathecal<br />
Analgesia for Cancer Pain”. Best Practice <strong>and</strong> Research: Clinical<br />
Anaesthesiology <strong>and</strong> Pain Management State <strong>of</strong> the Art. 2002 Vol 16<br />
No. 4 pp 651-665.<br />
3. Neural Blockade in Clinical Anaesthesia <strong>and</strong> Management <strong>of</strong> Pain.<br />
2nd Edition. Cousins <strong>and</strong> Bridenbaugh. pp 1004-1015.<br />
4. Cousins K, Duggan G et al. Intrathecal catheters: developing<br />
consistency in filter use <strong>and</strong> dressings in Perth, Australia. International<br />
Journal <strong>of</strong> Palliative Nursing 2003, Vol 9, No 7.<br />
5. Gestin Y, Vainio A <strong>and</strong> Pegurier A M. Long term intrathecal infusion<br />
<strong>of</strong> morphine in the home care <strong>of</strong> patients <strong>with</strong> advanced cancer.<br />
Acta Anaesthesia Sc<strong>and</strong> 1997; 41:12-17.<br />
31
PBLD 03<br />
Management <strong>of</strong> Ischaemic Limb Pain<br />
Dr Bronwen Evans<br />
Western Health Service, VIC<br />
THE SCENARIO<br />
John is a 55 year old man <strong>with</strong> Berger’s disease who is<br />
experiencing severe <strong>pain</strong> in his foot in association <strong>with</strong><br />
ischaemic ulcers <strong>and</strong> is begging for more <strong>pain</strong> relief;<br />
when you meet him he is rocking to <strong>and</strong> fro whilst<br />
rubbing his <strong>pain</strong>ful foot. What challenges await in the<br />
management <strong>of</strong> this man’s <strong>pain</strong> <strong>and</strong> how might one<br />
proceed?<br />
LEARNING OBJECTIVES<br />
The attendee will learn that the management <strong>of</strong><br />
ischaemic limb <strong>pain</strong> is complex. Complications <strong>of</strong><br />
polypharmacy <strong>and</strong> barriers to <strong>pain</strong> managment will be<br />
discussed as will possible solutions to these barriers.<br />
32<br />
2009 SPRING MEETING • FACULTY OF PAIN MEDICINE, ANZCA • ACUTE PAIN SPECIAL INTEREST GROUP OF ANZCA, ASA AND NZSA
Topical Session 03<br />
Incident/Procedural Pain Management<br />
<strong>with</strong>out an IV<br />
Dr Chui Chong<br />
Royal Perth Hospital, WA<br />
Pr<strong>of</strong>essor Colin Goodchild<br />
Monash University, VIC<br />
Assoc Pr<strong>of</strong>essor Kate Jackson<br />
Southern Health <strong>and</strong> Monash University, VIC<br />
Dr Odette Spruyt<br />
Peter MacCallum Cancer Center, VIC<br />
Ms Jill Woods<br />
Western Health, VIC<br />
This workshop may well take staff used to the critical<br />
care environment outside their comfort zone. It aims<br />
to show how it is possible to provide rapid, onset,<br />
short duration but intensive analgesia for eg. bed sore<br />
dressings, positioning for radiotherapy <strong>and</strong> significant<br />
incident <strong>pain</strong> in patients <strong>with</strong> bony metastases in<br />
hospices or nursing homes.<br />
It will inform participants <strong>of</strong> needle free alternatives to<br />
the IV bolus dosing or IV PCAs used by anaesthetists<br />
in acute hospital wards or procedure rooms.<br />
The two techniques presented will be transmucosal drug<br />
administration <strong>and</strong> the use <strong>of</strong> methoxyflurane analgesia<br />
via a Penthrox inhaler. At the end <strong>of</strong> the workshop<br />
participants will:<br />
1. underst<strong>and</strong> the analgesic as distinct from the<br />
anaesthetic use <strong>of</strong> drugs such as ketamine <strong>and</strong><br />
methoxyflurane.<br />
2. underst<strong>and</strong> the principles <strong>and</strong> practice <strong>of</strong> transmucosal<br />
drug delivery<br />
