SafeScript podcast 2: Managing chronic pain: Practical approaches for a complex problem

Hello I'm Lynn Weekes and today we will be talking about safely managing patients with chronic pain in primary care and in particular the complexity of treating pain in people with coexisting mental health conditions. We know that people with a mental health disorder and pain are at higher risk of harm from opioid analgesics and for example here in Victoria, 75 per cent of people who die from an opioid overdose have a mental health condition.

Joining me today to discuss this critically important topic and how these patients can be safely and effectively managed in primary care is Yvonne Bonomo, an addiction medicine specialist at the St Vincent's Hospital, Malcolm Hogg, a pain specialist from the Royal Melbourne Hospital and Ferghal Armstrong, a GP practicing about 70 kilometres from the Melbourne CBD.

Both chronic pain and mental health conditions are commonly seen in general practice and frequently in the same patient indeed this research showing a bi-directional relationship between chronic pain and mental health Disorders. Malcolm, can you talk to us about this neurophysiological relationship between pain and mental health conditions and why it's important, how it can guide management?

Malcolm Hogg (MH): So we see from the statistics that people who develop acute pain are more likely to develop chronic pain if they have pre-existing anxiety or depression so it's a risk factor for developing chronic pain. In those that do develop chronic pain there's a higher rate of depression in the order of 40 to 50 per cent of people with chronic and persistent pain have significant mood disorder. So this is the bi-directional, they’re risk factors for each other. The implication is then, what happens in opioid use we know on those with opioids if they're at high dose of opioids they're more likely to have a mental health diagnosis. And so if I see people on high doses of opioids with chronic pain, I should be looking for a mental-health diagnosis and be actively managing them. We also know that suicide rates are higher than those in chronic pains between two and three times the general population. But if you've got poorly control pain and a lot of psychosocial factors, then you're at higher risk of suicide and they're the group that are also receiving opioids so that's the second big risk factor that we need to take into account. And then the third implication is how do you actually manage it and opioids may contribute to the depression so actually reducing opioids may be part of the management of their depression. But also the other agents that you might like to use for mood disorders such as tricyclics and SNRI antidepressants have a role in pain management as well as depression and mood management. So these are the implications in a practical sense.

Lynn Weekes (LW): So there's a lot of crossover and it's hardly surprising then that we do see the use of opioid analgesics, benzodiazepines, quetiapine drugs in the same patient fairly frequently, in spite of what the guidelines might say and with all the best will in the world. Yvonne, starting with you and then Malcolm, realistically how would you manage a patient who's needing higher and higher doses say of oxycontin and they're taking valium maybe a couple of times a day or when they're feeling anxious, how do you start that conversation with that person?

Yvonne Bonomo (YB): Usually I start by talking to them and saying that I'm worried about their safety and that these combinations of medications can often be unsafe and so let's rationalise them and see how they respond to that. And sometimes you have to go quite slowly with them if you can see that they're getting terribly alarmed about you wanting to change the regimen. And so there needs to be more discussion around why it's unsafe and how we can get you feeling better if we rationalise these medications and have you on as few as possible.

LW: What about you Malcolm?

MH: Okay so from my perspective I try to reconceptualise their pain and their experience and for that I'd need to know a bit more about them in their early childhood development and the risk factors that led to the acute onset of pain. And then why did it then become a chronic disabling condition with opioids? So it can be reexplained to the patient and then they can reconceptualise as well as their other health care practitioner so that a better strategy, multi-dimensional strategy can be implemented for better pain management with the safety in mind.

LW: So Ferghal, in general practice you're treating the whole patient, is this patient just too complex, is it fair enough to say: I need to refer this person on or is it really something that you should be able to manage in general practice?

Ferghal Armstrong (FA): So I think we heard that everyone else in this podcast is also treating the whole patient and that's the message that is coming through. Secondly we can't avoid complexity in general practice so it can be a bit daunting when one is first confronted with this kind of problem. But you're not alone, there is help available to you, there is at least telephone advice and there are services that you can go to to get secondary care advice as you're waiting for a referral. And I think it's important to mention that the management of these patients is not just about how one writes a prescription. You know you mentioned Malcolm, multi-modal interventions, the access to physiotherapy and psychology is available even in relatively rural and remote areas so start the ball rolling. And that's that's the message that I would give to my colleagues: there are things that you can do whilst you're waiting for a patient to be seen by a specialist.

LW: Yes and things that are quite productive in that period. So then there are patients of course who already have an opiate use disorder as well as a mental health condition which we’ve flagged and they're at high risk again of adverse outcomes from their medication including high risk of suicide which you flagged. Ferghal, if you saw in SafeScript a record of a patient you've been treating for a while for pain and anxiety is sourcing prescriptions from another provider, first of all how do you feel?

