Pain management

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Instructions

This section provides a summary of the area of practice for this unit and highlights the importance of this topic to general practice and the role of the GP.

For the purposes of this contextual unit, pain is defined as ‘an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage’. The experience of pain is unique to each individual and is influenced by biological, psychological and social factors.1 There is a range of types of pain, including acute, subacute, chronic and recurrent pain.2

Chronic pain is defined as daily pain experienced for more than three months and is an escalating health issue that has a major impact on quality of life. It also carries a significant economic burden in lost productivity and health costs.2 Cancer-related pain is a type of chronic pain and can occur in patients at any point from the early to advanced stages of disease and causes severe and debilitating effects.2,3 This can make diagnosing and managing chronic pain in general practice a challenge.

Approximately one in five Australians are estimated to be experiencing chronic pain.2 In 2017, lower back pain was found to be the leading cause of disability globally.4 In Australia, an estimated 6.1 million people live with arthritis and other musculoskeletal conditions, which is projected to rise in the future.5 Aboriginal and Torres Strait Islander peoples are also at an increased risk of living with painful conditions,6 and some pain conditions are more prevalent in rural communities than major cities.7 Chronic pain is more common among Australians aged over 65, with one in three living with chronic pain.8 Up to 80% of residents of aged care facilities are living with pain, which is often under-treated or poorly managed.9 Chronic pain is more common in women,10 while 25–35% of children and young people are estimated to experience chronic pain.2 Pain is often under-treated, and up to 80% of people are missing out on treatment options that might significantly improve their health, wellbeing and functional participation.2

Comorbidity is common among people living with pain conditions. In 2018, research found that chronic pain commonly occurred with depression or anxiety (44.6%), osteoarthritis and degenerative arthritis (29.3%) and high blood pressure (25.1%).3 Suicide is reported to be two-to three-times higher in those suffering chronic pain compared to the general population.11 These comorbidities contribute to poorer health, societal and financial outcomes,2 making a holistic approach to patient care vital for general practitioners (GPs).

Effective chronic pain management involves a long-term holistic multidisciplinary approach. The goal of treatment is to improve function, quality of life and coping skills, with or without complete eradication of the perception of any pain. Up-to-date best practice guidelines enable GPs to identify the most effective pharmacological and/or non-pharmacological treatments to optimise a patient’s pain management. GPs can engage in early interventions through identification of yellow flag and other risk factors for chronic pain, implement preventive strategies to reduce the severity and incidence of pain through ensuring adequate acute pain management and provide psychological support for patients. Health education is an important part of pain management and includes providing information on the limitations of prescribed medications and potential side effects, as well as promoting physical health improvements through exercise, nutrition and weight loss.12 GPs also play an important role in minimising the risk of misuse of analgesics by avoiding (or deprescribing) opioids in accordance with best practice guidelines and government regulation.12,13

References
  1. Raja SN, Carr DB, Cohen M, et al. The revised International Association for the Study of Pain definition of pain: Concepts, challenges, and compromises. PAIN 2020;161(9):1976–82. doi: 10.1097/j.pain.0000000000001939.
  2. Australian Government Department of Health. The national strategic action plan for pain management. Canberra: Department of Health, 2021 [Accessed 22 October 2021].
  3. Deloitte Access Economics 2019. Cost of Pain in Australia. Canberra: Deloitte, 2019 [Accessed 22 October 2021].
  4. Institute for Health Metrics and Evaluation (IHME). Findings from the Global Burden of Disease Study 2017. Seattle, WA: IHME, 2018 [Accessed 22 October 2021].
  5. Arthritis and Osteoporosis Victoria. A problem worth solving: the rising cost of musculoskeletal conditions in Australia. Elsternwick: Arthritis and Osteoporosis Victoria, 2013 [Accessed 22 October 2021].
  6. Pain Australia. Who does pain affect. Deakin, ACT: Pain Australia, 2020 [Accessed 22 September 2021].
  7. Australian Bureau of Statistics. Australian social trends, Mar 2011: Health outside major cities. Canberra: ABS, 2011 [Accessed 22 October 2021].
  8. Blyth FM, March LM, Brnabic AJ, Jorn LR, Williamson M, Cousins MJ. Chronic pain in Australia: A prevalence study. Pain 2001;89(2–3):127–34 [Accessed 22 October 2021].
  9. Savvas S, Gibson S. Pain management in residential aged care facilities. Aust Fam Physician 2015; 44(4):198–203 [Accessed 22 October 2021].
  10. Australian Institute of Health and Welfare. Chronic Pain in Australia. Canberra: AIHW, 2020 [Accessed 22 October 2021].
  11. Racine M. Chronic pain and suicide risk: A comprehensive review. Prog Neuropsychopharmacol Biol Psychiatry 2018; 87(Pt B):269–280. doi: 10.1016/j.pnpbp.2017.08.020.
  12. The Royal Australian College of General Practitioners. Prescribing drugs of dependence in general practice. Part C2 – The role of opioids in pain management. East Melbourne, Vic: RACGP, 2020 [Accessed 22 September 2021].
  13. Therapeutic Goods Administration. Prescription opioids: Information for health professionals. Canberra: Department of Health, 2021 [Accessed 22 October 2021].