• the physiochemical properties needed for effective<br />
transmucosal delivery<br />
• drug selection<br />
• the different techniques<br />
• sublingual drugs<br />
• buccal lozenges<br />
• intranasal spray delivery<br />
3. the how/when/why <strong>of</strong> using a Penthrox inhaler<br />
4. be able to develop protocols using one or other <strong>of</strong> these<br />
techniques to improve the care <strong>of</strong> patients undergoing<br />
<strong>pain</strong>ful procedures or <strong>with</strong> severe incident <strong>pain</strong> thus<br />
improving the quality <strong>of</strong> life for patients in hospices,<br />
nursing homes <strong>and</strong> indeed at home.<br />
REFERENCES<br />
1. Zeppetella G, Ribeiro MD. Opioids for the management <strong>of</strong><br />
breakthrough (episodic) <strong>pain</strong> in cancer patients. Cochrane Database<br />
Syst Rev 2006; (1): CD004311.<br />
2. Good P, Jackson K, Brumley D, Ashby M. Intranasal sufentanil<br />
for cancer associated breakthrough <strong>pain</strong>.<br />
Palliative Medicine 2009; 23:54-58.<br />
3. Carr D.B, Goudas L, Denman W et al. Safety <strong>and</strong> efficacy <strong>of</strong> intranasal<br />
ketamine for the treatment <strong>of</strong> breakthrough <strong>pain</strong> in patients <strong>with</strong><br />
chronic <strong>pain</strong>: a r<strong>and</strong>omized, double-blind, placebo-controlled,<br />
crossover study. Pain 2005; 108: 17-27.<br />
4. Chong C, Schug S, Page-Sharp M et al. Development <strong>of</strong> a sublingual/<br />
oral formulation <strong>of</strong> ketamine for use in neuropathic <strong>pain</strong>.<br />
Clinical Drug Investigation 2009; 29(5): 317-324.<br />
5. Romagnoli A, Busque L, Power DJ. The “Analgizer ® ” in a general<br />
hospital: a preliminary report. Can Anaesth Soc J 1970;17(3):275-8<br />
6. Chin R, McCaskill M, Browne G, Lam L. A r<strong>and</strong>omised control trial <strong>of</strong><br />
inhaled methoxyflurane <strong>pain</strong> relief, in children <strong>with</strong> upper limb fracture.<br />
J Paediatr Child Health 2002;38(5):A13-A14<br />
33
PBLD 04<br />
A Case <strong>of</strong> Recurrent Acute on Chronic<br />
Visceral Pain – Here Pancreatitis – How<br />
to Balance Analgesia <strong>with</strong> Concerns about<br />
Opioid Usage<br />
Dr Winnie Hong<br />
Concord Repatriation General Hospital, NSW<br />
You are asked to manage a 42 year old woman <strong>with</strong><br />
a history <strong>of</strong> chronic pancreatitis who presents <strong>with</strong> an<br />
exacerbation <strong>of</strong> abdominal <strong>pain</strong> <strong>and</strong> normal amylase.<br />
She has been admitted <strong>and</strong> treated <strong>with</strong> parenteral<br />
opioids over the weekend, <strong>and</strong> is dem<strong>and</strong>ing better<br />
analgesia.<br />
LEARNING OBJECTIVES<br />
At the conclusion <strong>of</strong> this PBLD session, the participant<br />
should achieve the following:<br />
1. Differentiate between acute <strong>and</strong> chronic <strong>pain</strong><br />
presentations, the different approaches utilized <strong>and</strong><br />
the potential overlap <strong>of</strong> these<br />
2. Define specific pathophysiological processes relevant<br />
to treatment <strong>of</strong> <strong>pain</strong> in chronic pancreatitis<br />
3. Appreciate issues important in treating the opioid<br />
dependent patient <strong>with</strong> a <strong>pain</strong>ful condition<br />
4. Develop a strategy to treat opioid resistant <strong>pain</strong><br />
5. Utilise a comprehensive multidisciplinary approach<br />
to treat chronic visceral <strong>pain</strong><br />
