Hvordan hindre at akutt smerte blir kronisk? Audun Stubhaug, avd.leder, professor, Avd. for smertebehandling, OUS

Transkript

1 Hvordan hindre at akutt smerte blir kronisk? Audun Stubhaug, avd.leder, professor, Avd. for smertebehandling, OUS

2 Forebygge akutt til kronisk Omfang av problemet Mekanismer Risikofaktorer Evidens for forebygging? Sekundær forebygging?

3 Acute to chronic Possible models for prospective Acute postoperative pain studies exist Persistent postoperative pain Acute low back pain Acute zoster Chronic low back pain Postherpetic neuralgia

4 Langvarig post-kirurgisk smerte en human eksperimentell modell!

5 En postoperativ modell A nightmare: My breasts are sore, cold and feel like two (big) wounds

6 Langvarig smerte etter kirurgi Kehlet, Jensen, Woolf. Persistent postsurgical pain: risk factors and prevention. Lancet 2006;367:

7 Smerte-karakteristika Hypoaesthesia Trigger område- hypereksitabelt Allodynia-område Spontan brennende smerte

8 Den kirurgiske modellen Pre-op assessment Acute postoperative pain Persistent neuropathic postsurgical pain SURGERY 3/6 months 1 year

9 Secondary prevention Prevention Pre-op assessment Acute postoperative pain Persistent neuropathic postsurgical pain SURGERY 3/6 months 1 year

10 Secondary prevention Prevention Pre-op assessment Acute postoperative pain Persistent neuropathic postsurgical pain SURGERY 3/6 months 1 year Risk factors

11 Risikofaktorer Preoperative Perioperative Postoperative

12 Preoperative risikofaktorer Psyko-sosiale Nociceptive funksjon Andre smertetilstander Smerte I operasjonsområdet Genetiske faktorer Demografiske faktorer Kvinner > Menn Økende riskio ved lavere alder?? Cytostatika Strålebehandling

13 Clin J Pain, 2012, EPub ahead of print The overall pooled odds ratio, on the basis of 15 studies, ranged from 1.55 (95% confidence interval, ) to 2.10 (95% confidence interval, ). Pain catastrophizing might be of higher predictive utility compared with general anxiety or more specific painrelated anxiety.

14 Utkomme: Helserelatert livskvalitet (N=400) Risikofaktorer som kan forebygges: Postoperativ smerteintensitete Preoperative angst British J Surgery 2011

15 Preoperativ smerte

16 N=111 30% - langvarig smerte median median 64 mndr etter kirurgi Preoperativ smerte ga fedoblet risiko for langvarige smerter, odds ratio of 5.17, 95% confidence interval [CI] , P 0.002); Kjemoterapi ga 3dobletrisiko (OR 3.0, 95% CI , P 0.017).

17 Preoperativ smerte i området for kirurgi Risikofaktor for flere typer kirurgi: Lyskebrokk Galleoperasjoner - kolecystektomi Hysterektomi Ett eksempel!!

18 Langvarig smerte etter scolioseoperasjon som 13 åring. Nå arrkorreksjon, 7 år senere (dagkirurgi) Allodynia. Area with Spontaneous burning pain Pinprick hyperalgesia and Temporal summation Cold and heat allodynia Anaesthesia Reinnlagt med ekstreme smerter samme natt

19 BMJ; 2013, April 2411 women followed for 5-7 years after breast cancer surgery

20 Risk factors for pain(adjusted) Axillary lymph node dissection vs sentinel lymph node biopsy OR 2.04 ( ) Younger age y vs >70y: OR 1.86 ( ) <49 y vs > 70y: OR 1.78 ( )

21 Pain changed with time (progress and regress)

22 Andre smerteplager Mange studier har vist at pasienter med andre smerteplager som for eksempel fibromyalgi, irritabel tamsyndrim osv har betydelig økt risiko for kronisitet

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24 Betydningen av andre smerteplager Johansen A et al, 2014