Instructions

This section lists the knowledge, skills and attitudes that are expected of a GP for this contextual unit. These are expressed as measurable learning outcomes, listed in the left column. These learning outcomes align to the core competency outcomes of the seven core units, which are listed in the column on the right.

Communication and the patient–doctor relationship
Learning outcomes Related core competency outcomes
The GP is able to:   
  • demonstrate respect and empathy for people experiencing pain, both chronic and acute
1.1.1, 1.1.2, 1.1.3, 1.1.6, AH1.3.1, 1.4.4
  • use shared decision-making to develop pain management plans with people experiencing chronic and acute pain and take into consideration best practice guidelines around safe and effective prescribing
1.2.1, 1.2.2, 1.3.1, 1.4.3, AH1.4.1
Applied knowledge and skills
Learning outcomes Related core competency outcomes
The GP is able to:   
  • assess and treat both acute and chronic pain using pharmacotherapies and non-pharmacological therapies, including working collaboratively with other medical and allied health professionals in supporting people experiencing pain
2.1.1, 2.1.2, 2.1.3, 2.1.9
  • prescribe medication correctly and monitor for appropriate use and safety 
2.1.9
  • identify complex and severe pain syndromes and presentations requiring referral to non-GP specialists
2.1.3, 2.1.4, 2.3.2, 2.3.4, AH2.3.2
  • identify complex and severe pain syndromes and presentations requiring referral to non-GP specialists
2.1.10
Population health and the context of general practice
Learning outcomes Related core competency outcomes
The GP is able to:   
  • identify the social, economic and public health effects of pain and/or opioid dependence
3.1.4, 3.2.1, 3.2.2, 3.2.3, 3.2.4, AH3.2.1, RH3.2.1
Professional and ethical role
Learning outcomes Related core competency outcomes
The GP is able to:   
  • participate in ongoing professional development regarding best practice pain management
4.2.1, 4.3.1, 4.4.1, 4.4.2
  • consider personal values and attitudes towards patients with chronic pain and/or opioid dependence
4.2.2, 4.2.3, 4.2.4
  • maintain self-care strategies and avenues for debriefing when caring for patients with chronic pain and/or opioid dependence
4.2.2, 4.2.3, 4.2.5
Organisational and legal dimensions
Learning outcomes Related core competency outcomes
The GP is able to:   
  • develop and review clinical processes and policies on maintaining safety around prescription, dispensing and documentation of drugs of dependence
5.1.1, 5.2.3, 5.2.3
  • appropriately use billing items in management of patients with chronic pain and/or opioid dependence
5.2.3, AH5.1.3

Instructions

This section includes tips related to this unit from experienced GPs. This list is in no way exhaustive but gives you tips to consider applying to your practice.

Extension exercise: Speak to your study group or colleagues to see if they have further tips to add to the list.

