Domain – Pain management (cases)

Sam is 43 years old and presents to you with a long history of back pain which started several years ago and has been getting worse over the past several months. The pain is primarily in the lumbar spine and radiates to both buttocks.

Sam previously worked as an events organiser but was made redundant last year and hasn’t worked since. A few months ago, Sam’s mum was diagnosed with stage 4 metastatic breast cancer and has been quite unwell. For the back pain, Sam has been using paracetamol with codeine 500mg/30mg as required, usually three to four times a day, and occasionally uses a family member’s oxycodone capsules which were prescribed for cancer pain. Sam was hoping that you might prescribe more paracetamol with codeine, and maybe some oxycodone as this seems to help the pain better.

Communication and consultation skills
What ideas might Sam have about pain and how to manage it, and how might these differ from your own understanding of chronic pain and its recommended management?

Sam’s Ideas About Pain and Its Management

1. Immediate Relief: Sam might believe that the primary goal of managing pain is immediate and complete relief. This could lead to the preference for stronger medications like oxycodone, which provide rapid alleviation of symptoms.
2. Medication Dependency: Sam may not fully understand the risks associated with long-term use of opioids, including dependency, tolerance, and potential side effects. The preference for using stronger painkillers might stem from a lack of awareness about these risks.
3. Underestimating Non-Pharmacological Interventions: Sam might not be aware of or value non-pharmacological interventions for chronic pain management, such as physical therapy, exercise, cognitive-behavioral therapy, and lifestyle modifications. The focus might primarily be on medications for pain relief.
4. Influence of Personal Experience: Sam’s experience with managing a family member’s cancer pain might influence the belief that stronger opioids are necessary and appropriate for managing severe pain, irrespective of the underlying cause.
5. Psychosocial Factors: The stress from being unemployed and caring for an ill parent might exacerbate Sam’s pain perception and coping mechanisms. There might be a belief that managing pain pharmacologically is essential to function and cope with these stressors.

GP – understanding of Chronic Pain and Recommended Management

1. Multidimensional Approach: Chronic pain management in general practice is often viewed as a multifaceted approach involving pharmacological and non-pharmacological strategies. This includes physical therapy, psychological support, lifestyle modifications, and sometimes interventional procedures.
2. Risk of Opioid Use: GPs are acutely aware of the risks associated with long-term opioid use, including the potential for addiction, tolerance, and adverse effects. Therefore, they might prioritize non-opioid pain management strategies and aim to minimize opioid prescriptions.
3. Patient Education: Educating patients about chronic pain, its mechanisms, and the rationale for various treatment modalities is crucial. This includes setting realistic expectations about pain management and emphasizing the importance of a holistic approach.
4. Psychosocial Considerations: Recognizing the impact of psychosocial factors on pain perception and management, GPs often incorporate strategies to address stress, anxiety, depression, and other emotional factors contributing to chronic pain.
5. Chronic Pain as a Chronic Condition: Chronic pain is often managed as a chronic condition, similar to diabetes or hypertension. This involves long-term management plans, regular follow-ups, and adjustments in treatment strategies based on the patient’s progress and response to therapy.

What might Sam’s expectations and concerns be coming into the consultation with you? How will you explore these?

Sam’s Expectations and Concerns

Expectations:

1. Relief from Pain: Sam likely expects a quick and effective solution for pain relief, possibly hoping for stronger pain medication prescriptions like oxycodone.
2. Validation of Pain: Sam may seek acknowledgment and validation of the pain experience, wanting to be taken seriously and understood.
3. Support and Understanding: Given the personal and family stressors, Sam might expect empathy and emotional support from the healthcare provider.
4. Continuity of Care: Sam may expect continued access to the medications currently being used, assuming they are the best or only option for pain management.

Concerns:

1. Fear of Being Judged: Sam might be concerned about being judged for using a family member’s oxycodone or being perceived as drug-seeking.
2. Effectiveness of Treatment: There may be worries about whether any new treatment recommendations will be as effective as the current medications being used.
3. Impact on Daily Life: Concerns about how chronic pain and its management will affect the ability to function daily, especially with the additional stress of unemployment and caring for an ill parent.
4. Side Effects and Safety: Sam might have concerns about the safety and side effects of current or new medications, especially given the regular use of paracetamol with codeine and occasional oxycodone use.