SELECTED REFERENCES<br />
1. Perioperative management <strong>of</strong> acute <strong>pain</strong> in the opioid dependent<br />
patient. Mitra, Sinatra. Anesthesiology. Vol 101 (1) July 2004, 212-227.<br />
2. Chronic Pancreatitis:- the perspective <strong>of</strong> <strong>pain</strong> generation by immune<br />
interaction. Sebastiano et al. Gut. Vol 52 (6), June 2003, 907-911.<br />
3. Opioid –induced Hyperalgesia. Angst, Clark. Anesthesiology Vol 104<br />
(3) Mar. 2006, 570-587.<br />
4. Gabapentin prevents delayed <strong>and</strong> long lasting hyperalgesia induced by<br />
fentanyl in Rats. Van Elstraete et al. Anesthesiology Vol 108 (3),<br />
Mar 2008, 484-494.<br />
5. Oral methadone for chronic noncancer <strong>pain</strong>: A systematic literature<br />
review <strong>of</strong> reasons for administration, prescription patterns,<br />
effectiveness <strong>and</strong> side effects. The Clinical Journal <strong>of</strong> Pain. S<strong>and</strong>oval<br />
et al. Vol 21 (6), Nov/Dec 2005, 503-512.<br />
34<br />
2009 SPRING MEETING • FACULTY OF PAIN MEDICINE, ANZCA • ACUTE PAIN SPECIAL INTEREST GROUP OF ANZCA, ASA AND NZSA
Topical Session 04<br />
Getting to Opioid Detoxification, Part 1.<br />
Preparing the Patient: 3 Approaches<br />
Dr Robert Brzozek<br />
Health Services Group <strong>of</strong> TAC <strong>and</strong> Worksafe, VIC<br />
Dr Tobie Sacks<br />
St Vincent’s Hospital, VIC<br />
Dr Lisa Sherry<br />
Health Services Group <strong>of</strong> TAC <strong>and</strong> Worksafe, VIC<br />
Dr Helen Sweeting<br />
St Vincent’s Hospital, VIC<br />
The initial part <strong>of</strong> this will be looking at the use <strong>of</strong> opioid<br />
medication in compensable patients. This will be looking<br />
at it from the Transport Accident Commission <strong>and</strong> Work<br />
Safe Victoria perspective. The presentation will also look<br />
at the intersection between the monitoring roles <strong>and</strong><br />
the Federal <strong>and</strong> State governments <strong>and</strong> the insurers in<br />
addition to providing in sighted in-house clinical panel<br />
approaches to the operation <strong>of</strong> injured workers.<br />
This presentation will be given by Dr Lisa Sherry <strong>and</strong><br />
Dr Robert Brzozek, both <strong>of</strong> whom work as clinical<br />
advisers to the Health Services (TAC <strong>and</strong> WorkSafe<br />
Victoria).<br />
The second <strong>of</strong> this will be the presentation by Helen<br />
Sweeting. Her presentation is more clinically based<br />
looking at addressing issues arising when considering<br />
opioid <strong>with</strong>drawal from patients. Her presentation will<br />
outline why opening the draw may be important, how it<br />
is negotiated <strong>and</strong> the potential difficulties <strong>with</strong> a service<br />
delivery for opioid <strong>with</strong>drawal <strong>and</strong> expected outcomes<br />
from opioid <strong>with</strong>drawal.<br />
The third part <strong>of</strong> the presentation will be Dr Tobie<br />
Sacks, Psychiatrist. Dr Sacks will outline his view as<br />
a psychiatrist <strong>and</strong> <strong>pain</strong> specialist in his approach to<br />
dealing <strong>with</strong> patients on complex opioid medication<br />
regimes <strong>and</strong> how he addresses the issue <strong>of</strong> drug<br />
detoxification.<br />
35
PBLD 05<br />
Issues to Consider <strong>with</strong> Conversion to<br />
Buprenorphine<br />
Dr Helen Sweeting<br />
St Vincent’s Hospital, VIC<br />
TITLES<br />
1. Buprenorphine as analgesia in comorbid chronic <strong>pain</strong><br />
<strong>and</strong> opioid dependence.<br />