  1. Be patient-centred: keep the patient’s experience central to your decisions and recommendations. Ask yourself, will this improve this person’s experience of life and their ability to achieve their goals and aspirations?
  2. Living with chronic pain can be a terrifying and lonely time for people, even those with a lot of people around them. Having someone available to share their struggles with and share the journey can transform that person’s experience of chronic pain. Sometimes your consultations with people living with chronic pain can feel unproductive and frustrating in their lack of apparent progress, but take heart from knowing that being present on the journey is sometimes the most therapeutic thing you can do.
  3. Often there is a temptation to focus our treatment on the pain itself, rather than treating the person living with the pain. Tailor your treatments and medication choices to the likely aetiology and pain mechanism. Learn that classes of medication work differently depending on the underlying cause of symptoms and you will be able to better target treatments to the individual.
  4. Read widely in non-medical literature about experiences of illness, pain and suffering to help you understand and have empathy for what it might be like to live with chronic pain. For example, some interesting perspectives can be found in What’s Wrong with Me by Meghan O’Rourke, How to be Sick by Toni Bernhard and Illness as Metaphor by Susan Sontag.
  5. With all this said, remember that your patients are not your friends, and sometimes you will need to make difficult decisions that jeopardise the relationship for the sake of clinical and professional safety. Even when you make decisions that damage a patient’s perception of you, or their relationship with you, as long as you made those decisions in a respectful, professional and safe way, with the wellbeing of the patient as the priority, you have done your job whether they recognise that or not.
  6. Be aware that sometimes opioid toxicity can lead to an increase in pain, and the temptation can be to increase the opioid dose, thereby dangerously worsening the toxicity. It can be helpful to ask yourself before any increase in opioid dose, are there any red flags for opioid toxicity?

Instructions

  1. Read this example of a common case consultation for this unit in general practice.
  2. Thinking about the case example, reflect on and answer the questions in the table below.

You can do this either on your own or with a study partner or supervisor.

The questions in the table below are ordered according to the RACGP clinical exam assessment areas and domains, to prompt you to think about different aspects of the case example.

Note that these are examples only of questions that may be asked in your assessments.

Extension exercise: Create your own questions or develop a new case to further your learning.

Pain management

Sam is 43 years old and presents to you with a long history of back pain which started several years ago and has been getting worse over the past several months. The pain is primarily in the lumbar spine and radiates to both buttocks.

Sam previously worked as an events organiser but was made redundant last year and hasn’t worked since. A few months ago, Sam’s mum was diagnosed with stage 4 metastatic breast cancer and has been quite unwell. For the back pain, Sam has been using paracetamol with codeine 500mg/30mg as required, usually three to four times a day, and occasionally uses a family member’s oxycodone capsules which were prescribed for cancer pain. Sam was hoping that you might prescribe more paracetamol with codeine, and maybe some oxycodone as this seems to help the pain better.

Questions for you to consider Clinical exam assessment area Domains

What ideas might Sam have about pain and how to manage it, and how might these differ from your own understanding of chronic pain and its recommended management? What might Sam’s expectations and concerns be coming into the consultation with you? How will you explore these?

If you were going to recommend a different management plan from what Sam was expecting or hoping for, how might you negotiate shared decision-making with Sam about this?

  1. Communication and consultation skills
1,2,5

What information would be useful to gather from Sam and any previous doctors to help inform the management of the chronic pain?

What investigations and examination tests might be useful to investigate chronic back pain, and what information will they give you and how does it potentially change your management?

  1. Clinical information gathering and interpretation
2   

What red flags would need to be checked or excluded in assessing Sam’s pain? If Sam was older, or taking long-term steroid medication, would this raise any other considerations or concerns?

What characteristics and aetiological factors of the pain are important to consider when deciding which treatments are likely to be effective?

What socio-economic factors might influence Sam’s decision-making around treatment options?

  1. Making a diagnosis, decision making and reasoning
2

What non-opioid pharmacological treatments can be considered to manage chronic pain? 

What options could you consider to manage Sam’s back pain, and how might these change depending on how the symptoms evolve over the coming weeks and months?

If Sam were an older person in a residential aged care facility, would this influence management decisions and/or therapeutic options?

What if Sam were a sedentary 30 year old?

At what point would you consider referral to a specialist pain service?

  1. Clinical management and therapeutic reasoning
2   

If Sam were an Aboriginal or Torres Strait Islander, how might this affect your treatment decisions? What assumptions, biases and prejudices might arise for clinicians in caring for Sam and the pain symptoms?

