AS a GP, managing patients with chronic pain has never been so difficult. From the expectations of the patients with Dr Google at their fingertips to the restrictive prescribing practices to avoid opioid and drug dependence and doctor shopping, pain management has become fraught with danger for the family GP with limited pain management experience who relies on pain specialists for advice and guidance.
As an intern discharging patients after an operation, we were given very strict instructions on the prescribing of short term pain management medication on discharge. My first surgical team (vascular surgery) was unusual in that most of our patients had very little post-operative pain due to having a limited blood supply and a degree of neuropathy. Patients with nerve pain were much harder to manage but were not the norm.
Moving into the general surgical unit, we were given guidance by our superiors in prescribing discharge medication and instructing patients that if they needed pain medications beyond that period, then they should see their GP for a review, to be certain there was no post-operative complication.
Working in general practice 3 years later, being thrust into the position of being the post-operative review doctor was a rude awakening. It seemed to me that patients were lacking in patience (pardon the pun) and were reluctant to take the recommended time needed for recovery. This frequently meant that patients’ expectations were not being met, and they were relying on addictive pain medication to return to work. I would see patients discharged with 2–3 months of medications such as codeine for post-operative pain that should have resolved within 6 weeks, well managed with paracetamol and non-steroidal anti-inflammatories. Making matters worse were patients complaining of insomnia who continued to use these medications for sleeping rather than for pain — a slippery slope clinicians should be acutely aware of.
Ten years on and working back in rural emergency departments, I was again shocked at the number of patients presenting for prescriptions of opioids and drugs of addiction, despite the prescribing restrictions put in place.
On my first day, I notified the nursing staff that I would not be prescribing any Schedule 8 drugs for any patients who presented asking for this medication as they had “run out”, advising them they must return to their regular GP. This was met with many angry patients, but over the next few weeks, the nursing staff stood firm, the hospital’s policy was made clear and we had fewer patients asking for these medications.
What stood out to me in this environment compared with general practice was that with the support of coworkers and policy makers, and not knowing the patients in the community setting, it was far easier to say no and have their pain appropriately reviewed.
In Australia, we are bound by each state’s Medicines and Poisons Regulation, which, as a locum and visiting doctor, can be very challenging. What stands out as a doctor working in various states is that there is a distinct move to restrict the prescribing of drugs of addiction. What is also glaringly obvious is the lack of education accessed by practitioners for discharging doctors and GPs in the management of ongoing or chronic pain. The online training that is available via colleges and NPS MedicineWise provides valuable insight for practitioners but is often overlooked. It also fails to address the area of early intervention and management of patient expectations after procedures. Education often focuses on pain management once it has become a problem rather than as a preventive measure.
These links will assist practitioners in accessing these education sessions:
- Royal Australian College of General Practitioners (RACGP): Prescribing drugs of dependence in general practice — Part A — Clinical Governance Framework;
- RACGP Prescribing drugs of dependence in general practice — Part C1: Opioids;
- Australian College of Rural and Remote Medicine: Codeine Rescheduling; and
- NPS MedicineWise: Chronic pain.
There is currently a 12–18 month wait for chronic pain management reviews in most public hospitals in Australia, which results in many patients being financially destitute and depressed by the time they reach their first appointment. As a medical practitioner, I find the ongoing frustration of patients well justified and now, with restrictive prescribing, many patients are living with severe pain on a daily basis while waiting for pain management review.
In an attempt to avoid the numbers of deaths from prescription medication in the United States we have missed a key component in pain management. Rather than restricting the drugs of addiction we first need to educate medical practitioners in the management of post-operative pain. We also need to provide patients with a reasonable expectation for returning to their normal duties and the duration of time needed to rest and recuperate, in order to avoid unnecessary medications.
Finally, we need to address patients who have been prescribed medications in the long term with management plans that provide them with an adequate quality of life, rather than restricting their medication, which leaves them frustrated, angry and depressed. Managing medications of addiction must be a multidisciplinary effort that provides alternatives and solutions rather than restrictions that encourage patients to reach for alternatives, such as illicit drugs and alcohol. Prevention is far better than dealing with medication addiction and, as health professionals, we have an obligation to our patients and community to be sure we are managing these issues on a level that results in positive outcomes.
Dr April Armstrong is a rural doctor working in Western Australia, New South Wales and Victoria. She is the founder of the Business for Doctors social media group supporting 26 000 Doctors, and the 2015 WA Telstra Business Woman of the Year for her medical practice in Kalgoorlie.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.