2. Conversion to buprenorphine in a hospital setting for<br />
a patient experiencing adverse effects <strong>of</strong> high dose<br />
methadone.<br />
3. Use <strong>of</strong> topical buprenorphine in a case <strong>of</strong> misuse<br />
<strong>of</strong> tramadol <strong>with</strong>in the context <strong>of</strong> mild opioid<br />
neuroadaptation <strong>and</strong> chronic <strong>pain</strong>.<br />
OBJECTIVES<br />
At the end <strong>of</strong> the session the participant should be<br />
able to:<br />
1. Confidently initiate <strong>and</strong> titrate sublingual buprenorphine<br />
for managing chronic <strong>pain</strong> against a background <strong>of</strong><br />
opioid dependence <strong>and</strong> mild neuroadaptation to opioids<br />
2. Confidently initiate <strong>and</strong> titrate sublingual buprenorphine<br />
in a hospital setting for managing chronic <strong>pain</strong> <strong>with</strong>in<br />
the context <strong>of</strong> significant opioid neuroadaptation <strong>and</strong><br />
comorbidity.<br />
3. Utilise acquired knowledge to use topical buprenorphine<br />
for managing dual chronic <strong>pain</strong> <strong>and</strong> opioid dependence<br />
REFERENCES<br />
1. Rolley et al (2005) Buprenorphine: Considerations for Pain<br />
Management , Journal <strong>of</strong> Pain <strong>and</strong> Symptom Management,<br />
Vol. 29 No. 3 pp 297<br />
2. Freye et al (2007) Opioid Rotation from High-Dose Morphine to<br />
Transdermal<br />
3. Buprenorphine (Transtec ® ) in Chronic Pain Patients, Pain Practice,<br />
Volume 7, (2) pp 123–129<br />
4. Malin<strong>of</strong>f et al, Sublingual Buprenorphine Is Effective in the Treatment<br />
<strong>of</strong> Chronic Pain Syndrome, American Journal <strong>of</strong> Therapeutics 12,<br />
pp 379–384<br />
Topical Session 05<br />
Prescribing for Pain in the Elderly<br />
Assoc Pr<strong>of</strong>essor Pam Macintyre<br />
Royal Adelaide Hospital, SA<br />
Pr<strong>of</strong>essor Barbara Workman<br />
Monash University, Southern Healthcare Network, VIC<br />
LEARNING OBJECTIVES<br />
At the conclusion <strong>of</strong> the topical session, the participant<br />
should be able to<br />
1. Describe the changes in pharmacokinetics <strong>and</strong><br />
pharmacodynamics that occur as people age.<br />
2. Explain how these changes influence the prescribing<br />
<strong>of</strong> <strong>pain</strong> medications in the elderly.<br />
3. Apply new knowledge in <strong>pain</strong> assessment in the elderly.<br />
4. Describe some <strong>of</strong> the concepts in changed <strong>pain</strong><br />
perception in the elderly.<br />
REFERENCES<br />
1. Macintyre PE & Upton R (2008) Acute <strong>pain</strong> management in the elderly<br />
patient. In: Clinical Pain Management: Acute Pain 2nd edn. Macintyre<br />
PE, Walker SM <strong>and</strong> Rowbotham DJ (eds). London, Hodder Arnold<br />
2. AGS Panel on Chronic Pain in Older Persons (1998) The Management<br />
<strong>of</strong> Chronic Pain in the Older Person, JAGS 46:635-651.<br />
3. <strong>Australian</strong> Pain Society (2005) Pain in residential care facilities.<br />
http://www.apsoc.org.au/news.php?scode=9e2c2n<br />
4. <strong>Australian</strong> <strong>and</strong> <strong>New</strong> Zeal<strong>and</strong> College <strong>of</strong> Anaesthetists <strong>and</strong> <strong>Faculty</strong> <strong>of</strong><br />
Pain Medicine (2005) Acute Pain Management: Scientific Evidence 3rd<br />
edition. http://www.anzca.edu.au/resources/books-<strong>and</strong>-publications/<br />
(3rd edition in progress). Section 10.3 – Acute Pain in the Elderly.<br />
36<br />