How might chronic pain be affecting Sam’s mood and psychological wellbeing?

How might the pain affect Sam’s social relationships and capacity to find work?

  1. Preventive and population health 
1,2,3

When you first read the case study, did you make any subconscious assumptions about Sam’s gender or sex? Would your first impression of the situation be different if Sam’s gender was different to what you assumed? How might your perception of Sam’s gender impact (intentionally or unintentionally) your assessment, treatment and risk management decisions? 

What assumptions about socio-economic status, occupation, dress/clothing appearance and perceived health literacy might affect a clinician’s management decisions in caring for people with chronic pain?

What thoughts, emotions and concerns arise for you when someone presents asking for analgesics? How might these internal responses potentially affect the consultation with Sam?

  1. Professionalism
4   

What are the different legal and professional obligations when prescribing opioids for cancer pain and non-cancer pain?

Where can you find reliable information about Sam’s previous prescriptions?

  1. General practice systems and regulatory requirement
5   

Could acupuncture be an effective option to consider? What evidence is there to support acupuncture? Is learning to deliver acupuncture for chronic pain something you could consider?

  1. Procedural skills
2   

If prescribing opioids, what are the risk management strategies to consider to protect Sam, the community and Sam’s treating clinicians?

How might the management options be different if there is no clear aetiological diagnosis for the pain?

  1. Managing uncertainty
2   

If Sam were to later have an accidental opioid overdose, or present with symptoms and signs of opioid toxicity, how would you manage this?

What serious causes of back pain would warrant referring someone to the acute sector for urgent assessment? What signs or symptoms would suggest a more sinister underlying diagnosis?

  1. Identifying and managing the significantly ill patient
2

Instructions

This section has some suggestions for how you can learn this unit. These learning suggestions will help you apply your knowledge to your clinical practice and build your skills and confidence in all of the broader competencies required of a GP.

There are suggestions for activities to do:

  • on your own
  • with a supervisor or other colleague
  • in a small group
  • with a non-medical person, such as a friend or family member.

Within each learning strategy is a hint about how to self-evaluate your learning in this core unit.

On your own

Develop a scoring framework to assess a consultation on chronic pain.

  • Compare the scoring framework with the competencies listed above. What other elements could be addressed? Are these things you might want to use more during consultations?
  • What learning goals could you develop to focus on this?

Make a list of common causes of chronic pain. Make another list of different analgesics, adjuvant medications and non-pharmacological therapies used in the treatment of pain, and come up with a pain management plan for each of the causes of chronic pain that you identified.

  • Which pain syndromes did you find most challenging to identify treatment options for? Is there any area of pharmacology that it would be helpful for you to revise?
  • What learning needs did you identify in doing this activity? How will you address these learning needs? Where can you learn more about pain management and treatments? 

Complete some online resources and learning challenges, for example, from gplearning s:

    1. Effective pain management in general practice
    2. Chronic pain: An integrative approach
    3. Management of moderate acute pain and the role of combination analgesia
    4. AJGP Clinical Challenge – Medicinal cannabis
  • What areas did you find most challenging?
  • Are there any foundation topics that you would benefit from revising; for example, pharmacology or communication skills?
  • What legal aspects were discussed that need to be clarified for your particular state or territory?
With a supervisor

Identify a patient who has/had been living with chronic pain. Discuss with your supervisor and explore the various things that were tried and consider what else might have been considered. If you can’t identify a patient, ask your supervisor if they have an example you can discuss.

  • Why were this person’s symptoms so difficult to manage? Why might this have been the case? Did the initial or usual treatments work? If not, why not? Was it something about the type of pain that they had? Or were there things about this person’s life, body, context or current situation that were complicating or undermining the treatment?
  • Was the treatment plan carried out in the way that the doctors were intending? Did the patient understand the treatments and how they usually worked?
  • Was the initial assessment of the aetiology of the pain complete and accurate, or did it need to be revised or updated?
  • Were the initial treatment choices evidence-based? What do treatment guidelines recommend for that particular situation?

Ask a patient who you have treated for chronic pain what they thought about your care. Discuss the feedback with a supervisor or trusted colleague.

