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Ok. Well, um apologies for that. Uh We'll just keep rolling on it now is working. We don't know what we did. There we go. So there are lots of different reasons for someone to have pain in advanced cancer. Ok. It is not, it is II you know, to say someone's got, you know, the the the report comes back, the patient has lung cancer and they've got pain. What, what can I give or what can I do? Well, that gives me absolutely no information at all. There could be a multitude of reasons why this patient has pain. It is not direct tumor pain. And actually we find the most difficult pains are not even direct tumor pains. So taking some kind of pain history and coming to a pain diagnosis should not be beyond the realms of a second or third year medical students. This should be entirely possible to do. Ok. So the point is pain very common in advanced cancer, 70% will experience pain but in non malignant conditions, pain is still up there. Reported at around the 60 65% mark, which is maybe a little surprising that other conditions. Um would have a lot of pain, but this would include sort of Parkinson's disease. It's around the 50% MS, around the 40%. It's very hard to get exact figures for this M ND. At 85 heart failure has got this massive range somewhere between 20 80%. Uh CO PD also has a massive range and renal failure has got 60 to 90%. So lots of conditions are painful again. Coming back to this isn't just about a cancer tumor type pain. This is um taking it deeper and trying to understand what, where is the pain, of course, and what is the character of the pain, the nature of the pain and coming to a pain diagnosis. I don't really make diagnoses really in palliative care, but I do make pain diagnoses or the cause of something or the cause of the sickness, the cause of the nausea. Uh the, the the, yeah, the cause of things. So what are the types of pain? So I suppose if you're going to be thinking of pain, you can think about acute pains. So, POSTOP pain, that's very much acute, that's your acute pain team, um your breaks or your uh you know, your injuries, that's fine, that's acute pain. We know what that sort of pattern looks like or what it responds to and, and it's not probably going to be a long term problem. Chronic pain is a totally different world of pain. So if you have pain for more than three months, uh and it's not going to fall into sort of this cancer pain kind of description, it's probably chronic pain. So a lot of those patients with non malignant conditions who are dying of Parkinson's disease or other things, it's probably a chronic pain, chronic musculoskeletal pain, chronic back pain, all your chronic pains, those aren't opioid focused pains. Ok. So I will try to explain to you quite clearly how that isn't an opioid focused pain and why it is really important that you know, the pain that you're treating before you reach for an opioid. On the other side, we've got cancer pain and it used to just be cancer pain. But now it's a bit more complicated. You've got cancer pain and sort of active advanced disease. You've got cancer pain in patients who are either cured of cancer or long term surviving with their cancer. So, uh so patients, um not every patient who continues to have cancer in their body for two or three years will be palliative. They could be a long term survivor expected to live for many years. Again, you are not focusing on opioids in that condition because who's ever seen a healthy opioid addict after many years of opioid use? Nobody. So you're, again, you're thinking maybe less opioids there and then your anticancer treatment. So maybe they've had their cancer and they've got some side effects from their cancer treatment, some of those neuropathies or plexopathy. Again, it's not the direct tumor pain. You're gonna have to think about that. And what is the best? Is it a neuropathic agent? Is it something different? What is the, what is the treatment for that cause of pain? So, just to remind us that chronic pain, um you know, the risk of getting old is not great, but those are the numbers, lots of people have chronic pain in the UK uh up to maybe 50% it increases with age. So enjoy youth uh over 75 years old, 60% chance of getting that chronic pain ongoing, whether it's osteoarthritis or whatever it is. So, opioids are good and opioids are good, they are very useful drugs. So this is uh from Cochrane Library. This tells us it's, it's looking at opioids specifically for cancer pain. So, thinking of active cancer pain. Um and the evidence is never great. It shows that in about 19, out of 20 people with moderate or severe cancer pain who are given opioids and can tolerate them will have that pain reduced to mild or no pain within about two weeks. So basically, if you've got 20 people with t with cancer pain, that's from that direct tumor cancer pain. And you're gonna give them