Information for medical practitioners
- Facts and figures on chronic pain
- The impact of chronic pain
- The doctor-patient relationship
- How to assess pain
- What should a patient know about chronic pain and its management?
- Developing a pain management plan
- Treatment options for chronic pain
- Good practices in the pharmacological management of chronic pain
- Using opioids to manage chronic pain
- Pain management and drug dependence
- Do I need approval to prescribe pain medication?
Facts and figures on chronic pain
Pain is regarded as chronic when it does not go away and is experienced by a patient on most days of the week for at least 3 months.
About 1 in 5 Australians suffer from chronic pain.
A slightly higher proportion of females report having chronic pain than males do.
Prevalence tends to be higher in older individuals. At least 1 in 4 women aged 50 years or over report having chronic pain.
The leading cause of chronic pain is reported to be injury, commonly from playing sport, car accidents, home accidents and work accidents.
Almost two-thirds of people with chronic pain report that their pain interferes with their daily activities.
It is common for a person with chronic pain to consult their GP about their pain, but patients also seek advice from medical specialists (e.g. orthopaedic surgeons, rheumatologists, anaesthetists), and allied health professionals and alternative practitioners including physiotherapists, pharmacists, chiropractors, masseurs, acupuncturists, and naturopaths.
Use of oral analgesics by people in chronic pain is common. Paracetamol and non-steroidal anti-inflammatory drugs are the most frequently used, but a notable proportion of patients use vitamins, minerals and/or herbal and natural preparations.
The impact of chronic pain
Chronic pain can have an enormous impact on people. It may interfere with a person’s sleep patterns, their sexual activity, their ability to work and conduct daily activities, and it can cause emotional distress and lead to serious mental health problems, including depression.
The goals of pain treatment are to enhance functioning and reduce suffering and distress, while minimising the risk of adverse effects. While it is rare to eliminate chronic pain completely, it should be possible to control pain to a tolerable level and allow people to function at an acceptable level.
While acute pain can usually be attributed to an identifiable disease or damage process, finding an identifiable process for chronic pain can be very difficult. Sometimes the cause of the pain cannot be determined. This does not make the pain any less real to the patient.
The doctor-patient relationship
A collaborative doctor-patient relationship that is based on mutual respect and includes two-way communication is particularly helpful for patients with chronic pain.
Patients who have good relationships with their doctors tend to be more satisfied with their care. There are several ways a doctor can promote a good doctor-patient relationship:
- Empathise with the patient and take their complaint seriously. Whilst pain is a very subjective experience, it can be measured with a numeric, visual or verbal scale. Information about a patient’s pain can also be obtained by asking the patient to keep a pain diary.
- Maintain an optimistic and positive attitude in consultations.
- Resist the temptation to order investigations when the patient has already been thoroughly investigated – they are unlikely to reveal anything new and may only distract patients from taking responsibility for the management of their pain.
- Educate your patient about chronic pain and its treatment, and address any unrealistic expectations they may have formed.
- Discuss with the patient what you do and don’t know about their particular pain condition. Answer any questions your patient may have. Be honest if you do not have answers to all of the questions your patient asks.
- Provide sufficient information to your patient about their treatment options and the pros and cons of each option.
Because the management of chronic pain typically involves a number of medical practitioners and allied health professionals, some patients can be left feeling somewhat bewildered. To avoid this, it is important for the patient to have one person who serves as the primary care doctor – someone who is familiar with the person’s medical history and can co-ordinate the patient’s overall medical care. The GP is ideally placed to take on this role.
How to assess pain
Assessment of pain is essential to successful pain management. A pain assessment guides the selection of treatments, and provides a baseline against which to measure a patient’s progress during treatment.
Physical examination is only one aspect of pain assessment. Self-reports are the most reliable indicators of pain severity or intensity. Many patients have great difficulty in describing pain sensations.
