Editorials
General medicine Anaesthetics Substance‐related disorders
Volume 214 - Issue 9

The challenges of managing both chronic pain and opioid use in general practice

Author:  Hester Wilson

Med J Aust 2021; 214 (9): 416-417. || doi: 10.5694/mja2.51041
Published online: 17 May 2021

The safety and value of reducing opioid use are recognised, but difficult conversations and less accessible alternatives are barriers

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The safety and value of reducing opioid use are recognised, but difficult conversations and less accessible alternatives are barriers

Chronic pain affects about 20% of adults in Australia and New Zealand,1,2 and opioids have been enthusiastically embraced for treating it. Unfortunately, this has led to significant harm,3,4,5 and evidence of the long term effectiveness of opioids for relieving chronic pain is limited.3,6

In this issue of the MJA, Tardif and colleagues7 report data from the electronic Persistent Pain Outcomes Collaboration (ePPOC), including patient‐reported outcomes. This real world data encompassed more than 10 000 adults who attended specialist pain services in Australia and New Zealand during January 2015 – June 2020. The article by Tardif and colleagues provides further evidence that patient‐reported outcomes can improve while reducing opioid use, and that the greatest improvement can be associated with complete cessation of opioid treatment of chronic pain.

Patient‐reported outcomes are outcomes that matter to patients. Routine use of such measures in clinical practice is relatively new, and it is pleasing to see them employed in routine clinical settings for assessing patient progress. As a clinician, it is incredibly reassuring to know that a large group of patients, rather than a select study sample, experienced improved functional outcomes while tapering and discontinuing opioid use.

But (and this is a big but) how does this help general practitioners with their patients with chronic pain who are using opioids, and with those who are not and suffer severe, unremitting pain? There is massive pressure on GPs. We are told to avoid starting patients on opioids and to stop current opioid treatment, and as GPs we do understand the risks. We also understand that reducing opioid use may improve pain. But what else can we offer? How do we help patients to reduce opioid use? These conversations are difficult:8 the potential for conflict is high, with a negative impact not only on GPs’ wellbeing,9 but also on our patients, who may feel stigmatised and abandoned.10 GPs know that talking and physical therapies are safer than opioids, but we are also sympathetic to the patient experience; alternatives can be expensive, less accessible, and, for some patients, unhelpful.11 Opioids help some patients, and it can be difficult to find a compelling, specific reason to ask an individual to abandon them.

GPs are increasingly exhorted by pain clinics to stop prescribing opioids,12 but there is little practical support for this aim. Tardif and her colleagues report that opioid use for 53% of patients declined only slightly, did not change, or increased during the study period.7

If opioid use by patients treated for six months in specialist multidisciplinary pain services does not change or even increases, what hope do we in the community have of helping our patients to cut back? Many GPs have had the experience of patients returning from pain clinics in which opioid therapy was initiated at doses we were reluctant to continue. We have experienced frustration as patients we spent months convincing to reduce use returned from a pain clinic on higher doses than when we referred them, placing us in an impossible situation: the imprimatur of the specialist makes modifying opioid use by the patient even more difficult than before.

Recent changes by the Therapeutic Goods Administration and to the Pharmaceutical Benefits Scheme regarding opioid prescribing make sense. Introducing real time prescription monitoring is helpful, but GPs and people with chronic pain need greater support and timely, accessible, and adequately funded specialist pain, addiction, and allied health services. The current chronic disease management item numbers for allied health13 are inadequate in this regard. Telehealth may improve access somewhat, but services must be able to respond nimbly to GPs’ and patients’ needs.

We do not want to cause harm, and chronic opioid use and lack of treatment each increase the risk of harm for patients. There is a danger that GPs, fearful of increased regulatory pressures or exhausted by the complexities of assisting people with chronic pain, may disengage from this work, and that patients will be left untreated. Some patients may turn to medications and drugs from outside the health system, with greater risks of harm.

The capacity of specialist pain clinics is limited, and waits for appointments can be long, particularly outside large metropolitan centres.14 There is an urgent need for increased access to effective and safe pain management for all patients with chronic pain. We need greater engagement, support, and, dare I say it, greater respect for the expert role that GPs can play. Achieving all this is integral to improving the lives of people with chronic pain.

 

Author

  • Hester Wilson1,2,3
  • 1. The Langton Centre, Sydney, NSW
  • 2. University of New South Wales, Sydney, NSW
  • 3. Alice St General Practice, Sydney, NSW

Correspondence: Hester.Wilson@health.nsw.gov.au

Competing interests

I have no connections with the tobacco, alcohol or gaming industries. I have received funding for consultancies or for serving on expert advisory panels from Indivior, Lundbeck, Seqirus, Mundipharma, and Pfizer.

References

Linked content

  • MJA Research Letter: Opioid cessation is associated with reduced pain and improved function in people attending specialist chronic pain services

  • InSight+: Pain services effective, but high drop-out rate concerns

Provenance: Commissioned; externally peer reviewed.

View this article on Wiley Online Library