Can pain self-management avoid the need for opioids?

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‘We have the potential to navigate our profession through the Scylla and Charybdis of untreated pain and opiate overprescribing.
 
‘We shouldn’t be starting these drugs for chronic pain. We’ve got to stop starting bad pain care. We’ve got to start stopping bad pain care.’
 
‘While these things take time, we as GPs do have time – we look after people for decades.’
 
GP and pain expert Simon Holliday has a longstanding clinical and research interest in pain management.
 
He and his collaborators have just published an evaluation of their six-hour education session aimed at giving GPs the tools to effectively become their own multidisciplinary team and tackle the epidemic of chronic pain – without addiction-forming opioids.
 
The Health Education in Practice research was undertaken in response to calls by the Department of Health to make best practice chronic pain management accessible in primary care through short training courses.
 
When a patient of Dr Holliday’s who is reliant on opioids comes in, he will undertake a quick pain outcome score.
 
‘I’ll say, “It seems you’ve got really terrible pain and yet you’re on a really high dose of opiates. That shows that your opioid-based pain care is not very good … and you’re putting yourself at risk”,’ he said.
 
‘“It’s almost certain opiates are causing all sorts of other problems for you. I’d like to look at how we can improve your situation, quality of life, and ability to work and get your life back on track”.’
 
This reframing of the situation is key to starting a discussion around pain self-management.
 
If Dr Holliday’s patient accepts the idea, the two of them will begin planning to taper opioids (except in dependency situations), as well as implementing ‘excellent self-management’.
 
One in five Australians (1.6 million people) aged 45 and older had chronic pain in 2016. During the past two decades, opioids have been pushed to treat the problem, expanding the patient base out from palliative care and cancer pain.
 
While opioids can play a useful role for some patients with chronic non-cancer pain according to a Cochrane review, soaring prescription rates have placed the use of opioids to treat chronic non-cancer pain under increasing scrutiny. Close to 40% of people in the US reported using pharmaceutical opioid analgesics during 2015.
 
In Australia, dispensing of these opioids rose 15-fold between 1992 and 2014, with around 16% of the population prescribed an opioid annually as of 2019.
 
Deaths have shot up in many countries in tandem, with opioid overdoses killing 900 Australians in 2018 according to a recent report.
 
The World Health Organization (WHO) last year pulled two opioid guidelines over concerns they had been influenced by pharmaceutical companies, according to the British Medical Journal.
 
‘In the decade leading to 2016, the rate of [opioid-related deaths] almost doubled to three each day with over three-quarters involving [pharmaceutical opioids],’ Dr Holliday and his co-authors write.
 
‘Tapering or termination of long-term [opioids] may actually increase [opioid-related deaths] without the introduction of active pain self-management as well as strategies used for opioid maintenance in dependency.’

A key challenge is the fact opioids are comparatively simple and initially effective, though efficacy reduces over time, potentially leaving people in pain – and ultimately dependent.
 
Pain self-management has become a lodestone for doctors who want to avoid the well-documented harms of the huge increase in pharmaceutical opioids.
 
‘Opiates are fantastic in acute pain and post-surgery. We use them in palliative care and end-of-life care. And we use them long-term for dependency treatment, where they really are fantastic for harm minimisation,’ Dr Holliday told newsGP.
 
‘But the evidence is that opiates don’t have any role in chronic pain at all, frankly.
 
‘The evidence we do have is that it can make chronic pain worse, make function worse and come with side effects, including increased pain as well as diversion, overdose and death.’


GP and pain expert Simon Holliday has a longstanding clinical and research interest in pain management.

The problem is that achieving good pain self-management has been commonly thought to require a team of pain specialists, GPs and allied health experts such as physiotherapists to help patients introduce a healthier lifestyle and find non-pharmaceutical ways of reducing pain.
 
But the wait for a multidisciplinary team for chronic pain in major cities can stretch to 18 months. Access is often impossible in rural areas, according to Dr Holliday.
 
Dr Holliday’s new research is aimed at GPs who want to treat chronic pain without starting patients on opioids – and who do not have good access to a multidisciplinary team.
 
‘GPs manage the vast majority of [chronic pain] and do so without the resources and interventions of specialist multidisciplinary teams,’ Dr Holliday said.
 
‘We showed that it is feasible to assemble [a multidisciplinary team] involving specialist pain practitioners and GPs to deliver brief chronic pain training as standard continuing medical education to disseminate competencies appropriate for a GP’s clinical workflow.’
 
According to Dr Holliday, it is ‘essential’ for GPs to become competent in non-pharmaceutical strategies for treating chronic pain.
 
‘Our workshop had five hours on the active self-management of chronic pain. Many strategies are the same as you’d use in active self-management of chronic anything, from diabetes to arthritis to obesity. It’s often about healthy lifestyles and a healthy psychology,’ he said.
 
‘It’s eminently usable for doctors, but no pharmaceutical company would support these sorts of measures. You don’t get taken to dinner by a drug company to talk about difficult conversations and motivational interviewing.
 
‘No one has ever evaluated chronic pain education for GPs where the education wasn’t pharmaceutically focused. Other evaluations ask questions like, “When was your first dose of opiates?”
 
‘We had a lot of trouble getting funding for this. No one is interested in evaluating medical education. There’s an assumption that any medical education must be good, but pharmaceutical companies know medical education can certainly change practice, and not necessarily in the public interest.’
 
Australia’s 2019 national plan for pain management calls for a suite of assessment and monitoring tools for chronic pain combining best practice assessment and the sociopsychobiomedical approach.

Dr Holliday and his co-authors state the plan envisages the upskilling of ‘time-poor GPs in early interventions, including [pain self-management], to prevent the chronification of acute pain’.
 
‘This study indicates such training may be considered viable,’ the authors write. ‘One report estimated that a nationwide continuing professional education program for GPs would be cost-effective based solely on the reduction of [opioid related deaths].’
 
The course hosted at the RACGP’s 2017 conference ran for six hours and was attended by 99 GPs. In follow-up surveys, GPs reported improved knowledge of pain self-management and less reliance on addictive pharmacotherapy.
 
‘Evidence-informed chronic pain management emphasises non-pharmacological and non-invasive pain self-management [a multidisciplinary engagement with multimorbidity], the non-initiation or deprescribing of opioids, and a harm minimisation approach to addictive pharmacotherapies,’ Dr Holliday and his co-authors note.
 
‘The prevalence of chronic pain and opioid consumption is higher in populations with demographics characterised by low levels of education, low income, rurality and complex psychosocial issues.
 
‘Such populations are less willing or able to access specialist [multidisciplinary teams] and are more likely to dropout from pain self-management. 
 
‘GPs offer greater geographical and financial accessibility, along with opportunistic and longitudinal care. This may explain why population-level research shows strengthening of the [general practice] sector improves many health outcomes, including mortality.’
 
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