  • What feedback did you receive? Have you received this feedback before?
  • How could you apply this feedback to future patients?
  • With your supervisor, develop a learning plan for any aspects that you identified for improvement.

Conduct an audit of all the patients you’ve prescribed opioids for over the course of one week (or month, depending on how many patients come up in your results), and discuss with your supervisor. In your audit include the following information:

    1. What was the medical diagnosis for which the opioids were prescribed?
    2. What kind of pain was being treated? For example, nociceptive, neuropathic, muscular, nociplastic.
    3. Was it a new prescription or a repeat prescription?
    4. How long had the patient been on opioids (if a repeat script)?
    5. What non-opioid pharmacological therapies were being used?
    6. What non-pharmacological therapies were being used, or had been offered/attempted?
    7. Was a formal pain scoring assessment used?
  • What other therapies might be considered for these patients?
  • How do your results compare with clinical guidelines?
  • How are you managing risk in your opioid prescribing, and how could this be improved?
  • How does your prescribing compare to your supervisor’s? How does your supervisor manage opioid prescribing risks?
  • Did you find any of these consultations challenging or complex?
In a small group

Role-play a consultation in which a patient presents to a new GP requesting a prescription for opioid analgesics for their chronic back pain. They’ve never had a regular GP before but attend a local bulkbilling clinic to receive scripts for paracetamol with codeine or opioids. If you are watching the role play, write down helpful comments or suggestions about the ‘doctor’s’ communication skills. Then give constructive feedback.

  • What was your feedback about communication skills? How did that compare with the rest of your group?
  • What do you still need to consider? Were other communication strategies suggested that might have been effective?

On pieces of card, write down the name of a specific opioid, and a route of administration. For example, write ‘oxycodone, oral’ or ‘fentanyl, topical (patch)’. Shuffle the cards, and then put each card on the floor or on a table, spread out and face down so that none of you can see which card is which. Each person picks up a card and holds on to it. Leave at least one card on the floor or table. Once everyone has picked a card, choose one of the leftover cards and decide on a reference dose for that opioid and its route of administration. Then, everyone must work out what the morphine equivalency opioid conversion would be for the opioid and route of administration written on their chosen card. Come back together and discuss your answers.

  • Refer to whatever reliable and validated opioid conversion charts or tables are available to you. Safer Care Victoria has an opioid conversion resource.
With a friend or family member

Invite a trusted friend or family member to share with you a time when they had severe pain (eg pain during labour). Ask them to describe what it felt like and the impact the pain had on their mental wellbeing and their ability to carry out normal activities. Your role is to just listen to their story. Don’t try to offer any solutions or suggestions that might have helped alleviate the pain, and don’t critique any pain management strategies they used.

  • How did it feel listening to someone you know and trust share an experience of pain?
  • Was this story new to you? If not, how did hearing it again give you a different understanding of it?
  • Did you find it challenging to hear their story and be unable to offer any medical advice or treatments?
  • Did this story bring up any similar experiences of your own?
  • How might this influence your management of pain in the future?

Ask a variety of friends and family members who have children what they have done in the past when one of their children was experiencing pain.

  • How did they manage it? What non-pharmacological approaches did they try? Did they use medications? How did they work out how much to give and how often?
  • What would prompt them to take the child to the doctor?

Instructions

These are examples of topic areas for this unit that can be used to help guide your study.

Note that this is not a complete or exhaustive list, but rather a starting point for your learning.