opioids for about two weeks, the vast majority you are going to manage that pain for. So, opioids are good with direct tumor pains. Ok. Great. Perfect opioids. Are also good for nerve pain. So now I know in we would often say opioids are not particularly good for nerve pain, but actually, they are not bad. Ok. Again, we're thinking about the cancer induced the tumor, cancer induced nerve pain. So the tumor is pressing on a nerve, this nerve pain. So this kind of shows us that actually, um if you've ever worked out, what a number needed to treat is for, say, a number needed to treat pregabalin for nerve pain. It's because as they've done studies, the number gets smaller and smaller. Ok. The number gets bigger and bigger, they realize that nerve pain killers are maybe not as good as we always thought. So this is sitting in my head, I suppose we've got pregabalin, it's got a number needed to treat of about 10 or so. Um So you need to treat 10 people to get one benefit. And that's because uh it, the medicines aren't as effective as say, even the strong opioids. If you've got a nerve pain, then you know, you're sitting at around a five, five people to treat to get benefit from one. Again, this is if it is cancer causing your nerve pain, but opioids are very bad, very, very bad. So if you've been watching any of the sort of the dope sick or the Netflix documentaries on the Opioids, you will know something about the opioid pain crisis, which is predominantly in America. So the, um, Sackler family are the, probably the most hated family in America. And here you see them ceremoniously taking off the name. So they, they, they, so I think it's two brothers and a sister and they ran Per Do Pharma, uh, a company that's now closed and it was in the eighties. But they started pushing this wonder drug, oxycontin for every ache and pain, chronic pain, acute pain, every ache and pain that you had, you went to your doctor and they in America and they would have given you this. Um apparently it wasn't addictive. So that's what their bad science studies showed. And even in the nineties, they knew at that point that it was addictive and they continued to push it. So they would whine and dine the medics and the pharmacists and anybody who was prescribing this drug, they pay for them to go to conferences and they continued this right into the naughty whenever they were sure that it was causing problems. So the Sackler family then took all the money out of the company. Um Basically the company became closed and you can't sue them anymore. Um And because of this, they donated lots of money to sort of good causes and arts causes. So a lot of, a lot of um groups don't want their name associated with this a family, but it is a good lesson to us on medicine and safe medicine, prescribing. Ok. So these are the they talk about the three waves of death for opioid overdose. So this is the first one in the, the light teal color. So that's kind of happened. Um If you like, so it's prescription overdose should be coming down. Now, then the next one was heroin, which at least doctors don't have to take any particular responsibility for. But then this is the kind of the final one that's set to peak. So this is synthetic opioid substances. So this is your fentaNYL patches, you know, just the wee peeing patch. You know, the it's just considered a wee ping patch and the doses that we know that you can get up very high on those very quickly. So that's, that's coming up now. So you can see these deaths happening and this was not, I would have to say because of cancer pain, this is whenever you use the principles of cancer pain, prescribing in the wrong context. Ok. So chronic pain has got a whole process that is entirely separate. And in one person's body, you can, I can have my lung cancer tumor, but I can have my terrible osteoarthritis. At the same time, it is possible to have two pains in the one body and one can be related to your cancer. And and you can actually do 23 pains very commonly. We see this. So just this is to remind you that chronic pain is a whole separate process with exercise programs, physical activity, psychological therapy, all of this kind of thing, all of the intervention, nerve stuff is not opioid focused and it is very clear. Um don't give it opioids for chronic primary care pain, evidence of long term harm along with any lack of evidence for effectiveness in opioids. Persuaded the committee to recommend again starting opioid treatment for people with chronic primary pain. So it's all right to know that in chronic pain, about 10% of patients will respond to an opioid. Ok, that's fine. But the other 90% will come back again and again and say, well, it must be doing some good. Just give me some more. It must be doing some good because that's, that's the attitude. So it's safer to not start and not create those problems. So, opioids are scary. Opioids are scary to patients. Ok?