Issue 8 / 11 March 2013

IMPROVED communication between specialist and primary care services is crucial for patients with chronic pain and could have both preventive and clinical benefits, says a pain management expert.

Dr Malcolm Hogg, head of pain services at the Royal Melbourne Hospital, said by addressing the “disconnect” between general practice and specialist pain services health outcomes for patients would be greatly improved.

He was commenting on an MJA editorial, published online today, by Professor Geoffrey Mitchell, which said waiting times for assessment and treatment of chronic pain patients in specialist multidisciplinary clinics and the transition to community-based care were two key “fault lines” in the current models of care for patients with chronic pain. (1)

Professor Mitchell, professor of general practice and palliative care at the University of Queensland, said while formal collaboration between GPs and specialists in chronic pain management had not been formally tested in clinical trials, trials in stroke treatment and palliative care had shown the benefits of formal case conferences.

“The key to success is to recognise that the work patterns and demands of general practice and the specialist team are fundamentally different, and the parties only need to make contact for a short time to conduct the case conference”, Professor Mitchell wrote.

Dr Hogg said the disconnect between acute pain services, outpatient pain clinics and general practice was largely caused by federal–state funding barriers. Long waiting lists due to a lack of access to outpatient pain services also resulted in extended lag times and contributed to communication difficulties, he said.

“There are problems on both sides”, Dr Hogg said. Acute hospitals and chronic pain clinics might not fully appreciate the importance of good communication and GPs, particularly those in corporate practices, might be hesitant to return phone calls because of time and funding constraints.

Dr Hogg said some of the outcomes of this lack of coordination of pain management services to community care included a higher uptake of the disability support pension, potential for excess reliance on opioids for pain management in the community and higher risk of psychological distress and suicide related to chronic pain.

He agreed with the MJA editorial that a formalised process could be beneficial but said there were difficulties in coordinating times when all health care parties were available.

“Possible alternatives that should be considered [include] email-based, question-and-answer discussions”, he said, adding that practice coordinators had a role in facilitating such discussions.

Dr Hogg said while GPs could sometimes access funding through the Chronic Disease Management Medicare items, this funding may not be available to their specialist counterparts. This Medicare funding was also not available in the acute and subacute phases, when optimal management could be most effective.

“We need realignment of the funding process”, he said.

Dr Hogg said better education of and engagement with GPs would lead to earlier, optimal care, which would have long-term benefits for patients.

“The earlier and better you manage pain, the better the outcome. Those patients waiting 12, 18, 24 months [to access pain management services] have a lower chance of recovery than if they had received early, optimal care.”

Consumers Health Forum CEO Carol Bennett welcomed the call for more collaboration and the “growing recognition of chronic pain as a stand-alone issue, not just a symptom”.

“Consumers with chronic pain have to repeat their story to doctors and specialists again and again. It can take years to identify their issues and find treatment”, Ms Bennett told MJA InSight.

Ms Bennett said improving collaboration between GPs and specialists would reduce the need for consumers to repeat their stories, lower the risk of communication errors and make it easier for consumers to find the treatment they need.

– Nicole MacKee

1. MJA 2013; Online 11 March

Posted 11 March 2013

4 thoughts on ““Disconnect” in managing pain

  1. Anonymous says:

    we gp not only have time restraint but also lots of gps dont like prescribing opiates etc so it does become hard to manage patients with chronic pain.
    also they need to see specialist to make that ‘diagnosis; ‘especially when patient is on work cover otherwise becomes hard to access these services

  2. Zenon Gruba says:

    The very sad thing about managing patients’ chronic pain syndromes, is that there is no management. Analgesics, narcotics and epidurals is all that medicine has to offer.
    There are a whole range of non-evidence based procedures that work very well. These include acupuncture, myofascial therapy, prolotherapy, to mention a few. They are simple to apply. They are harmless and non-addictive. For non-neuropathic pain, I am getting consistent pain remissions in just a few consultations. With humble respect, I believe that it is time to talk to our non-evidence based collegues about what works for them.

  3. Lynton Giles says:

    A very effective way of dealing with chronic spinal pain patients was established at the Townsville General Hospital, initially in conjunction with James Cook University in 1995, to deal with this issue using a multidisciplinary team approach incorporating acupuncture, chiropractic spinal manipulation and medicine. The multidisciplinary spinal pain unit ran successfully from July 1995 until late 2001 and was a good referral option for GPs and others. Unfortunately, myopic politics put an end to the unit that was established by visionaries. Some results were published as follows: (1) Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation; L Giles & R Muller, Spine 2003; 28: 1490-1503, (ii) Long-Term Follow-up of a Randomized Clinical Trial Assessing the Efficacy of Medication, Acupuncture and Spinal Manipulation for Chronic Mechanical Spinal Pain Syndromes; R Muller & L Giles, J Manipulative Physiol Ther 2005;28:3-11, and (iii) Patient Satisfaction, Characteristics, Radiology, & Complications Associated with Attending a Specialized Government-Funded Multidisciplinary Spinal Pain Unit: L Giles, R Muller & G Winter; J Manip Physiol Ther 2003;26:293-299.

  4. David D. says:

    A holistic approach to pain management is usually the best.  But each situation and client is different, of course. But by approaching pain management from various angles and using different but complimentary strategies, usually much improvements can be acheived over time.  –David @ Mind & Body Inc.

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