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Can 8 simple questions tackle pain and opioids?

By Helen Signy

A new online decision-support tool has been launched by the NSW Agency for Clinical Innovation (ACI) to help reduce the rampant over-prescribing of opioids for the treatment of chronic non-cancer pain.

The Quicksteps program, developed by the ACI’s Pain Management Network, is a series of eight questions that take GPs through chronic pain management using decision-support tools to create tailored, individual chronic-pain management plans for patients.

Each question highlights where a management plan is needed and provides links and videos at each step to facilitate discussions with patients.

The program was launched in response to the skyrocketing over-prescription of opioids for chronic pain, despite insufficient evidence that they are effective beyond three months1. Opioid therapy for chronic pain has increased 15-fold in the past decade2.

Chronic pain – or pain that has lasted for more than three months – affects about one in five patients presenting to general practice in Australia, according to BEACH data3. Although a number of guidelines recommend that medication be used only as an adjunct to non-pharmacological options, the data shows that more than half of patients are managing chronic pain with medication alone4.

“There has been a disconnect between the use of these medications and our understanding of how they work and why they are effective. And we still don’t have any evidence that tells us opioids are effective long term treatment for chronic pain,” says Sydney GP Dr Hester Wilson, a member of the Agency for Clinical Innovation’s Pain Management Network.

New US guidelines on the management of chronic pain released by the Centers for Disease Control in March prefer non-pharmacologic therapy and non-opioid pharmacologic therapy for chronic pain. Australian guidelines advocate that GPs attempt to de-prescribe opioids at every visit with a patient with chronic pain.

Yet many GPs appear to be unsure how to manage chronic pain beyond writing a script, says Jenni Johnson, network manager for chronic pain with the Agency for Clinical Innovation. 

“A patient will present to the GP in agony with a sports injury and go home with a script, then four weeks later comes back and is sent for X-rays and referrals – three months can go by so fast and you have only seen the patient a couple of times,” she says.

“By three months the injury should have healed. What we need to be doing is manage chronic pain better so we can reduce opioid prescriptions across the state and across the country.”

8 Quick Steps to manage chronic pain without opioids

Step 1: Does history and examination suggest an underlying red flag condition?
What’s causing the pain? Possible fracture? Possible tumour or infection? Possible significant neurological deficit? One or more red flags indicate urgent referral to appropriate provider.

Step 2: Is psychological distress high?
Use a musculoskeletal pain questionnaire (provided) in the early phase of assessment (4-12 weeks) in workers compensation cases and as a predictor of long-term disability. High scores suggest a psychological or mental health plan referral with ongoing review or Pain Management Plan is needed.

Step 3: Is the patient actively engaged in self-management?
Measure the patient’s ability to maintain some normal activities despite the pain, their non-drug ways of self-calming, their approach to active problem solving, alarmist thinking and avoidant behaviours. Patients who are not actively engaged in self-management may need referral to a psychologist.

Step 4: Are medications effective in managing pain and improving function?
If no, then complete a health plan. Discuss with your patient the concept of central nervous system sensitisation and neuroplasticity – that the experience of pain can be reduced over time (patient video provided).

Step 5: Are there indicators of medication risk?
Is the dose greater than 40mg morphine equivalent daily? Treatment for more than 90 days? Side effects evident? If yes, consider de-prescribing opioids (Opioid risk tool and patient education materials provided).

Step 6: Are key physical activities declining due to pain and distress; for example, work, standing, walking?
If yes, then refer to a physiotherapist for conditioning (patient materials on pain and physical activity provided).

Step 7: Is sleep affected?
If yes, consider referral to a psychologist or for a sleep study (patient materials on pain and sleep provided).

Step 8: Could nutrition be improved?
If yes, consider referral to a nutritionist (patient materials on pain and lifestyle provided).

This content was independently produced by Cirrus Media with a sponsorship from Pfizer Australia.

1. eTherapeutic Guidelines. Analgesic: chronic pain. 2012
2. Blanch B, et al. Br J Clin Pharmacol 2014;78:1159–66.
3. Henderson JV, et al. Pain Med 2013;14:1346–61.
4. SAND abstract No. 112 from the BEACH program 2007–08

A new online decision-support tool has been launched by the NSW Agency for Clinical Innovation (ACI) to help...

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