Prescribing drugs of dependence in general practice

Part C2 - The role of opioids in pain management - Chapter 3

Approach to pain management

Part C2 - The role of opioids in pain management
    7. Approach to pain management
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Last revised: 22 Jun 2020

Good pain management has significant benefits. For many people, it can transform their quality of life, allowing them to work, go to school and participate in the community rather than being functionally disabled by pain.

Management of pain has tended to rely heavily on medication. People are often aware of the downsides of pain medication, but accept it (or sometimes resent it) as a necessary evil to allow them to get on with their lives. In contrast, they are largely unaware of, or are sceptical about, non-drug pain management techniques. The general impression is that alternative pain management techniques are less likely to work the more severe the pain.

So while prescription of pain medication in Australia has increased markedly over the past 30 years, non-drug therapies have had a much slower uptake (both clinically and in the research context). As understanding of pain improves and evidence of benefit for alternative and comprehensive pain management interventions grows, patients have more options to meet their needs and expectations.

This may have particular benefit for the many patients with pain who have chronic health conditions, which can complicate their pain management with medications.

Understanding the contextual and placebo effect in chronic pain management

The manner in which a clinician explains and delivers therapy has an impact on outcome.79 Practitioners who master not only the disease and treatment, but also cultivate a therapeutic relationship may be more effective at pain management.80

Doctor–patient relationships have been acknowledged as having an important therapeutic effect, irrespective of any prescribed drug or treatment.184,185 Despite limitations, separate systematic reviews consistently report positive clinical findings with positive doctor–patient relationships.184 A relatively consistent finding is that doctors who adopt a warm, friendly, and reassuring manner are more effective than those who keep consultations formal and do not offer reassurance.80

‘Context’ extends beyond the one-on-one interaction between patient and doctor. A practice environment and culture that nurtures mutual trust, empathy, respect, genuineness, acceptance and warmth can improve the experience of patients, and have a beneficial effect on medical outcomes.80

Placebo effects

A placebo is a substance or procedure that does not have an inherent ability to produce an expected or desired effect. However, placebos have been shown to have dose-response, time-effect and side-effect profiles similar to non-placebos.185

There is some confusion between the terms ‘placebo response’ and ‘placebo effect’:

  • a placebo response is exactly that – a therapeutic response to the administration of a known placebo186
  • a placebo effect is the part of the therapeutic response (a genuine or psychological effect) that is not attributable to the properties of active ingredients.185–187  

Placebo effects are a result of the sociocultural context of treatment. These effects are integral to routine pain management practice.79,188,189 Outcomes are influenced by multiple contextual determinants including the doctor– patient relationship, expectancy, classical conditioning, and social and observational learning.7,79,188 There is significant variability in the degree and the duration of these contextual or placebo effects.190–194

There may be multiple pathways for the placebo effects. Some studies indicate that the magnitude of placebo analgesia is higher when the placebo analgesic effect is induced via suggestion combined with conditioning,195 rather than via suggestion or conditioning alone. Other studies show that placebo effects in pain can be mediated by endogenous opioids,196,197 cholecystokinin,197 endogenous cannabinoid systems,198 and dopamine release.199

As the understanding of placebo effects has progressed, the ethical debate for their use has changed. While it is still widely accepted that placebos should not be administered in a deceptive manner, using the placebo effect to augment routine ‘active’ treatments has become less contentious.188,200

More research in clinical settings is needed to determine the practical value of the use of placebos. However, practitioners should consider the way they deliver information – it may significantly alter expectations, harness placebo effects and potentially optimise treatment outcomes.

Understanding the patient experience

It is necessary to have a thorough appreciation of patients’ beliefs, needs and expectations about pain and treatment to achieve good pain management.201

Even with similar physical injuries, different patients will experience highly variable degrees of pain and disability. As the pain experience is influenced by complex biomedical, psychological and social factors, so too does pain interfere with many and possibly all aspects of the patient’s life – restricting daily living, leisure activities and sleep.202,203

Patients who experience greater pain severity report lower quality of life. Many patients regard pain reduction as the most beneficial component of their treatment.204,205 A fundamental part of pain management is building a collaborative partnership between the patient and GP. This involves empathetically showing the patient:

  • their experience is valid
  • their pain is understood and believed
  • you are interested in them as a person (who is experiencing profound changes in their life) and not just in their symptoms
  • their opinions about management matter
  • you are positive and optimistic about improving their situation.206–208

While many patients have a specific diagnosis, they often have not been given an explanation for their pain. Discussing the cause and meaning of the pain is essential because it results in higher motivation to engage in a treatment plan.203

The management of chronic pain often involves several medical practitioners and allied health professionals, which may cause some patients to feel confused and overwhelmed. Therefore, it is important to have one person who serves as the primary care doctor – someone who is familiar with the person’s medical history and can coordinate the patient’s overall medical care. The GP is ideally placed to take on this role.

