5 ways a specialist pain physician can support general practitioners in managing chronic pain

The credit for this article should go to Dr. Tim Hucker, specialist pain physician, who wrote it. Thanks Tim!

No one needs to tell a busy general practitioner that pain is a big problem!

Pain is a problem in its incidence, prevalence and impact and this includes both acute, chronic and cancer pain.

In many of our pain blogs, the following figures come up time and again and will resonate with many general practitioners:

• Chronic pain affects at least 1 in 5 of us.
• In 2007, 3.1 million Australians experienced chronic pain.
• Up to 80% are not getting the care they need.
• 70-80% patients have moderate to severe pain after surgery.
• The prevalence of pain at cancer diagnosis and in the early stages is approximately 50%, rising to 75% in latter stages.
• The cost to the economy of chronic pain in $34billion/year

It’s not the role of this blog article to discuss why there is such a shortfall between the number of pain specialists and the frequency and severity of the problem you face. However it is interesting to note there are only 65 qualified and registered pain specialists in Victoria with the qualification Fellow of the Faculty of Pain Medicine of the Australian and New Zealand College of Anaesthetists (FFPMANZCA).

So, how can a pain specialist actually help you in your busy general practice? Here are 5 ways a pain specialist with access to all forms of pain therapy can assist general practitioners in managing pain patients.

1. Pain specialists manage complex cases of chronic pain

Many of the patients presenting with chronic pain have a complex and multifaceted history!

Common pain scenarios presenting to specialist pain medicine physicians might include:

- The patient with persisting back and leg pain after what seems like successful spinal surgery (post perative persistent syndrome). Some patients have even had multiple spinal surgeries. We need to tease out the possible aetiologies of their persistent pain. For example:
- If the pain never changed after the surgery, it may be the incorrect diagnosis or
- If the pain returns after 3 months, it might be epidural fibrosis or
- If the pain returns after 1 year, it might be a new spinal problem.
We’ll spend the time with the patient and work this out for you, formulating a differential diagnosis, and then a diagnostic and therapeutic plan of action.

- The elderly patient with mobility problems unable to have joint replacement surgery due to multiple co-morbidities like hepatic and renal failure compromising pharmacological options. These, you would no doubt agree are common. There are interventional and other pain management options for these patients.

These examples are just the tip of the iceberg. Now add in to the melting pot, the complexity of funding issues, difficult relationships with work cover providers, the inevitable alteration in mood and anxiety state, poor sleep quality and the effects of the pain on relationships, and before you know it your consult length will blow out and OUT!

The final straw is that chronic pain is not always blessed with easy treatment solutions. Most of the NNTs for pain medications for instance are 4 (at very best) or higher and when used only provide a certain amount of pain reduction and functional improvement. And then there are the side effects of those medications. So it's vital and imperative that medications are combined with the other 3 pillars of pain managment - interventions, physical and psychogical therapies.

Often the complexity of the solutions matches the complexity of the case.

So how can specialist pain physicians help you?

The basic mantra of all chronic pain issues is to refer to pain physicians early. This will allow early access to all four pillars of multidisciplinary pain therapy:
- 1. Medications
- 2. Pain interventional therapies
- 3. Physical therapy
- 4. Psychological therapy

Figure 2. This is what a step-wise multidisciplinary interventional treatment approach looks like.

This allows patients to be cared for in the correct manner, supported and empowered, ultimately optimising their prognosis.

For example if you’re presented with a case of neuropathic pain, do prescribe your first line combination antineuropathic agents like pregabalin, gabapentin, duloxetine or venlafaxine & titrate upwards BUT if the pain is not improving within a few weeks or if patients are experiencing drug limiting side effects, then refer early to a pain specialist team.

We can then create a plan for you to adjust, titrate, swap and even tinker with your prescriptions for optimal antineuropathic effects. We would also get patients access to the other 3 pillars of pain therapy, if/when appropriate – interventional pain therapies, psychology and physical therapy. Patients also need to be empowered and supported.

