Persistent pain management in Australian general practice

Persistent pain is a common, albeit challenging, condition to treat in general practice. Analgesics, particularly opioids, are frequently employed, despite limited evidence to support long-term use and concerns regarding their safety (Chou et al. 2015). Our study aimed to identify the perceived barriers to optimal pain management in Tasmania, and potential ways in which these could be overcome.

An electronic survey, administered through Lime Survey, was distributed to Tasmanian General Practitioners (GPs) through direct email to all general practices in the state and the inclusion of information about the study in the Local Primary Health Network e-newsletter, which is distributed monthly to all practices in Tasmania. The survey involved tick-box answers based on previously identified barriers to pain management In addition, free text responses were available so that GPs could provide additional barriers and strategies used. An incentive of the chance to win one of five A$100 vouchers was used to enhance recruitment.

Approximately 700 GPs work in Tasmania (Tasmania Medicare Local Limited 2015), of which 41 completed the survey. Although, we acknowledge this low response, several important barriers to optimal pain management were identified. Participants were asked ‘Which of the following do you think are the major barriers to the management of persistent pain in general practice?’ Responses included: patients’ expectations (63.4%); access to pain clinics (53.7%); poor physiotherapy funding (43.9%); risk of medication side effects (36.6%), misuse, abuse or diversion of drugs (31.7%) and poor access to psychologists (31.7%).

As noted, patients’ expectations were identified as a barrier to pain management. Although almost three-quarters (73.2%) of the GPs reported undertaking discussions with patients about expectations and nearly half (48.8%) indicated that they discuss trialling opioids, there is still room for improvement. Without such discussions, patients may assume that freedom from pain is achievable and that once an analgesic is started for persistent pain it will be automatically continued, making any subsequent discussions regarding de-prescribing more challenging. Although several initiatives exist that focus on improving patients’ expectation and knowledge, and public awareness of pain and its management (Pain Australia 2014), improved implementation of these would appear appropriate.

Whereas specialist pain clinics make good use of physiotherapy and psychology services, there is only one publically funded multidisciplinary pain clinic in Tasmania, creating a significant barrier to treatment. To assist in overcoming this, different approaches must be considered. As nurse- and pharmacist-run pain clinics have been found to reduce pain and improve physical functioning (Hadi et al. 2016), one potential approach is to expand the role of pharmacists and nurses already working with GP practices. These professionals could discuss treatment trials and expectations, and provide education about analgesics and pain management while potentially freeing up the time of the GP to deal with the often complicated clinical aspects of the patient’s care. While noting the GPs’ concerns about access to allied health professionals and pain clinics, improved teamwork within primary care may enhance the management of persistent pain, and help support GPs in this challenging area.

Associate Professor Bereznicki reports that he received personal fees from Boehringer Ingelheim Pty Ltd and grants from Aspen Pharmacare Australia; however, these were outside the scope of this work.