2009 SPRING MEETING • FACULTY OF PAIN MEDICINE, ANZCA • ACUTE PAIN SPECIAL INTEREST GROUP OF ANZCA, ASA AND NZSA
Topical Session 06<br />
Acute Pain Management for Orthopaedics.<br />
Managing the Pain <strong>and</strong> Fast Tracking the<br />
Rehabilitation <strong>of</strong> Patients Undergoing Knee<br />
or Hip Replacement<br />
Dr Charles Kim<br />
St Vincent’s Hospital <strong>and</strong> Melbourne Health, VIC<br />
Ms Cathy Senserrick<br />
Austin Health, VIC<br />
Mr Andrew Shelton<br />
Austin Health, VIC<br />
Dr Jane Trinca<br />
Austin Health <strong>and</strong> St Vincent’s Hospital, VIC<br />
Dr This workshop aims to address the many twists <strong>and</strong><br />
turns involved in attempting to maximize post-operative<br />
analgesia <strong>and</strong> peri-operative care in order to improve<br />
the journey <strong>of</strong> patients requiring knee <strong>and</strong> hip<br />
replacements in Melbourne tertiary hospitals. This<br />
workshop has been developed by a team <strong>of</strong> health<br />
pr<strong>of</strong>essionals <strong>with</strong> major input from Ms Anne Daly,<br />
Ms Narelle Peake <strong>and</strong> Ms Megan Yeomans <strong>with</strong><br />
contribution from Pr<strong>of</strong>essor Peter Choong.<br />
The speakers will describe:<br />
• The literature <strong>and</strong> evidence behind the analgesic choices<br />
to optimize rehabilitation<br />
• The gold st<strong>and</strong>ard physiotherapy required to optimize<br />
outcome <strong>and</strong> the available evidence available to support<br />
this <strong>and</strong> the barriers faced in achieving this<br />
• The analysis <strong>of</strong> nursing practice <strong>and</strong> care plans in order<br />
to improve the individual patient journey<br />
• How hospitals <strong>and</strong> government analyze outcome <strong>of</strong> joint<br />
replacements <strong>and</strong> the numerous variables involved in<br />
the interpretation <strong>of</strong> these figures<br />
There are many factors involved in determining the<br />
course <strong>of</strong> treatment for patients <strong>with</strong> severe knee <strong>and</strong><br />
hip pathology referred for joint replacement. Whilst<br />
many analgesic techniques have been tried to aid the<br />
rehabilitation process such as epidural, continuous<br />
peripheral blockade, there is conflicting evidence as to<br />
whether such techniques alter the final outcome. Other<br />
factors that need to be considered are the status <strong>of</strong> the<br />
patient pre-operatively <strong>and</strong> whether physical therapy<br />
<strong>and</strong> education preparation is important. In addition<br />
ward culture may be <strong>of</strong> particular importance in<br />
determining how efficiently patients can be rehabilitated.<br />
It must not be forgotten that the surgeon can have a<br />
major influence on the overall journey <strong>of</strong> the patient.<br />
At the completion <strong>of</strong> the workshop, participants will:<br />
• Be able to describe the may factors influencing analgesic<br />
choice for knee <strong>and</strong> hip replacement, be cognisant <strong>of</strong> the<br />
evidence for use <strong>of</strong> these techniques <strong>and</strong> be confident to<br />
interpret this evidence<br />
• Appreciate that there are numerous non-analgesic<br />
factors influencing outcome<br />
• Be aware <strong>of</strong> interventions that health services are using<br />
to combat some <strong>of</strong> the barriers to efficient rehabilitation.<br />
• Be cognisant <strong>of</strong> the statistics that are kept by health care<br />
agencies <strong>and</strong> how these should be interpreted<br />
