A report from the NT coroner this week about an opioid-related death raises a question I started asking after my very first referral to a pain clinic: what is the point of referral if the patient comes back on the same — or an even higher — dose of opioids?
The coroner’s case involved a Darwin mother with chronic pain and an opioid addiction. Every doctor involved found the interaction difficult, and the patient’s use of the system repeatedly thwarted attempts at reduction.
Each time there was a plan to reduce her dose, a new acute pain event or crisis occurred.
Other medications started creeping in — a sleeping tablet, and pregabalin (Lyrica), which seems to have somehow marketed itself as the high-dose alternative for desperate situations.
One of the frustrated GPs referred the patient to a pain specialist.
If I was designing my ideal pain clinic, it would consist of a specialist doctor (a physician or GP), a psychologist, an exercise physiologist and perhaps a social worker. I could refer patients who had a fixed belief that high-dose medication was helping their chronic pain, even though I observed the exact opposite.
The psychologist would help reframe the meaning of chronic pain. The physiologist would get them moving again, shifting the focus back to function. The specialist would oversee the safe but very strict reduction of their inappropriate analgesia. Contracts would be signed, prescriptions monitored, and we might actually get somewhere.
This coroner’s case typifies why I have almost given up on pain clinics for patients with opioid problems.
In practice, a patient can use the long waiting list as a tool to pressure me into prescribing in the meantime.
When they eventually see the expert — and here I accept that pain clinics vary widely — the specialist may have a superb knowledge of anaesthetics and pain receptors, but that is not actually the core skill required.
In this case, the patient remained on significant daily doses: Sixteen Endone tablets, 80mg methadone, 300mg pregabalin and 75mg amitriptyline.
The patient now believed she had a ‘specialist-condoned’ regime which the GP was expected to prescribe. So in order to reduce her Endone, another GP had to request a review with that aim.
At review, the specialist did not touch the opioid dose, but instead increased both the pregabalin and amitriptyline.
Giving evidence at the inquest was one of the patient’s GPs — and one of the NT’s most experienced clinicians — Dr Sam Heard. The coroner described him as “a most engaging, knowledgeable and impressive witness.”
“It’s as if even a hint of pain implies failure.”
Dr Heard explained to me the role hospitals play in worsening the problem.
“As GPs, we’re quite vulnerable to specialist forensic views about our handling of these patients. Yet hospitals start Endone and then send people home on it. In Aboriginal households I see unused packets lying around, where the kids are playing.
“This is a relatively new concept, where doctors and nurses in hospitals feel it is their duty to use every means possible to get their patients entirely pain-free, even if that requires inappropriate medications. It’s as if even a hint of pain implies failure.”
Like me, Dr Heard has become increasingly disillusioned over time by the value of referral to a pain specialist. “The public message from pain clinics is ‘Come along and you can be pain-free’. People wave clinic letters at me to justify awful management. Inevitably they increase opioids.”
Dr Evan Ackermann, in his role as Chair of the RACGP Expert Committee Quality Care, also provided expert evidence to the coroner. He has seen some pain clinics doing excellent work with the very difficult task of deprescribing. But he also is concerned that the quality is quite variable.
“The problem is the lack of accreditations and standards for pain clinics. Some are good, but a common experience is that opioids are increased.
“This leaves GPs in an awkward position, particularly after having waited so long for their patient to access the clinic in the first place.”
Chronic pain in the setting of overuse of opioids and benzodiazepines is a highly complex problem that is not going to be solved by the introduction of new analgesics or non-opioid alternatives such as pregabalin.
The concept of a multi-modality pain team working with the patient and their GP is brilliant, and has enormous potential to save lives, save money, and restore function and dignity.
It appears that the problem is a wide variation in quality, so let’s introduce accreditation standards for pain clinics, and that must include feedback surveys of local GPs.
Because currently, I am giving feedback only by omission: my reluctance to refer.
Reblogged this on Dr Thinus' musings and commented:
Such a sad state of affairs and certainly descriptive of what I have seen in the ACT over the last 13 years
Australia needs to grow accustomed to the reality that primary care is a specialty.
G.P.s need to be less reticent about overruling harmful interventions made by other specialists.
E.D.s need to stop handing out addiction-starter packs to every patient who stubs their toe.
” I could refer patients who had a fixed belief that high-dose medication was helping their chronic pain, even though I observed the exact opposite.”
May I ask how you ‘observed the exact opposite’??
The argument is being made that GPs are not inferior to hospital doctors. This is, certainly, true. However, how are they any more clever than the Pain Specialist as this article seems to say?
Pain Specialists usually end up rotating the opioid along with getting the pain seen to by the Pain Psychologist for pain education and Ex Physiologist/Physio to improve mobility. These can be easily done in primary care as well. Pain Specialists, when they feel that nothing they do is working, would resort to unproven procedures which, at best, works only for short periods.
There are conditions where telling the patient that it is ‘all in the head’ or improving mobility does not help, for e.g. Endometriosis.
Therefore, it is very common to find Pain Specialists struggle, just as GPs do, in certain clinical presentations.
We try and simplify things at all times, but medicine is not black and white.
Perhaps, the answer lies in developing safer and effective pain killers. Palexia seems promising. Quite safe with no risk of addiction or diversion with no street value. Also, can’t be taken with other opioids because of its weaker mu receptor affinity.
Yes, I’m trying to simplify it too!
Thanks John for your observations.
I am not asserting that GPs are, as a group, more clever than pain specialists. I am arguing that the pain clinic system in many parts of Australia too often falls well short of what I would like to see available.
I have no trouble thinking of many, many patients over the years where their escalation of opioids has caused the ‘exact opposite’ of helping their chronic pain. Indeed, it is unusual to find someone on high-dose opioids for non-cancer pain where high doses of opioids have helped more than harmed.
Evidence in the literature supports me in this view – e.g. “The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop,” found at https://www.ncbi.nlm.nih.gov/pubmed/25581257
I agree with your other points that pain specialists, like GPs, struggle with the issue, and that medicine isn’t black and white, and in short, it is a very tough gig working in this area!
I am far less optimistic than you that the answer will lie in a new type of medication, but I suppose time will tell.
This accurately articulates a lot of what I feel about pain clinics.
The other gripe I have is that a few of my patients are put on massive doses of lyrica (pregabalin) which increases their appetite and hence their weight (in one patient increase of 100% of weight, a patient I inherited from another GP). This of course leads on to more problems – pain in knees, hips and back, unable to exercise … and the cycle continues. And when this particular patient saw another pain specialist, she was told she was too obese and she should see her GP to refer her for ‘free bariatric surgery in a private hospital’!
My psychiatrist put me on 2 X 120 mg of Lyric twice a day for chronic pain. Did not last long Not worth a pinch of sh.t !!!!!!!!