Reconfiguring the doctor-patient
environment in musculoskeletal pain
What you say, matters
John Petrie
Dunedin, 1st April 2016
Disclaimer: Commercial support from...
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Ciba-Geigy
Lilly
MSD
Novartis
Roche
Pfizer
Sanofi
Wyeth
Abbvie
Degeneration
• Dissolving, disintegrating, descent, damaged, dissipation,
debasement, decline
• Colloquially “damaged, worn out, stuffed, rooted, collapsing,
munted (cantab)”
• An invariably negative connotation
Miscommunication
Dr SAYS:
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Patient HEARS:
Degeneration
Wear & tear
No cure
Learn to live with it
Take your painkillers only when
necessary
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Disintegrating
Continuing damage
Nothing can help me
I’ll wind up in a wheelchair
I must just suffer the pain
Iatrogenic Disability
Mechanism of Pain
• Originally it was thought that a
sensory input caused a pain
"signal" to be sent directly to the
brain via a single nerve
• Today’s science reveals a much
more complex process, and chain
of events
Nerve pulse transmission
Electrical
Chemical
Electrical
There are many influences on the end pain experience.
Pain
Physicians view
• Presenting symptom
• Aid to diagnosis
• Outcome measure
• Frustrating impediment to sense of
professional competence
Patients view
• Distressing symptom
• Harbinger of disease
• Threat to independence and freedom
of choice
• Major emotional and social stressor
Placebo
Nocebo
Expectations change the effectiveness of opioids
What is more powerful - opioid or verbal instruction?
“neutral statement”
“This will help reduce pain”
“This will make you more
sensitive to pain”
Bingel et al., (2012); Rief et al., (2011)
Back pain expectations and treatment effects
90
80
70
60
50
Improved
with
accupuncture
Improved
with
massage
Higher
expectations
of Rx
Lower
expectations
of Rx
Kalauokalani et al (2001)
Propecia 5 mg and sexual side effects:
Informed
Uninformed
40
30
20
10
0
Erectile
dysfunction
Decreased libido
Ejaculation
disorders
(Mondaini et al., 2007)
The words we use for medication..
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Analgesics = Pain “killers”
NSAIDs = Non-Steroidal Anti Inflammatory Drugs
Arthritis Drugs
Immunosuppressants
Cancer drugs
• All with potent Nocebo implications
Relative Risk
• Taking a NSAID leads to a 30 to 40% increase in heart attacks
P Value significance
• > .01 for diclofenac &coxib
CNT Study authors summary
• We undertook meta-analyses of 280 trials of NSAIDs versus
placebo (124 513 participants, 68 342 person-years) and 474
trials of one NSAID versus another NSAID (229 296
participants, 165 456 person-years).
Lancet 2013; 382:769-79
Natural Frequency
• Compared with placebo, of 1000 patients allocated to a coxib
or diclofenac for a year, three more had major vascular events,
one of which was fatal.
Lancet 2013; 382:769-79
Chance of Injury or Death on NZ Roads
1:337
NewSpeak for Medical Practitioners
• Mobility Enhancing Medicine
– Identifies the purpose of the medication
– Uplifting phraseology
– Benign identification of chemical constituents
– Positive framing
• Regenerative Bone Changes
– Identifies bone response to osteoarthritis
– Often age-appropriate in the absence of disease
Evidence about Opioid Therapy
• Benefits of long-term opioid therapy for chronic pain not well
supported by evidence.
• Short-term benefits small to moderate for pain; inconsistent
for function.
• Insufficient evidence for long-term benefits in low back pain,
headache, and fibromyalgia.
U.S. Department of
Health and Human Services
Centers for Disease
Control and Prevention March 2016
Opioid-induced hyperalgesia
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Pain persists or increases with increased opioid dose
Pain increases with constant opioid dose
Pain worse on opioid treatment than before treatment with opioids
Duration of analgesia decreases with duration of therapy
Pain becomes increasingly diffuse and less well defined in character
Opioid Tolerance v Hyperalgesia
Non-Opioid Therapies
• Non-opioid medications (eg, NSAIDs, TCAs, SNRIs, anticonvulsants).
• Physical treatments (eg, exercise therapy, weight loss).
• Behavioural treatment (eg, CBT).
• Procedures (eg, intra-articular corticosteroids).
U.S. Department of
Health and Human Services
Centers for Disease
Control and Prevention March 2016
Is it Arthritis?
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Rheumatoid Factor (RhF) present in 80% of RA patients
False +ve in 5% normals, increases with age
Anti CCP more specific, false +ves in low range
Evidence of synovitis required to consider the diagnosis
Is it Arthritis?
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HLAB27 present in 9% of NZ population
Spondyloarthropathy has a prevalence of ≈1%
≈90% of carriers will not have Ankylosing Spondylitis
Clinical features are necessary to consider the diagnosis
Xrays often normal in early stages
Is it Arthritis?
• 70% of hyperuricaemic patients will never get gout
• 40% of patients with acute gout will have a normal uric acid at
presentation
• Allopurinol does not prevent acute gout
• Gold standard of diagnosis is the presence of uric acid in joint
aspirates
Is it Arthritis?
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+ve ANF (or ANA) is not diagnostic of SLE
False +ves occur in up to 40% of normals
May be more common in Fibromyalgia
Absence of clinical features militates against considering the
diagnosis
• Low prevalence of Lupus 1:2,000
Is it Arthritis?
• Radiology reports misclassify age-appropriate changes as
“Degenerative”
• “Degenerative arthritis” often used as a synonym for
Osteoarthritis
• Clear evidence of a poor correlation between Xrays of lumbar
spine, hip & knee and symptoms of pain