• Have an appreciation <strong>of</strong> surgical factors that may be<br />
<strong>of</strong> importance in improving outcome<br />
REFERENCES<br />
1. The Role <strong>of</strong> the Anesthesiologist in Fast-Track Surgery: From<br />
Multimodal Analgesia to Perioperative Medical Care; Paul F. White,<br />
, Henrik Kehlet, , Joseph M. Neal, Thomas Schricker, Daniel B. Carr,<br />
Franco Carli, MD, <strong>and</strong> the Fast-Track Surgery Study Group; Anesth<br />
Analg 2007;104:1380 –96<br />
2. PROSPECT: Providing evidence-based <strong>and</strong> procedure-specific<br />
recommendations <strong>and</strong> clinical decision support for the management<br />
<strong>of</strong> postoperative <strong>pain</strong>. www.postop<strong>pain</strong>.org<br />
3. The Effect <strong>of</strong> Single-Injection Femoral Nerve Block Versus Continuous<br />
Femoral Nerve Block After Total Knee Arthroplasty on Hospital Length<br />
<strong>of</strong> Stay <strong>and</strong> Long-Term Functional Recovery Within an Established<br />
Clinical Pathway; Francis V. Salinas, MD, Spencer S. Liu, MD, <strong>and</strong><br />
Michael F. Mulroy, MD; (Anesth Analg 2006;102:1234 –9)<br />
4. Continuous Femoral Nerve Blockade or Epidural Analgesia After Total<br />
Knee Replacement: A Prospective RCT; Michael J. Barrington, David<br />
Olive, FANZCA, Keng Low,David A. Scott, ,Jennifer Brittain, <strong>and</strong> Peter<br />
Choong; (Anesth Analg 2005;101:1824 –9)<br />
5. Multimodal <strong>pain</strong> management after total hip <strong>and</strong> knee arthroplasty at<br />
the Ranawat Orthopaedic Center. Maheshwari AV, Blum YC, Shekhar L,<br />
Ranawat AS, Ranawat CS; Clin Orthop. 467(6):1418-23, 2009 June<br />
6. Continuous lumbar plexus block for postoperative <strong>pain</strong> control after<br />
total hip arthroplasty. A r<strong>and</strong>omized controlled trial; Marino J, Russo<br />
J, Kenny M, Herenstein R, Livote E, Chelly JE Journal <strong>of</strong> Bone & Joint<br />
Surgery - American Volume. 91(1):29-37, 2009 Jan<br />
7. Multi-modal, pre-emptive analgesia decreases the length <strong>of</strong> hospital<br />
stay following total joint arthroplasty; Duellman Tj et al; Orthopedics.<br />
32(3):167, 2009 Mar<br />
37
8. Continuous lumbar plexus block provides improved analgesia<br />
<strong>with</strong> fewer side effects compared <strong>with</strong> systemic opioids after hip<br />
arthroplasty: a r<strong>and</strong>omized controlled trial.Siddiqui ZI. Cepeda MS.<br />
Denman W. Schumann R. Carr DB. Regional Anesthesia & Pain<br />
Medicine. 32(5):393-8, 2007 Sep-Oct<br />
9. Effectiveness <strong>of</strong> accelerated peri-operative care <strong>and</strong> rehabilitation<br />
intervention compared to current intervention after hip <strong>and</strong> knee<br />
arthroplasty. A before-after trial <strong>of</strong> 247 patients <strong>with</strong> a 3-month followup;<br />
Kristian Larsen, Karen Elisabeth Hvass, Torben B Hansen, Per B<br />
Thomsen <strong>and</strong> Kjeld Søballe; BMC Musculoskeletal Disorders 2008, 9:59<br />
10. Pre-operative predictors <strong>of</strong> the length <strong>of</strong> hospital stay in total knee<br />
replacement; I. D. M. Smith,; R. Elton,; J. A. Ballantyne, <strong>and</strong> I. J.<br />
Brenkel, FRCSEd, J Bone Joint Surg Br 2008; 90-B: 1435-1440<br />
11. Targeted postoperative care improves discharge outcome after hip or<br />
knee arthroplasty,Leonie Oldmeadow et al 2004; Archives <strong>of</strong> Physical<br />
Medicine <strong>and</strong> Rehabilitation 85(9)1424-7<br />
12. Factors Influencing Early Rehabilitation After THA Systematic Review<br />
Vivek Sharma MD, Patrick M. Morgan MD, Edward Y. Cheng MD; Clin<br />