Shared decision making

Management of pain, in particular chronic pain, requires many of the generic skills of GPs. While the evaluation of pain mechanisms is important to determine therapeutic options, pain is fundamentally a patient experience, so addressing patient experiences and thoughts has high priority. SDM is a process of bringing evidence into the consultation and incorporating it into a discussion about the patient’s values, expectations and preferences: it is the integration of communication and evidence skills.209–211

Very few clinical situations involve just one option and almost no treatments are 100% effective or 100% free of side effects. When considering pain management options, often the evidence does not strongly support a single clinically superior option.209,210,212 Hence, pain management typically involves a preference-sensitive decision that is likely to be strongly influenced by patients’ beliefs and values.212–214 As most patients overestimate the benefits of medical interventions and underestimate the risks, it is important to know what expectations patients have, help correct any misperceptions and be honest about uncertainty (to do with their pain condition and with treatments).

Integrating the patient perspective has the potential to increase the patient’s satisfaction with the consultation, as well as result in better decisions and in improved management of the illness and health outcomes.215

Communicating likely response to treatment

Defining success

Patients and doctors need a common understanding of what success means in pain management.

Successful pain relief does not always mean complete resolution of pain. In the research setting, a 50% reduction tends to be considered a successful outcome. However, across a range of pain conditions (acute and chronic), patients rate a 30% reduction in pain intensity as clinically meaningful.216–220 Before experiencing pain reduction, it may be hard for a patient to judge what amount of resolution would mean success for them. Here, realistic goal setting is needed.

When assessing success of treatment, in addition to pain reduction, it may be useful to look at effect on other factors affected by pain. These include sleep, depression, fatigue, quality of life, function and ability to work.221

Success or failure can typically be determined within 2–4 weeks of starting drug therapy; when success is achieved it tends to be long lasting.221

Setting expectations

Not all treatments will achieve clinically meaningful pain reduction and no single drug will successfully treat more than a minority of patients with a painful condition.221 Many patients will be unaware of this.

Many medications will fail or have unacceptable side effects, however; experience, (and some evidence) suggests that failure with one drug does not necessarily mean failure with others, even within a class. Because success rates are low, a wide range of drugs and non-drug therapies (ie multimodal) may be needed, especially in complex chronic conditions.81,221 The best order in which to use drugs, in terms of efficacy, harm, or cost, is not always clear.221

The principles of treatment should be to measure pain, expect and recognise analgesic failure, and to react to it, pursuing analgesic success rather than blindly accepting failure.221

Box 8.

Helping patients make informed decisions

The RACGP’s gplearning platform has developed an online activity to help GPs communicate information about risk and benefits to patients. The activity provides a framework for assisting patients to share in decisions about their treatment. 

Multidisciplinary care – when GPs work in collaboration with psychologists, physiotherapists and exercise physiologists to provide non-drug pain therapies – is frequently recommended in chronic pain management.

Multidisciplinary treatments have been reported as effective for various types of chronic pain in adults, but the reports are inconsistent. Inconsistencies in the reported results may be due to the differences in the definition of multidisciplinary treatment, the treatment combinations, treatment intensity, and the setting and heterogeneity of the study populations and control groups. Multidisciplinary biopsychosocial rehabilitation interventions are seen to be more effective than usual care and physical treatments in decreasing pain and disability in people with chronic low back pain.222

It is important that all treating team members have a shared understanding of the patient experience, how the team members will work together and what each team member will contribute. This aspect of collaboration is often overlooked.

Pain clinics

Referral to a pain clinic should be considered for patients with complex chronic pain, but care should be exercised to determine the philosophy of the clinic. Multidisciplinary pain clinics in Australia tend to have differing philosophies of management; for example, some clinics focus on interventional pain techniques while others focus on multidisciplinary care.

International research reveals that pain facilities use a wide range of pain interventions and employ a variety of healthcare professionals, without evidence to support ideal composition of multidisciplinary services. A comparable situation appears to exist in Australia.

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