On Saturday 27 February 2016, the NCPHN held a workshop in Byron Bay on acute and chronic pain management. This large topic was dealt with over four hours and this article will review the highlights and take-home messages of an event that was well attended by GPs and allied health professionals.
The event was well run and chaired by experienced and well-known GP educator Hilton Koppe. The program gave practical advice for managing challenging patients with significant chronic pain.
The keynote speaker was Professor Michael Nicholas, Pain Management Research Institute, University of Sydney, Royal North Shore Hospital. He pointed out that whilst acute pain is a useful warning signal, chronic pain causes major disability and suffering.
Once pain following an injury persists beyond the normal healing time of up to three months the only realistic option is to reduce its impact. The focus needs to be on self management and daily functioning rather than trying to ‘fix up’ the pain. For a GP this revelation can be a relief from relying exclusively on the procedural or medication approach, which rarely seems to totally succeed for chronic pain sufferers, and may even make matters worse.
Community surveys and clinical studies show consistently that people experiencing chronic pain who employ active self-management strategies, such as maintaining daily activities despite the pain, will undergo less pain-related disability than those who adopt more passive approaches, such as resting or relying on others to perform their daily tasks.
Whilst some people may be able to employ their own graded self-management strategies, many will require help in acquiring these skills. GPs will often need to refer chronic pain sufferers to appropriate structured multidisciplinary pain clinics that use cognitive behavioural methods.
The problem is that there is a dearth of specialised public hospital based clinics, resulting in long waiting lists. Access for people in rural areas is particularly difficult.
As GPs today are collaborating more with allied health professionals there is scope for more community management of chronic pain, whether in the practice setting or private allied health facilities. Alternatives such as these are will be needed in the future to keep up with the burgeoning demand.
In an ageing population, and with surveys showing between 10-30% of the population suffering from chronic pain, the burden of this disease on individuals and the health system is huge. While more self-management is clearly needed, it is not yet evident exactly what works, and more research is needed in this area.
For those with chronic pain, some 60% have disability, with depression also common (50%-80%), and the combination inevitably leading to a poorer quality of life.
Acute pain treatments usually relieve occasional headaches, post surgical pain and epidurals for pain during childbirth, but for those with chronic pain on average the reduction in pain with these commonly used treatments is about 30% at best.
So how effective are long term opioids? A review article in Annals of Internal Medicine (January 2015) concluded there is a lack of evidence for the long term benefit of opioids for pain and daily functioning. In addition, there is evidence for dose dependent risk of harms, e.g. overdose, opioid abuse, fractures, myocardial infarction, opioid induced hyperalgesia and sexual dysfunction. The higher the dose, the higher the risk. There are also the well known side effects of opioids, which disappear with dose reduction.
A comprehensive paper, ‘Reconsidering opioid therapy’, from the Health Professional Resources, Hunter Integrated Pain Service concluded that existing evidence does not support the long term efficacy and safety of opioid therapy for chronic non-cancer pain. It provides useful tips for weaning a patient off opioids.
A Cochran Study showed a coordinated intervention covering several domains of the biopsychosocial model was more likely to benefit patients with chronic low back pain in the long term than usual GP or medical specialist care or physical treatment alone. This involved teaching patients with chronic pain how to limit its effect on their lives by having them play an active role. This includes adhering to medication, exercise, meditation etc – all with goals understood and agreed to by the patient.
A biopsychosocial framework needs to be explained to the patient rather than simply saying “try this and see if it helps”. It is important to validate the pain the patient is experiencing and to differentiate between acute pain (a useful warning) and chronic pain with central nervous system sensitisation (fault in wiring).
There are some excellent resources available for patients and health professionals. One highly one recommended is the NSW Agency for Clinical Innovation's Pain Management Network. This ACI resource is an easy-to-negotiate website for patients, with video interviews and steps for self management. There is also a useful section for health professionals.
Local clinicians can access regional information on local pain management on the North Coast via the HealthPathways website. It may be useful to bookmark this site in your browser and on your desktop.
The ACI has also created purpose-designed care plan and team care arrangement template for GPs and practice nurses for chronic pain management.
So, rather than just writing analgesic scripts for patients re-presenting with chronic pain, aim for more self-management. For those with internet access the Pain Management Network resources mentioned above may be helpful. For others, a care plan with appropriate referrals and reviews will be needed. For the most difficult of cases, referring to a local pain clinic for multidisciplinary care will be required. Whatever treatment is used, the biopsychosocial approach produces the best outcomes.