Exploring Sam’s Expectations and Concerns

Communication and Consultation Skills:

1. Open-Ended Questions:
   • “Can you tell me more about how your back pain is affecting your daily life?”
   • “What has been your experience with the medications you’re currently using?”
   • “What are your main concerns about your pain and its treatment?”
2. Active Listening:
   • Pay close attention to Sam’s responses, showing empathy and understanding.
   • Use verbal and non-verbal cues to indicate that you are listening and valuing what Sam is saying.
3. Reflective Statements:
   • “It sounds like your pain has been really difficult to manage and is affecting many aspects of your life.”
   • “You’ve mentioned that the current medications help with your pain. Can you tell me more about how they help and any issues you’ve experienced with them?”
4. Empathy and Validation:
   • “I understand that managing chronic pain can be incredibly challenging, especially with everything else you’re dealing with.”
   • “It’s important to me that we find a way to manage your pain effectively and safely.”
5. Exploring Beliefs and Knowledge:
   • “What do you believe is the best way to manage your pain?”
   • “Have you tried any other methods for managing your pain besides medication?”
6. Addressing Concerns:
   • “I want to make sure we address any concerns you have about your pain management. What worries you the most about your current treatment?”
   • “Are there any side effects or issues you’ve noticed with the medications you’re using?”
7. Setting Expectations:
   • “Let’s discuss some realistic goals for managing your pain. While we may not be able to eliminate it entirely, we can work on strategies to help you manage it better and improve your quality of life.”
   • “I’d like to explore both medication and non-medication approaches to help manage your pain. Would you be open to discussing some options?”
8. Collaborative Planning:
   • “How do you feel about trying some additional treatments along with your current medications?”
   • “We can develop a plan together that includes regular follow-ups to adjust your treatment as needed and ensure you’re getting the best possible care.”

If you were going to recommend a different management plan from what Sam was expecting or hoping for, how might you negotiate shared decision-making with Sam about this?

1. Explore Alternatives Together:
   • Discuss various treatment options, including non-pharmacological interventions and lifestyle modifications.
   • Example: “There are several other approaches we can consider, such as physical therapy, exercise, and cognitive-behavioral therapy. These can help improve your pain and quality of life without the risks associated with strong pain medications.”
2. Highlight Benefits of a Comprehensive Approach:
   • Emphasize the benefits of a multi-faceted approach to chronic pain management.
   • Example: “Combining different strategies can often provide better relief and improve your overall well-being. For instance, physical therapy can strengthen your back muscles, and cognitive-behavioral therapy can help you cope with pain more effectively.”
3. Address Concerns and Misconceptions:
   • Listen to and address any concerns or misconceptions Sam may have about the proposed alternatives.
   • Example: “I understand that you’ve found oxycodone helpful, but there are other ways to achieve long-term pain relief that can also enhance your ability to function daily. Let’s talk about any concerns you have regarding these options.”
4. Collaborative Decision-Making:
   • Involve Sam in the decision-making process, ensuring that his preferences and values are considered.
   • Example: “Based on what we’ve discussed, which of these options do you feel most comfortable trying? We can start with a plan that includes both medication and non-medication strategies and adjust it as needed.”
5. Set Realistic Expectations and Goals:
   • Help Sam set realistic expectations and goals for pain management.
   • Example: “While we may not be able to eliminate the pain entirely, our goal is to reduce it to a manageable level and improve your ability to do the things you enjoy. We’ll work together to find the best approach.”
6. Plan for Follow-Up and Adjustments:
   • Ensure regular follow-ups to monitor progress and make necessary adjustments to the treatment plan.
   • Example: “We’ll schedule regular follow-ups to see how you’re doing and make any necessary changes to your treatment plan. This way, we can ensure that you’re getting the best possible care

Clinical information gathering and interpretation
What information would be useful to gather from Sam and any previous doctors to help inform the management of the chronic pain?
What investigations and examination tests might be useful to investigate chronic back pain, and what information will they give you and how does it potentially change your management?

