“Disconnect” in managing pain

IMPROVED communication between specialist and primary care services is crucial for patients with chronic pain and could have both preventive and clinical benefits, says a pain management expert.

Dr Malcolm Hogg, head of pain services at the Royal Melbourne Hospital, said by addressing the “disconnect” between general practice and specialist pain services health outcomes for patients would be greatly improved.

He was commenting on an MJA editorial, published online today, by Professor Geoffrey Mitchell, which said waiting times for assessment and treatment of chronic pain patients in specialist multidisciplinary clinics and the transition to community-based care were two key “fault lines” in the current models of care for patients with chronic pain. (1)

Professor Mitchell, professor of general practice and palliative care at the University of Queensland, said while formal collaboration between GPs and specialists in chronic pain management had not been formally tested in clinical trials, trials in stroke treatment and palliative care had shown the benefits of formal case conferences.

“The key to success is to recognise that the work patterns and demands of general practice and the specialist team are fundamentally different, and the parties only need to make contact for a short time to conduct the case conference”, Professor Mitchell wrote.

Dr Hogg said the disconnect between acute pain services, outpatient pain clinics and general practice was largely caused by federal–state funding barriers. Long waiting lists due to a lack of access to outpatient pain services also resulted in extended lag times and contributed to communication difficulties, he said.

“There are problems on both sides”, Dr Hogg said. Acute hospitals and chronic pain clinics might not fully appreciate the importance of good communication and GPs, particularly those in corporate practices, might be hesitant to return phone calls because of time and funding constraints.

Dr Hogg said some of the outcomes of this lack of coordination of pain management services to community care included a higher uptake of the disability support pension, potential for excess reliance on opioids for pain management in the community and higher risk of psychological distress and suicide related to chronic pain.

He agreed with the MJA editorial that a formalised process could be beneficial but said there were difficulties in coordinating times when all health care parties were available.

“Possible alternatives that should be considered [include] email-based, question-and-answer discussions”, he said, adding that practice coordinators had a role in facilitating such discussions.

Dr Hogg said while GPs could sometimes access funding through the Chronic Disease Management Medicare items, this funding may not be available to their specialist counterparts. This Medicare funding was also not available in the acute and subacute phases, when optimal management could be most effective.

“We need realignment of the funding process”, he said.

Dr Hogg said better education of and engagement with GPs would lead to earlier, optimal care, which would have long-term benefits for patients.

“The earlier and better you manage pain, the better the outcome. Those patients waiting 12, 18, 24 months [to access pain management services] have a lower chance of recovery than if they had received early, optimal care.”

Consumers Health Forum CEO Carol Bennett welcomed the call for more collaboration and the “growing recognition of chronic pain as a stand-alone issue, not just a symptom”.

“Consumers with chronic pain have to repeat their story to doctors and specialists again and again. It can take years to identify their issues and find treatment”, Ms Bennett told MJA InSight.

Ms Bennett said improving collaboration between GPs and specialists would reduce the need for consumers to repeat their stories, lower the risk of communication errors and make it easier for consumers to find the treatment they need.

- Nicole MacKee

1. MJA 2013; Online 11 March

Posted 11 March 2013