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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.
This is a problem that is extremely complex. I’ve seen several sides of the argument, I’m a paramedic and nurse. I watched my ex husband go through X 2 Disc replacements and drug addiction, which lead to divorce and finally his death from chronic heart disease.
I have been an advocate of strict pain relief regime and thorough patient education. Now I have been subjected to further life experience, an acute back injury and a lateral discectomy. It’s early days, but I have suffered greatly with pain and it’s ongoing. I’m one tough cookie, but this nerve pain can break you. As a clinician it is a interesting educational experience. I now understand at a deeper level, the effects of this type of pain has on your body and mind, it’s awful.
I’m utilising both western and eastern medicine to heal. But you can never fully understand unless you experience it. I didn’t understand how pain can be all consuming.
It’s fine to suggest people manage their pain with physio, OT, psychology, etc but it costs. A lot. For most people it is simply out of reach.
Effective pain relief is now increasingly difficult to get. Doctors, even those whom you’ve seen for years, have treated your pain, and seen your x-rays are reluctant to prescribe anything more the extra strong Panadeine. They are worried about health departments investigating them or colleagues questioning their methods. Seeing them is now an exercise in humiliation.
If you have no money for the gold class treatment suggested by Matt and others you are left to fend for yourself. Your daily life becomes one of doing the best you can but things get harder and harder to do. You are never at rest, never in comfort. Your family life suffers. Your work life suffers. At 56 all you can see is ever increasing pain for the next couple of decades, combined with humiliation and belittlement by medical practitioners who have little understanding and even less empathy.
Is it no wonder suicide rates are climbing? I’ve just stopped having my regular endoscopy and other tests in the hope I get cancer sooner than later. At least then I can die without the stress of suicide on those around me, but I’m also no longer a pain ridden burden on them.
Researchers and doctors just using numbers to get the result they want should congratulate themselves. At least the “studies” and “stats” show the new regime is working.
https://www.betterpainmanagement.com
https://www.aci.health.nsw.gov.au/chronic-pain
There is evidence that restricting and reducing opioids doesn’t worsen pain control, but does improve mood and general functioning, given the significant side-effects of long-term opioids – including worsened pain. Ensuring that all doctors are well-educated about these matters is crucial, not least to ensure that patients are properly educated and can understand why drugs might actually do them more harm than good.
Restrictive prescribing is essential to ensure that those who are not properly abreast of all the issues cannot overprescribe these very harmful medications. Telephone advice from pain units is widely available for refractory patients waiting to be seen.
Great to get a GP’s perspective on this difficult problem. However, I do believe there is a misinterpretation in the analysis of access to pain clinics:
“Qualitative data gathered through interviews with primary care clinicians found that primary care clinicians perceive that the current wait time for their patients to access pain management clinics is 12-18 months. These views are not consistent with ePPOC data”
“The current median waiting time for patients waiting to access pain management and support services, as identified through the analysis of ePPOC data, is 63 days”. This is from the ACI report you have hyperlinked in the article.
There may be a perception of long waiting times and there is some variation between clinics but the data suggests otherwise.
Managing acute pain well seems likely to facilitate early return to mobility and function and might well lessen longer term chronic pain problems.
But can anyone (especially orthopaedic and anaesthetic colleagues) explain why I’m seeing a steady trickle of post-operative patients on as many as FOUR separate opioid medications? Two long acting and two immediate release preparations are not uncommon; lately, mixtures of tapentadol and oxycodone appear fashionable. Sometimes they’re all recommended ‘prn’.
One drug, in slow-acting (for background pain) and immediate-release (for breakthrough), would be at least plausible. But why multiples? Is there evidence or a guideline I’ve not been able to identify?
A pain specialist is not going to be a magic cure, But if seeing one it shouldn’t wait months to years!
Options are- see a private pain specialist (maybe find some way for the pt to cover any gap). Go straight to this for compensable pts (ask the insurer to cover travel if not available locally..)
see a non- pain rehab Dr, who may have a lot more experience with pain, as it’s what many deal with every day
Find the relevant multidisciplinary practitioners
18 months is ridiculous but there is often another way.
Matt Bryant points out the need for a coordinated, multidisciplinary approach. Unfortunately the services we need to provide this are not adequately funded to provide timely and consistent treatment for all of the patients who would benefit from this. The most obvious barriers to appropriately managing chronic pain in the community are short consultation times in general practice, and long waiting lists for pain management specialists.
Recent changes in pain-prescribing practices are having dramatic impacts on many so-called “legacy patients”, who have been prescribed long-acting opioids to manage chronic, non-cancer, pain. Over the last few years increasing numbers of these patients are reporting that concerned GPs have referred them for 12 to 18 months of waiting for a specialist to properly assess and treat their pain, but have immediately initiated abrupt dose reductions or complete cessation of treatment. While there are obvious risks associated with inappropriately liberal prescription of opioids, there are also risks associated when chronic or acute pain is not adequately addressed, especially in patients who have a previous history of chronic opioid therapy or of illicit opioid use.
Here are some tips from a consumer’s point of view on managing these risks sensitively…
https://www.medicalhub.com.au/between-a-rock-and-a-hard-place-opioid-dependence-addiction-withdrawal-and-pain/
No doubt you will already have made up your own mind about medical acupuncture without reading all the evidence as many before you have. However the science is that Acupuncture reduces TNF ( tissue necrosis factor), reduces ICU stays and has the best outcomes in chronic pain by a country mile (J Pain 2016). Post operative pain – well- Pfannenstiel incision – day 2 -Pain level 3/10 no problem. Physiology sorted. No doubt if it’s not in the RACGP guidelines- it’s not in the universe. OR am I talking to EBM person?
Great article, thanks April. I think you missed something though. The most important aspects of managing chronic pain, supported by current models and evidence, are team based, allied health approaches: physio to get people moving again, psychology to help with people’s fears and any psychiatric co-morbidity, and OT to help with goals, ADL’s and work. This work can be done really well in primary care. Best practice pain management is the other side of the coin of opioid overdose and other harms. Best practice pain management is not being taught to medical students or post graduate doctors enough.
Thank you April information was good reading