A variety of pain measurement tools are available for doctors to use. They include numeric scales, visual analog scales, and verbal rating scales. The numeric and visual scales typically appear as a horizontal line rated from ‘no pain’ at the left end to ‘worst possible pain’ at the right end. The patient marks the line according to the pain they feel. In verbal rating scales, descriptors are used to rate the patient’s pain, e.g. no pain, mild pain, moderate pain, severe pain, worst possible pain. The tool used should be appropriate to the patient’s cognitive development, language, culture and preference. For example, faces scales (comprising a series of cartoon faces ranging from a happy face to a very sad/tearful face) are most appropriate for children who may have difficulty translating their pain into a numerical value or a verbal descriptor.
Assessment tools have been developed that attempt to capture a more global picture of a patient’s pain experience. They consider multiple dimensions of pain such as the characteristics of pain, the emotional aspects of pain, and functional impairment. More widely known multidimensional scales include the Brief Pain Inventory (a short and long form is available), the McGill Pain Questionnaire, the Behavioral Assessment of Pain Questionnaire, and the Pain Outcomes Questionnaire.
Ask the patient to keep a pain diary. The patient should record in the diary when the pain begins, where they feel it, how long the pain lasts, how the pain feels (using standard pain scales to rate the pain helps to objectify it), what triggers it, what makes it better, and what makes it worse.
Information collected in the pain diary will help you assess the effectiveness of treatment and help you identify potentially more effective strategies for the patient to use.
Psychological, social and occupational functioning
A pain assessment should include evaluation of a patient’s psychological functioning. A person with chronic pain may develop negative beliefs about their experience of pain or negative thoughts about themselves. A high proportion of people with chronic pain also suffer from depression and anxiety. A person who has anxiety or depression often feels their pain more acutely and is more disabled by it. If left untreated, anxiety or depression may increase and loom over all aspects of the patient’s life and make pain control and return to normal life very difficult. People who have poor psychological functioning may need referral to a psychologist who can help them with strategies for dealing with any detrimental thoughts, emotions or beliefs.
Assessment should include a measurement of the patient’s ability to perform household chores, work tasks, leisure interests, and sleep. Tracking a patient’s participation in normal household activities, attendance at work, and participation in non-work-related activities such as going out with family and friends and engaging in hobbies, provides a measure of how disabling pain is but also an indication of progress during treatment.
Chronic illness has major effects on families of a patient with chronic pain. It may distress family members to see their loved one in pain, but over time can lead to feelings of frustration, anger and resentment. Each member usually needs to make an adjustment in response to the patient’s reduced ability to participate in activities of everyday living. For couples there may be a loss of intimacy and a re-structure of roles. Families often experience a financial loss. Engaging family members in the assessment and treatment process allows for the patient’s functioning at home to be evaluated and also provides family members with the opportunity to better understand the problem of chronic pain and how to deal with it. Some families may need referral to a psychologist, counsellor or family therapist.
What should a patient know about chronic pain and its management?
Patient education should be an integral part of treatment for chronic pain. It commonly includes:
- information about the nature of the pain, including the likely duration of symptoms
- instruction on how to use a pain diary and pain measurement tools
- discussion about the goals of therapy
- information on methods of pain relief (medications available to treat chronic pain and non-pharmacological pain management strategies that can be used) and the pros and cons of appropriate treatment options
- addressing any fears the patient may have and any barriers there may be to pain management.
Suitable written material can be provided. Pamphlets have been developed by the NSW Therapeutic Advisory Group for patients with chronic pain, low back pain, and migraine.
Encourage your patient to check out reliable sources of information such as books, the internet, other health professionals, and support organisations. Although there are many reputable sites on the internet, warn patients that some material on the internet may be incorrect or misleading.
A number of other issues can be raised with the patient to facilitate treatment:
- Expectations about treatment must be realistic – complete relief from chronic pain is rare.
- The exact cause of chronic pain cannot always be identified.
- The patient should be responsible for the day-to-day management of their pain. A person who uses their own skills and resources is much better placed to lead a normal life than one who relies solely on prescribed medication.
- There are numerous self-management methods that patients can try to improve their quality of life, including relaxation techniques, simple cognitive and behavioural strategies (e.g. distraction, visualisation, positive self-talk), physical exercises, massage, hot/cold treatment, good sleep and rest patterns, and a healthy diet. The patient may initially need some basic instruction on how to use some of these strategies.