FA: Well it's only natural to feel a little bit affronted but one has to minimise the injured pride you know, it's not about you it's about the patient. You have to accept that this patient is presenting to you with a chronic relapsing disorder and abandonment is not the treatment of this chronic relapsing disorder. So saying you know: please leave, I'm not going to look after you anymore. It's not the right thing to do on moral and ethical levels. So having got over that injured pride then I think for me the next step would be to understand the risks associated with that patient, both the pharmacological risks as per SafeScript, the physical comorbidity risks and also the risks of addiction. And I think at that point a discussion on substance use disorder and whether or not it's a possible diagnosis that needs to be had as well. Having made that risk assessment then they I think a harm minimisation plan needs to be tailored to the patient and there are various things that one can do in that harm minimisation plan to then progress that patient’s care and that plan may or may not involve pharmacotherapy.

LW: I think what you're describing there is very much a continuation of management of a patient? Maybe thinking about discharging that patient at some point if you need to to another part of the system for care or or sharing care perhaps with another part of the system?

FA: I prefer the phrase sharing care, I don't think GPs are ever in the position of discharging their patients. Hospital physicians can discharge a patient back to the care of their GP but I don't think GPs can discharge their patients.

LW: Your code of practice really is looking at continuity of care for the person. I like also that concept that you talk about a chronic relapsing condition and I think when we're talking about opiate use disorder that it’s really important that we do think about the chronic condition. And I guess that brings us to the medication-assisted treatment for opioid disorder. It's been shown to significantly improve patient safety over and above other treatments and it should be considered for patients at high risk. Yvonne, I think you prefer to call it opioid agonist treatment, how do you go about starting someone on opioid agonist treatment?

YB: Well firstly I try to find out how they feel about it and what they know about it because many people will have preconceived ideas about what it actually is and what it does. You hear terms like “liquid cuffs, things like that so I ask them if they've heard of it and what they think about it and then from there I can work out what the best way to talk about it is. Sometimes we need to dispel those myths.

LW: So people are thinking that it really it's going to limit their experience of life or make them feel less?

YB: Yes or you're saying: I'm an addict. I'm not an addict etcetera etcetera. So talking through with them and just finding out where they're at in terms of what they know about opioid agonist treatment. And yes we we do call it agonist treatment because the other term, the traditional term has been substitution treatment where we actually find it's quite stigmatising and it's a misconception that you're just substituting one drug for another. And if patients pick up that notion then there's a fair bit of judgment and stigma associated with that. So we talk about how neuroadaptation has occurred and that opioid agonist treatment is about addressing that neuroadaptation so that they can get on with life and do the things that they want to do and not be held back by their pain condition and the medication regimen.

LW: So your body's got used to this treatment so we're needing to manage that?

YB: Exactly, so that you feel more comfortable, you feel better and you can get on and do the things that you want to do in life.

LW: What about the practical steps you take then?

YB: So often we will after that conversation give them some reading material to go away and think about it first and then at subsequent visits we start the treatment.

LW: And you agree on a therapeutic goal at some point with the patient or is that something that you have in your mind?

YB: Certainly in in our mind, it depends on the individual. Some people want to know where will this end and others just want to take it one step at a time, so it's really on a case-by-case basis. But the main message is that the main treatment goal in the first instance is to be feeling physically better, not having these peaks and troughs with non-OAT treatment.

LW: And being safe presumably?

YB: Exactly yes.

LW: Ferghal, what would you say to general practitioners who aren't convinced they could manage medication-assisted treatment of opioid disorder in general practice, what are the opportunities there? It's not something you might do often so you might need some help.

FA: So first I would say that opioid agonist therapy is actually part of the remit of general practice and it should be considered as such. In Victoria at least, general practitioners have the right to prescribe for five patients using a particular type of OAT and they can do that without any specialist training. However the third thing is to say that you're not alone there are lots of experts out there and there are lots of resources out there to help you actually get started on your journey into prescribing for these patients. And that kind of help can involve access to experts and including the Echo Project, I think we all might want to speak a bit about Echo. The pharmacotherapy area-based networks are available to provide advice and support and also the RACGP, not only has it produced written documentation to help you through this conundrum but it also provides training to actually become a pharmacotherapy prescriber. So you're not alone and you should consider it as part of your core business.

LW: And I think there's also a quick up-skill on the Department of Health and Human Services website for buprenorphine in particular so if you're interested in using buprenorphine you can use that as a really helpful way to get started. Yvonne, do you want to tell us about Echo?

YB: So Echo is a project that started in the United States and essentially it's a community of practice that's online for health professionals in opioid prescribing. And so it runs on a Wednesday morning before people start work, so very early, but cases are presented by people who are either at the hub or at what we call spokes, in rural and regional Victoria. They're deidentified cases but they provide an opportunity to talk together as a group about how do we go about managing this particular person and their complex comorbidities that they might have. It's open to anybody who's interested in just listening to how people approach these sorts of quite complicated management issues at times

LW: But we don't all live in Melbourne so we can use things online or use other telecommunications. Malcolm, you also practice in in Ballarat, which is not so far out of town but still not yet a rural area. How do you find the referral services there and what other strategies do you need to put in place?