When patients attend a pain clinic and following a detailed assessment with a pain specialist they will be presented with a list of therapeutic options specific to them and their condition. These treatment options may range from simple pain medication adjustments to pain management programs or even spinal cord stimulation and many other options in between. These therapies will be administered by combining GP and specialist care aiming for the best possible outcomes.

2. Pain specialists will create the multidisciplinary team for you and your patients

General practitioners already have great expertise in managing patients in a multidisciplinary paradigm. Being the lead of, or a vital component in, such a team is far more common in the community than in many specialists’ practice.

A multidisciplinary pain clinic should offer the same. In almost all cases our patients will be involved with different members of the team, each one specialized within their own field within the pain management framework.

An example is the patient with persistent pain following a minor wrist fracture, who has quickly developed complex regional pain syndrome (CRPS). A pain specialist should manage the pain medications and perform pain interventions as well as also coordinate a team of pain experts like hand therapists or occupational therapists or physiotherapists with specific experience in managing chronic pain. This should be combined with psychological therapy when appropriate. The team needs to act quickly but in a multidisciplinary and interdisciplinary manner, which will maximise the resolution of symptoms and therefore improve the prognosis.

Whilst a medical pain specialist is obvious, it’s not unreasonable to think that psychologists, physiotherapists and occupational therapists can be considered pain specialists too.

3. Pain specialists can have that tricky discussion

There can be significant issues that might complicate pain management, which results in tricky consultations. Probably the biggest cause for concern and the thorniest topic is based around the use of opioid therapy in chronic pain.

Pain specialists can act as gatekeepers and supporters for GPs.

Pain psecialists are well versed in explaining, without confrontation, why opioids should be limited; we mix the clinical, legal and effectiveness arguments and can ensure that this is handled as smoothly as possible. Pain specialists can help put conditions in place for prescriptions such as opioid contracts, we can advise when opioids should be stopped and importantly we can offer other options where available. We also have additional time for these consultations.

It shouldn’t be forgotten that opioids might be effective in a small group of patients with chronic pain. Opioids are used effectively in cancer pain. In these situations, pain specialists can help when opioid efficacy is limited and we would look at other options, like interventional therapies or opioid rotations.

4. Pain specialists keep you up to date

The field of pain management is changing quickly and pain specialists have a vital role as educators. In the short history of the specialty of pain medicine, pendulums have swung widely and many changes have occurred. Dissemination of information is vital for pain specialists. We love educating.

In the lifetime of the specialty, the pendulum has swung from liberal opioid prescription to tightly controlled prescription, from the WHO ladder of analgesic use to increasing calls questioning that ladder’s wisdom and currently wide scale uptake of the field of neuromodulation and spinal cord stimulation.

Whilst the above paragraph suggests a contrary nature, what it does show is that the field of pain medicine is both proactive and reactive; responding to evidence. I

It’s a specialist pain physician's job to keep you as well as your patient and their families up to date and informed.

5. Pain specialists can advocate for you and your patients in the hospital setting

There is a huge amount of hospital practice that impacts a GP and the management of their patients. Take for instance opioid use. Between 1992 and 2012 there was a 15 fold increase in the number of opioid prescribing episodes, accidental opioid poisoning deaths virtually doubled, episodes of opioid related harm changed from predominantly heroin to “other sources” (basically opioids from medical sources). Currently the majority of opioids abused come from medical sources.

Figure 3. The oxycodone molecule

Pain specialists are advocating for GPs who face the burden of this problem. We are firmly in your corner. Our pain specialists are involved in a multi-centre trial highlighting the dangers of filling the community pool of opioids by poor discharge prescriptions. Feeding back to the hospitals some of the community problems faced by GPs is in the best interests of our patients.

Overall, the above examples amongst many others show there is a lot in common between the general practitioner and the specialist pain physician.

This develops a symbiotic relationship that is in the best interest of both parties and ultimately for the good of our patients.