Orthop Relat Res (2009) 467:1400–1411<br />
13. Multidisciplinary rehabilitation programmes following joint<br />
replacement at the hip <strong>and</strong> knee in chronic arthropathy; Fary Khan,<br />
Louisa Ng, Senen Gonzalez, Tom Hale, Lynne Turner-Stokes Cochrane<br />
database <strong>of</strong> Systematic Reviews Year: 2008<br />
14. The effect <strong>of</strong> an educational program to improve health-related quality<br />
<strong>of</strong> life in patients <strong>with</strong> osteoarthritis on waiting list for total knee<br />
replacement: a r<strong>and</strong>omized study. Nunez M, Nunez E, Segur JM,<br />
Macule F, Quinto L, Hern<strong>and</strong>ez MV, Vilalta C: Osteoarthritis Cartilage<br />
2006, 14(3):279-285<br />
15. Effect <strong>of</strong> preoperative exercise on measures <strong>of</strong> functional status in<br />
men <strong>and</strong> women undergoing total hip <strong>and</strong> knee arthroplasty. Rooks<br />
DS, Huang J, Bierbaum BE, Bolus SA, Rubano J, Connolly CE, Alpert S,<br />
Iversen MD, Katz JN: Arthritis Rheum 2006, 55(5):700-708<br />
16. Pre-operative education for hip or knee replacement. McDonald S,<br />
Hetrick S, Green S<br />
17. Cochrane Database Syst Rev 2004, (1):CD003526<br />
38<br />
2009 SPRING MEETING • FACULTY OF PAIN MEDICINE, ANZCA • ACUTE PAIN SPECIAL INTEREST GROUP OF ANZCA, ASA AND NZSA
Topical Session 07<br />
Detoxification Part 2<br />
How to do it: 3 Approaches<br />
Dr Charles Brooker<br />
Royal North Shore Hospital, NSW<br />
Pr<strong>of</strong>essor Jon Currie<br />
St Vincent’s Hospital, VIC<br />
Dr Mike McDonough<br />
Western Health, VIC<br />
This session aims to examine the difficulties surrounding<br />
patients in whom inappropriate or unstable opioid use<br />
has developed. Cases will be presented highlighting<br />
successes <strong>and</strong> failures <strong>of</strong> detoxification approaches<br />
followed by a series <strong>of</strong> expert viewpoints <strong>of</strong> the<br />
appropriate detoxification techniques.<br />
Specific difficulties occur where opioid detoxification is<br />
viewed as an essential safety intervention in the ongoing<br />
management <strong>of</strong> the patient but the clinician’s view<br />
conflicts <strong>with</strong> the patient’s own desire to continue using<br />
opioids. Recent situations where this has been presented<br />
as a “human rights” issue will be discussed.<br />
Time will be allowed for an open forum discussion <strong>and</strong><br />
participants can add to the quality <strong>of</strong> the discourse by<br />
underst<strong>and</strong>ing the legal <strong>and</strong> clinical obligations that may<br />
arise relating to their own specific practice.<br />
39
Notes<br />
40<br />
2009 SPRING MEETING • FACULTY OF PAIN MEDICINE, ANZCA • ACUTE PAIN SPECIAL INTEREST GROUP OF ANZCA, ASA AND NZSA
Organising Committee<br />
Dr Carolyn Arnold<br />
Dr Jane Trinca<br />
Dr Bronwen Evans<br />
Dr Julia Fleming<br />
Dr Malcolm Hogg<br />
Assoc Pr<strong>of</strong>essor Kate Jackson<br />
Dr Terry Lim<br />
Dr Clayton Thomas<br />
Convenor<br />
Co-Convenor<br />
Committee Member<br />
Committee Member<br />
Committee Member<br />
Committee Member<br />
Committee Member<br />
Committee Member<br />
Conference Secretariat<br />
Christine Gill<br />
630 St Kilda Rd<br />
Melbourne VIC 3004<br />
Ph: +61 3 9510 6299<br />
Fax: +61 3 9510 6786<br />
Email: cgill@anzca.edu.au<br />
www.anzca.edu.au/fpm/events/2009springmeeting<br />
COMBINED CME SPRING MEETING • FACULTY OF PAIN MEDICINE, ANZCA • ACUTE PAIN SPECIAL INTEREST GROUP OF ANZCA, ASA AND NZSA<br />
• ACUTE PAIN SPECIAL INTEREST GROUP OF IASP