- A network of support people, such as family members, friends and fellow sufferers, can provide important emotional and practical help for when it is needed.
Developing a pain management plan
An important component of treatment is a pain management plan. This is a written document agreed upon by the patient, the GP, and the pain management team.
A pain management plan should specify the goals of therapy, and a timeframe for reaching each goal. The goals should be realistic and relevant. Examples of goals include: reducing the severity of pain, improving physical function, increasing activity at home or work, increasing participation in social activities, reducing medication use, increasing self-management of pain and related problems, improving mood, improving sleep patterns. The more specific the goals are written up, the easier they are for patients to comprehend and for the progress of the treatment to be measured. For example, ‘walk to and from the shops every day’ is better than ‘walk more often’.
The plan should outline all of the treatments or strategies to be used, when they are to be used, and any possible side effects.
The pain management plan can help GPs, Emergency Department physicians and locum practitioners to provide consistent care. Liaison between senior Emergency Department physicians and the GP should occur as early as possible. Use of Chronic Disease Management items on the Medicare Benefits Scheme may facilitate this process. The plan should address ‘after hours’ care to help patients deal with exacerbations that may occur out of normal business hours. The patient’s GP and/or pain management team should be informed of Emergency Department visits and locum consultations, especially where there is an increased frequency of these presentations.
Progress should be evaluated at regular intervals. Where progress is less than satisfactory, the treatment/s may need adjustment. The patient’s compliance with the plan may also need evaluation.
Treatment options for chronic pain
Management of chronic pain generally requires a multi-modal approach which emphasises the role of non-drug techniques. It should not rely on pharmacological therapy alone. Non-pharmacotherapy options include patient education, behaviour therapy, cognitive therapy, cognitive-behaviour therapy (CBT), physical therapy, family therapy, complementary and alternative therapy (e.g. manipulative methods, acupuncture), and surgery and other invasive procedures.
Medication frequently forms part of a patient’s treatment. Selection of medication should take into account the patient’s medical history, the nature of the pain (e.g. type, site, severity), and factors that may affect a patient’s compliance with the prescribed regimen such as age, cognitive state, route of administration and tolerance. Useful guidelines and tools are available on the Hunter Integrated Pain Service website.
Good practices in the pharmacological management of chronic pain
Before starting patients on medication, it is important to review their medication history, including:
- use of over-the-counter products (e.g. paracetamol, NSAIDs) or adjuvant agents, including information on dosage, duration of treatment, and any adverse reactions
- establish whether past treatment failures were the result of an inadequate therapeutic trial of medication, inappropriate dosage adjustments, inadequate management of side effects, or patient misconceptions about the goals of therapy
- use of alternate, herbal and complementary medicines.
Regular dosing should be used rather than an ‘as required’ approach.
Maximal doses should be used before moving to the next line of medications.
Assess the patient’s response to medications after 2 to 3 weeks of use.
If the patient does not respond, review and explore the reasons for non-response. It may be that the medication is having little or no effect on the patient’s pain, or it may be that the patient is underreporting their response (perhaps due to unrealistic expectations) or they are not taking the medication as instructed (perhaps because of unpleasant side effects or forgetfulness, or general concerns about taking medication).
Explain to the patient:
- why analgesics are part of the treatment plan
- how and when to take the medication
- what side effects to expect and how to manage them
- how the effectiveness of the medication will be measured and progress monitored
- the doctor should be consulted before stopping or changing medication.
Treatment of chronic pain should be reviewed regularly. Assessment should include:
- the patient’s level of comfort (or degree of analgesia)
- medication-related side effects
- physical and psychosocial functioning
- review of pain diary entries, if being used.
Using opioids to manage chronic pain
Existing evidence does not support the long term efficacy and safety of opioid therapy for chronic non-cancer pain.
Ideally, assessment by a pain clinic or consultation with a pain medicine specialist should precede the prescription of oral opioids.