MH: So in addition to the Ballarat region, you go further out into north west Victoria for example and so the suggestion and recommendation is to develop links and associations and learn from your colleagues in that sort of referral pathway. There are health pathways to do local referrals but there are also secondary pathways down into the tertiary services in the city. Now most of them have a rapid access pathway or a telephone consultation approach or telehealth services so a bit like the Project Echo concept of a hub-and-spoke model. If you have a complex patient, you should be able to develop the links to the secondary and tertiary services to provide support and if need be in-person assessment.

LW: If you haven't done that before you would go and look at your PHN health pathway?

MH: I think so, that will give you the links to the local services and if they cannot help then it's the next one along. What the advantage of of having those relationships is you develop your own team in the community. And so I just telehealth into both Mildura and the Hamilton region and what we’ve found is that over five years, we've got to upskill staff members, of exercise physiologists, psychologists, nursing and GPs, so they're essentially providing quality services in the community that the patients appreciate. They've learned over time, they don't participate in every case but they learn by the interaction that we have. And so the referrals that we get now are much higher quality and need consultation rather than full-on hands-on management.

LW: And those people are having service provided really conveniently, near home, and they're more likely to come more often.

MH: Yes and so for this cohort in Victoria of high-dose opiates, high level of distress, we know there's a higher proportion of those in rural and out-of-urban areas where the service provision is least and their engagement is the big crucial issue. So getting them into Melbourne is going to be near impossible but having some linkages and development over time of both staff, but also engagement with the patient, works best.

LW: That's a really good service and and Ferghal, for you in general practice, Koo Wee Rup is not exactly the bush but it is the urban fringe, bit beyond the urban fringe of Melbourne, how do you find accessing services?

FA: I'm very lucky I've got the the involvement with Echo that's already been mentioned but you know in my area the pharmacotherapy area-based network is very supportive and there are networks that cover the entire of Victoria so it's about accessing or identifying people, key people within those networks that are able to start the development of your personal network of expertise. You don't necessarily have to know everything, you just have to know who to call.

LW: And building that team over time seems like a really good strategy because you'll all get know each other and trust each other and understand each other's work practices. Malcolm, coming to you, there are GP clinical advisors in the community who are available, how can we use those and can you tell me a bit more about them?

MH: So you know we've had an established drug and alcohol consultation service by telephone. With the SafeScript initiative, there's been development of GP champions specifically in the rural areas where we've got the clinical need and so those champions have had additional training through both drug and alcohol and pain services and are there to provide leadership to other GPs who may have issues. And are part of a consultative advisory service as part of pain consultative advisory services, as part of the SafeScript initiative. And I think they will also know the pathways and they know that connections and can promote and encourage that staff development in the local regions and their linkages to the specialist services.

LW: So it sounds like a great way to get started if you’re not sure where else to start.

MH: I think it is and this is what we find over time is there input over time gives confidence to other practitioners to broaden the depth of knowledge and to broaden the skill set that their confidence in that their service delivery model can can grow. Rather than being reliant on: ah there's a very long wait list so I won't even bother referring to a tertiary service and I won't bother managing them. We’re actually encouraging engagement in knowing about these issues and actively managing them.

LW: Yes, as Ferghal said earlier, get the ball rolling because there's no need to wait, there’s good things you can be doing immediately.

FA: Can I just say one more thing about that so there are, to my knowledge, there are 12 GP clinical advisors and they cover the entire Victoria, I think they're mapped out to the networks. And the number for accessing their service is the same as the DHHS telephone hotline which is 1800 812 804.

LW: Thank you all very much. Patients with mental health conditions are more predisposed to chronic pain and Versa. If a patient with a mental health condition has a coexisting opioid use disorder, they are at increased risk yet again. Medication-assisted treatment of opioid dependence should be considered for these patients and SafeScript can help monitor their safety and support care by two or more health professionals. Good medical practice involves ensuring that appropriate continuity of care is provided for all patients. Abruptly discharging a patient from your care or stopping treatment in patients who have been taking high-risk medications over a long period of time may be contrary to patient safety. As we have learned in today's podcast, patients with complex comorbidities can continue to be safely and appropriately cared for in the primary care setting and safe management of these patients is well within the skillset of GPs.

There were three key points for me today. It’s important to understand the relationship between chronic pain and mental health conditions, as this can help guide therapy; patients with mental health conditions are at higher risk of harms from opioid analgesics and patients with opioid use disorder and a mental health condition really should be considered for medication-assisted treatment of dependence because they have much better outcomes when this is the case.

More information resources to support your management of chronic pain and mental health can be found in the SafeScript online training modules and your local PHN SafeScript health pathways. The SafeScript GP clinical advisory service provides peer-to-peer to GPs managing patients with complex pain addiction or mental health needs and they can be contacted on 1800 812 804. Links to these resources can be found at the Department of Health website www.dhhs.vic.gov.au/safescript. Thank you for listening today, thanks to our guests Yvonne Bonomo, Malcolm Hogg and Ferghal Armstrong. Our next podcast will look closely at patient safety and using benzodiazepines, I hope you can join me.

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