25 Nociceptive function

26 Preoperative QST assessments may predict up to 54% of the variance in postoperative pain experience, particularly after cesarean section, and in development of persistent postsurgical pain. The predictive ability of thermal methods requires stimuli of suprathreshold intensity,

27 Postoperative pain following anterior cruciate ligament repair

28 Estimated risk (%) for PPP related activity impairment NRS pain score during 47 deg C stimulation

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30 Genetic factors

31 Individual genes of special interest Catechol-metyl-O-tranferase gene (COMT) Melanocortin gene μ-opioid receptor gene(oprm1) GTP cyclohydrolase gene (GCH1) sodium-channel gene SCN9A CACNJ2-gene

32 One new and promising genetic risk factor- a potassium channel subunit Risk allele prevalence is high, with 18 22% homozygous, and 50% heterozygous.

33 Risk allele prevalence is high, with 18 22% of the population homozygous, and an additional 50% heterozygous.

34 Acute pain after thoracic surgery predicts long-term post-thoracotomy pain Reproduced in numerous prospective studies..but Katz J et al. Clin J Pain 1996;12:50-55

35 Analgesia Postoperative pain intensity is a risk factor for persistent pain. Thus, we may hope we can reduce prevalence and severity of persistent postsurgical pain by optimal management of acute postoperative pain. However, no large, well-designed, randomised study has shown such a direct effect of generally improved analgesia.

36 Immobilisering Gips i 4 uker

37 N=30

38 4 uker gipset underarm hos friske N= 21 Etter 4 uker gips: 21/21 Temperaturforskjell 16/21 redusert bev tommel 12/21 endret følesans 4/21 temporal summasjon 7/21 spontan smerte Forandringene varte i opptil 5 uker etter gipsfjernelse Butler SH et al, 2000

39 Opioider Er morfinbehandling risikosport?

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41 Smerte og hypersensitivitet etter 6 uker: > 10 ganger øket risiko for kronisitet

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44 Secondary prevention We need proven Prevention interventions Pre-op assessment Acute postoperative pain Persistent neuropathic postsurgical pain SURGERY 3/6 months 1 year Identifikasjon of risk subjects is possible: Risk factors Preoperatively Catastrophizing Preoperative pain Comorbid pain Type of surgery Early postoperatively Pain Sensory function

45 Sekundær forebygging Smerte 2-6 uker etter traume/operasjon Overfølsomme Sekundær forebygging. Ingen studier. Forslag til studier: Clonidine Gabapentin/pregabalin Corticosteroider Vitamin C Andre antihyperalgetiske medikamenter

46 Doctors pour drugs of which they know little, for diseases of which they know less, into patients - of whom they know nothing Voltaire

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52 Participants 496 volunteer patients of occupational health clinics acute, work related LBP (<14 days) Texas, Massachusetts, Rhode Island Procedure Completion of screening questionnaire 3 month follow up Cluster analysis Relate subgroups to 3 months outcome Identify risk factors and possible preventive strategies

53 11 domains Pain intensity Functional limitations Pain catastrophizing Kinesiophobia Depression Organizational support Life impact of pain Recovery expectations Co worker support Physical demands at work Work satisfaction (Bio)-psycho-social model

54 Reme et al. (2012). J Occup Rehabil

58 Reme et al. (2012). J Occup Rehabil Pain intensity 3 months

59 Disability 3 months * * Reme et al. (2012). J Occup Rehabil

60 RTW 3 months Subgroups OR 95% CI P-value Low risk 1 Work Physical Emotional <.001 Reme et al. (2012). J Occup Rehabil

61 Early interventions only in high risk group - guided by individual risk factors Screening High Risk Low Risk Physical Work Emotional

62 Hva kan vi gjøre Identifiser risikopasienter Redusere angst/preop smerte? Unngå Immobilisering Opioider?? Antihyperalgetiske medikamenter? Sekundær profylakse ved langvarige smerter?

63 Hvordan hindre at akutt smerte blir kronisk? Audun Stubhaug, avd.leder, professor, Avd. for smertebehandling, OUS