In NSW, if a patient is suspected or known to be drug dependent, authorisation to prescribe opioids for that patient must be obtained from the NSW Ministry of Health prior to starting treatment. More information is available on Prescribing a Schedule 8 opioid or benzodiazepine.
Before initiating opioid therapy, the doctor should:
- clearly explain the goals of opioid therapy (complete pain relief may not be achievable) and the time course over which these goals should be attained
- discuss the likelihood of developing physical dependence and tolerance, and any concerns about abuse or diversion
- explain to the patient that opioids may at first affect their alertness and impair their thinking and that they should avoid driving or similar activities until the effects dissipate
- explain other side effects (e.g. constipation) and how they may be managed
- explain that patients who receive opioids for a medical reason and who have no history of drug abuse or addiction are unlikely to develop an addiction problem, but if there is reason to suspect that the patient is developing problems, referral to a specialist in pain medicine, mental health or drug services may be necessary
- document the patient’s informed consent to treatment in the medical record.
It is important that the appropriate dose is prescribed. An appropriate dose is one which achieves satisfactory functioning with adequate pain control and tolerable side effects. A common error is to use inadequate doses of opioid analgesics.
Injectable opioids are rarely necessary to treat chronic pain, and should be reserved for patients with acute pain.
Pethidine has a relatively short duration of action and is not recommended for the management of chronic pain.
Pain management and drug dependence
Some patients who are prescribed opioids engage in problematic drug-related behaviours. In NSW, clinical advice on the management of a patient with problems related to opioid dependence is available from the NSW Drug and Alcohol Specialist Advisory Services on 1800 023 687 or (02) 9361 8006.
If a doctor suspects a patient of seeing other doctors – ‘doctor shopping’ – to obtain opioids or other drugs liable to abuse such as benzodiazepines, they can contact Medicare Australia's Prescription Shopping Program registered with the service, doctors can obtain information on the amount and type of Pharmaceutical Benefits Scheme (PBS) medicine recently supplied to patients who have been identified as obtaining medicine in excess of their medical needs.
Patients who are suspected or known to be drug dependent will inevitably require treatment for pain at some stage, and have a right to have their pain managed in the same way as other patients.
Those who are on substitution therapies (e.g. methadone or buprenorphine maintenance), or those who are physically dependent on prescribed or illicitly obtained opioids will need to have their baseline opioid requirements met in addition to pain treatment. Because of their tolerance, they may require higher or more frequent doses for pain control. Pain management for such patients is ideally carried out by specialists in drug and alcohol or pain medicine.
In NSW, for a patient who is drug dependent or for whom a doctor suspects is drug dependent, authorisation to prescribe opioids (Schedule 8 drugs) must be obtained from the NSW Ministry of Health (Pharmaceutical Services) before treatment is initiated.
Do I need approval to prescribe pain medication?
To prescribe under the Pharmaceutical Benefits Scheme (PBS), you will need to obtain a Federal Government authority from Medicare Australia for particular medications.
In addition to a Federal authority, you may require approval (in the form of a written authority) from your State or Territory health authority (e.g. NSW Ministry of Health). It should be noted that different legal requirements exist between States and Territories in Australia.
In NSW, a doctor must obtain an authority from the NSW Ministry of Health (Pharmaceutical Services), after 8 weeks of continuous treatment with any of the following medications in order to continue prescribing:
- any injectable drug of addiction
- alprazolam (from 1 February 2014)
- buprenorphine (except transdermal preparations)
If a patient is suspected of being drug dependent, an authority must be obtained before starting treatment with any medication classified as a drug of addiction (i.e. drugs listed under Schedule 8 of the NSW Poisons List.)
For details of requirements for an authority in NSW refer to Requirements for an Authority to Prescribe Drugs of Addiction Under Section 28 of the Poisons and Therapeutic Goods Act (TG212) or contact the Duty Pharmaceutical Officer at Pharmaceutical Services, NSW Ministry of Health, on (02) 9391 9944 if you have any queries about prescribing opioid treatment in NSW. More information about prescribing opioid medication and to obtain an application form for authority to prescribe an opioid is available on Prescribing a Schedule 8 Opioid or Benzodiazepine.