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. Continue reading