GPs can help patients manage chronic non-cancer pain – with fewer opioids

With concerns rising throughout the world about a spike in opioid addiction and its related harms, efforts are under way to restrict opioids to time-limited scenarios, such as end-of-life care, cancer pain, acute pain and dyspnoea, or longer-term to opioid dependency management.
 
So where does that leave the people experiencing chronic non-cancer pain who are considering going to a GP for help? Potentially better able to deal with their pain, according to a new study published in Australian Prescriber.
 
In the study, ‘Prescribing wellness: Comprehensive pain management outside specialist services’, lead author and addiction specialist GP Dr Simon Holliday and his co-authors call for a wider recognition of GPs’ abilities to help tackle complex, long-term pain through lifestyle changes.
 
They suggest that GPs are capable of giving people experiencing chronic pain the mental and physical techniques to help them reduce their sensations of pain without the use of opioids.
 
For example, the researchers suggest tackling the link between obesity and chronic pain through better nutrition, and the link between increased pain thresholds and human contact by encouraging social activities.
 
‘Education allows patients to reframe their treatment needs away from solely tissue-focused and passively received interventions,’ they write.
 
‘Explaining the neuroscience of pain has actually been shown to improve pain, movement and fear-avoidance, especially when provided with active strategies such as encouraging the patient to gradually resume normal activities in a paced manner and assistance with sleep disturbance.
 
‘GPs have the advantage of capacity, accessibility (geographical and financial) and the potential to provide longitudinal, holistic and opportunistic care. For this reason, it is important GPs do not feel that treating chronic pain simply requires a choice between prescribing opioids or referring to specialist care.
 
Dr Holliday told newsGP the study is about empowering GPs to do what they do best.
 
‘We can do what we do really well, if we just understand that we can do excellent pain care,’ he said.
 
‘Our previous research has shown that merely educating GPs about the importance of avoiding quick fixes to complex pain problems does not reduce overall opioid provision.
 
‘This project is designed to empower GPs to offer excellent multimodal pain care and encourage non-judgemental opioid care. GPs should not delay opioid tapering until triggered by the identification of the kinds of behaviours and attitudes usually seen in illicit heroin users.
 
Dr Holliday said GPs often feel they have to choose between opioid prescriptions, or referral to the ‘gold standard’ of multimodal pain care centres.
 
‘Tertiary pain centres can have waiting lists of 18 months, or be a long way away from people in the bush,’ he said. ‘So relying on these two options is a disaster waiting to happen, giving poor pain outcomes and increasing opiate availability.’
 
The study described the fact much information about chronic pain management for GPs had been funded by commercial sources, leading to an over-reliance on opioids despite their lack of benefits for most patients.
 
‘When benzodiazepines were first marketed in the 1960s, their main hook was often that they weren’t as bad as barbiturates,’ Dr Holliday said. ‘Now we’re doing the same with opioids, with marketing mainly focusing on how newer formulations are relatively safer than the older ones.
 
‘And, just as we saw escalating deaths from barbiturates, we’re seeing that for opioids and benzodiazepines.
 
‘For the last decade we have seen prescription opioids, rather than heroin, as the cause of opioid-related presentations to addiction clinics, to emergency departments and to the morgues.
 
‘So, we now have evidence to reassure our patients that we’re not making things worse by not initiating or by tapering opioids for a patient. If we look more at how they’re living their life, their family, relationship, their drinking or drug habits to deal with pain, if we talk about all these things to get them moving, walking the dog – we can coach them.
 
‘We can say there’s no quick fix. If we had a magic cure, we would have given it to them by now. But we can work together to help them reclaim their life, to help them reach the goals they want to reach. This is going from a disease focus to a health focus.’
 
Dr Holliday cites a recent landmark randomised control trial for 240 American veterans with moderate-to-severe musculoskeletal pain commencing a comprehensive pain management program. The researchers followed these veterans over the course of a year and found that treatment with opioids did not improve pain levels or functional outcomes and, in fact, caused significantly worse medication-related adverse effects.
 
Pain, according to Dr Holliday, needs to be properly understood as more than just a stimulus sent up nerves to the brain.
 
‘In the 2014 NRL Grand Final, Sam Burgess played the whole game with a fractured cheekbone. His endogenous opiates were so maxed out for his team, he didn’t notice until he finished the game,’ he said.
 
‘People can do these things because our endogenous opioid system regulates our pain experience. But when we start to rely on external opioids, we hijack this system and end up in trouble.’

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