Dr. Patricia Morley-Forster
Program Director
Several important developments occurred in 2012-2013 for the Western Pain Program. In September, the Pain Management Program at St. Joseph’s Health Care London moved to a 3,326 sq. ft. state-of-the-art facility on the third floor of the hospital. This includes procedure rooms, physician offices and a fluoroscopy suite dedicated to pain management. The fluoroscopy suite allows us to offer a number of fluoroscopically-guided procedures for intractable pain such as nerve root blocks, lumbar and cervical epidural steroid injections, and radiofrequency facet denervation for chronic back and neck pain.
St. Joseph’s Outpatient Pain Clinic receives over 5,000 patient visits per year and this number is growing.
Another exciting event in 2012 was the launch of two websites: the Western Pain Medicine website and St. Joseph’s Pain Management Program website. The Western Pain Medicine website is our virtual voice in research and education, describing the faculty, research, resources, and our contributions to education including upcoming speaking events and conferences. There is also an extensive history of the Earl Russell Research Chair in Pain Management and Research.
A new triage system to streamline our referrals was developed in 2013. It was implemented with direction from Dr. Kate Ower and RN Cathy Rohfritsch. This new triage system has been very effective in reducing the average wait time for new patients to 3-6 months depending on the service required. Urgent consults, specifically complex Regional Pain Syndrome, can be seen within 2-3 weeks.
Clinical Care
In 2011-2012, the outpatient Pain Clinic received 1771 referrals, and almost 5000 patient visits of which 1102 were new referrals. The medical faculty consists of five anesthesiologists, four physiatrists, and one neurologist. Additional health disciplines involved with the team are a psychologist, two RNs, one RPN, a pharmacist and a social worker. Although we bring different training and perspectives to our assessments, we are united in a common value as stated in our Strategic Plan: “We understand that each individual’s experience of pain is unique , affecting their relationships and work-life in a complex manner”.
Managing the wait list for new referrals continues to be our major clinical challenge. The triage nurse faced an increased number of referrals in the fall of 2011 with the untimely death of Dr. David Boyd, at University Hospital. We are working on the development of patient care pathways for specific chronic pain syndromes (eg. peripheral neuropathic pain, post-herpetic neuralgia, complex regional pain, failed back surgery, fibromyalgia and post-surgery pain syndromes) and a clear discharge process to define when care is being returned to the family doctor.
In May 2012, two Strategic Planning Sessions for the Outpatient Chronic Pain Clinic were held. Our two areas of focus for research and clinical care will be:
Education
Anesthesia residents rotate through the Pain Clinic for one block. We also offer Physiatry residents a three month rotation as part of their training requirement. Pain Management continues to be a popular selective with Family Medicine, and Psychiatry.
In March 2012, the Pain Clinic Faculty collaborated to give a three day conference entitled: “A Balanced Approach to Pain Management.” The venue was the In-Medic Pain Management Clinic, a community pain clinic on Adelaide Street. There were almost forty registrants, most of whom were from South Western Ontario but one anesthesiologist came from Sydney, Nova Scotia. We plan to hold these conferences bi-annually.
The first Patient Education Day was held at SJHC on June 8, 2012 and approximately 60 patients attended. Speakers were Dr. Pat Morley-Forster, Dr. Heather Getty, Cathy Lowery RN, and Donna Tierney and Tammy Rice from Physiotherapy and Occupational Therapy. Feedback was very positive and the plan is to offer three Education Days annually.
In 2011-2012 we were fortunate to have the services of an excellent Chronic Pain Fellow, Wilson Tay, from Singapore. He worked extensively with the neurosurgeons, Dr. Andrew Parrent and Dr. Keith McDougall to train in insertion of Spinal Cord Stimulators, a skill he will utilize in Singapore. Another fellow, Maan Kataan, an anesthesiologist from Saudi Arabia, trained under the neurologist, Dr. Dwight Moulin in the field of Neuropathic Pain diagnosis and management.
Interdisciplinary Pain Rounds (MAINPORT –accredited) was held on the fourth Thursday of each month, and featured invited speakers with national and international reputations. As well as the email list, announcements are posted on www.londonpain.ca, and in the Schulich School of Medicine and Dentistry’s weekly electronic newsletter.
“Breakfast and Learn” sessions for all Pain Clinic staff are held on the fourth Friday every month, with the In-Medic Pain Management Clinic staff also attending.
One of the main educational goals highlighted in the updated Strategic Plan 2012-2014 is to become an accredited training program for the new Royal College Subspecialty in Pain Medicine which should be starting in July 2014.
The other main educational goal we are working towards is to increase teaching hours in Year 4 of the medical undergraduate curriculum to 36 hours by 2014 as requested by the Schulich School of Medicine Curriculum Committee.
Research
Over the next four years, our goal is to increase research output in our two areas of focus - neuropathic pain, and interventional procedures for back pain.
Completed Projects:
The Neuropathic Pain Database (NePDAT) study: This multicenter two year cohort study to investigate the long-term outcome of management of neuropathic pain using standard pharmacologic guidelines was finally completed in December 2011. Total enrolment was 798 patients. It will be submitted for publication by the end of 2012.
Dr. Dwight Moulin, Principle Investigator (PI) Dr. Pat Morley-Forster, Co-Investigator (CI)
Plasma concentration of ketamine and norketamine in patients receiving topical ketamine 10% gel for chronic neuropathic pain.
Dr. Raj Manikandan (Fellow), Dr. Pat Morley-Forster, Supervisor
Ongoing Projects
IV Lidocaine for Neuropathic Pain: This is a crossover trial comparing intravenous lidocaine to intravenous benadryl as the active placebo with follow-up over six weeks in each study phase. Enrolment by Dr. Dwight Moulin (PI), Pat Morley-Forster (CI)
Near-infrared Spectroscopic Measurement of Tissue Oxygen Saturation and the Vascular Occlusion test in Complex Regional Pain Syndrome: Dr. Geoff Bellingham (PI). This is a comparison of tissue oxygen saturation after a 3 minute vascular occlusion test as measured by NIRS in upper limbs affected by CRPS vs those of normal volunteers.
Methadone vs Morphine for Neuropathic Pain: This is a multi-centre CIHR-funded RCT to compare the efficacy of oral methadone vs morphine in the management of chronic neuropathic pain. One barrier to its implementation is that Health Canada methadone- prescribing regulations vary among provinces.