  • For a patient living with acute or chronic pain, consider the person’s cultural, spiritual and religious beliefs, values and background, and their community context, appreciating the wide diversity of cultural perspectives of pain and its management.
  • Have a comprehensive understanding of medico-legal issues around the prescription, administration and storage of Schedule 8 medications (eg opioids, benzodiazepines).
  • Perform a functional assessment of a person living with acute or chronic pain and consider the need to adapt your assessment when there are significant communication barriers; for example, language differences, cognitive impairment, neurological conditions. Identify:
    • any possible predisposing, precipitating and perpetuating factors that might be contributing to the pain
    • its effect on the person’s life
    • any self-coping and protective/supportive factors being used or already in place
  • Prepare treatment plans with people experiencing pain using shared decision-making and a respect for culture and community to promote autonomy and dignity. Consider each of the following possible pain syndromes or presentations, and with reference to current guidelines and evidence, develop effective management plans, including psychological therapies, allied health, pharmacology and referral to tertiary pain services:
    • acute pain following trauma/injury
    • pain associated with acute illness (eg acute abdomen pain)
    • chronic headaches
    • chronic back pain (predominantly muscular, without sciatica)
    • chronic back pain with sciatica (neuropathic)
    • cervical radiculopathy
    • chronic arthropathies (eg osteoarthritis)
    • fibromyalgia
    • complex regional pain syndrome.
  • For each of the following pharmacological therapies used in the treatment of pain, identify and describe the indications, contraindications, risks/cautions and typical dosages used in chronic pain management:
    • opioid medications
    • non-opioid analgesics (eg paracetamol)
    • non-steroidal anti-inflammatories
    • medicinal cannabinoids
    • adjuvant medications, including:
      • tricyclic antidepressants
      • serotonin-norepinephrine reuptake inhibitor (SNRI) antidepressants
      • anticonvulsants
      • anaesthetic agents
      • muscle relaxants (eg benzodiazepines).
  • Describe the ways in which pain and/or opioid dependence impacts on whole communities, and the social, economic and public health effects and implications.
  • Identify and describe the possible signs and symptoms of opioid toxicity, or opioid ‘over-treatment’.
  • Outline the signs, symptoms and emergency management of opioid overdose, including resuscitation for people with respiratory depression or arrest from opioids.

Instructions

The following list of resources is provided as a starting point to help guide your learning only and is not an exhaustive list of all resources. It is your responsibility as an independent learner to identify further resources suited to your learning needs, and to ensure that you refer to the most up-to-date guidelines on a particular topic area, noting that any assessments will utilise current guidelines.

Journal articles
Discusses comprehensive and holistic management strategies that can be used in a community setting to help people living with chronic pain. A valuable resource to help make a comprehensive assessment and develop a holistic and effective management plan for people living with chronic pain. A helpful resource for developing cultural competency in clinical practice, particularly in shared decision-making, holistic assessment and treatment, and person-centred care; vital for working with Aboriginal and Torres Strait Islander peoples and communities in pain management. Discusses the unique challenges and strategies for caring for people experiencing pain who live in residential aged care. 
Textbooks
A comprehensive and useful textbook for clinical communication skills, especially in challenging consultations like shared decision-making and negotiating treatment plans with people living with chronic pain.
  • Silverman J, Kurtz S, Draper J. Skills for communicating with patients. 3rd edn. Boca Raton, FL: CRC Press, 2013. (Available from the RACGP library.)
Online resources
Highlights important considerations for providing palliative care for Aboriginal and Torres Strait Islander peoples and communities. Contains links to many resources, services and information useful for health practitioners as well as community members experiencing pain.
Learning activities
  • The Royal Australian College of General Practitioners. gplearning:
Pharmacological and non-pharmacological therapies for people experiencing pain, particularly chronic pain.  
    • Effective pain management in general practice
The risks and benefits of complementary therapies, with a focus on evidence-based, effective complementary therapies.
    • Chronic pain: An integrative approach
This module is helpful for developing and reinforcing effective communication skills to foster safe and trusting therapeutic relationships.
    • Communication skills in general practice
Explores comprehensive acute pain assessment, current recommendations for stepped care, including opioids and combination analgesics, and highlights the risks and benefits associated with different treatments. 
    • Management of moderate acute pain and the role of combination analgesia 
This module tests knowledge of medicinal cannabis, and links to resources to help gain experience in prescribing cannabis for chronic pain. 
    • AJGP Clinical Challenge, June 2021, Medicinal cannabis
This webinar assists GPs to empower people to self-manage chronic pain and engage with health-improving activities and discusses strategies for prescribing and de-prescribing opioids.
Other
A useful guide for converting opioid doses when switching between different opioids or modes of delivery. Outlines the evidence for prescribing opioids and adjuvants in the primary care of acute and chronic pain outside of active cancer treatment, palliative care and end-of-life care.  
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Printed from the RACGP website at https://www.racgp.org.au/education/education-providers/curriculum/curriculum-and-syllabus/units/pain-management 6/10/2022