Information to Gather from Sam and Previous Doctors

1. Medical History:
   • Details about the onset, duration, and progression of the back pain.
   • Previous diagnoses related to back pain or other chronic conditions.
   • History of treatments tried, including medications (doses, frequencies, effectiveness), physical therapy, surgeries, or other interventions.
2. Pain Characteristics:
   • Description of the pain (e.g., sharp, dull, aching, burning).
   • Pain intensity on a scale of 1 to 10.
   • Factors that aggravate or alleviate the pain.
   • Impact of pain on daily activities, sleep, and quality of life.
3. Medication Use:
   • Current and past use of medications, including over-the-counter drugs, prescription medications, and any use of controlled substances like opioids.
   • Any side effects or complications experienced with current or past medications.
4. Psychosocial Factors:
   • Impact of pain on mental health (e.g., depression, anxiety).
   • Current stressors, such as unemployment and caring for an ill family member.
   • Coping mechanisms and support systems available.
5. Lifestyle Factors:
   • Physical activity levels and any limitations due to pain.
   • Work history and current employment status.
   • Lifestyle habits, such as smoking, alcohol use, and diet.
6. Previous Medical Records:
   • Obtain records from previous doctors, including notes on diagnoses, treatments, imaging studies, and lab results.
   • Any referrals or consultations with specialists (e.g., pain management, orthopedics, neurology).

Investigations and Examination Tests

1. Physical Examination:
   • Inspection: Look for signs of deformity, asymmetry, swelling, or muscle atrophy.
   • Palpation: Identify tender areas, muscle spasms, and temperature changes.
   • Range of Motion: Assess the flexibility and range of motion of the lumbar spine.
   • Neurological Exam: Check reflexes, muscle strength, and sensation to identify any neurological deficits.
   • Special Tests: Perform tests such as the straight leg raise (SLR) to assess for nerve root irritation or compression.
2. Imaging Studies:
   • X-rays: Useful for detecting bone abnormalities, fractures, degenerative changes, and alignment issues.
   • MRI: Provides detailed images of soft tissues, including intervertebral discs, spinal cord, nerves, and muscles. Useful for diagnosing herniated discs, spinal stenosis, and other soft tissue abnormalities.
   • CT Scan: Offers detailed images of the bone structures and can be used to identify fractures, bone lesions, or detailed anatomy not clearly visible on X-rays or MRI.
3. Laboratory Tests:
   • Complete Blood Count (CBC): Can help rule out infections or systemic inflammatory conditions.
   • Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP): Markers of inflammation that may suggest inflammatory or infectious processes.
   • Serum Calcium, Vitamin D, and Bone Metabolism Markers: Useful in evaluating bone health, especially in patients with a history of fractures or osteoporosis.
4. Electrodiagnostic Studies:
   • Electromyography (EMG) and Nerve Conduction Studies (NCS): Assess the electrical activity of muscles and the function of peripheral nerves, useful for diagnosing conditions like radiculopathy or peripheral neuropathy.

How These Investigations Inform Management

1. Confirming Diagnosis:
   • Detailed imaging and physical examination findings help confirm or rule out specific diagnoses, such as disc herniation, spinal stenosis, or degenerative disc disease.
2. Identifying Underlying Causes:
   • Lab tests can reveal underlying systemic conditions contributing to pain, such as infections, inflammatory diseases, or metabolic bone disorders.
3. Tailoring Treatment Plans:
   • Accurate diagnosis based on imaging and physical findings allows for targeted treatments, such as physical therapy for mechanical pain, medications for inflammatory conditions, or surgical consultation for structural abnormalities.
4. Monitoring Progress:
   • Baseline imaging and lab tests provide reference points to monitor the effectiveness of treatment and make adjustments as needed.
5. Assessing Risk Factors:
   • Identifying risk factors, such as osteoporosis or poor muscle strength, guides preventive strategies and interventions to reduce the risk of future complications.

Potential Changes in Management

1. Non-Pharmacological Interventions:
   • Physical therapy, exercise programs, cognitive-behavioral therapy, and lifestyle modifications based on the findings of physical and neurological exams.
2. Pharmacological Management:
   • Adjusting medication regimens based on the underlying diagnosis and patient response, considering alternatives to opioids such as NSAIDs, muscle relaxants, or nerve pain medications.
3. Surgical Interventions:
   • Referral to a specialist for surgical evaluation if structural abnormalities, such as significant disc herniation or spinal stenosis, are identified.
4. Multidisciplinary Approach:
   • Involving other healthcare professionals, such as pain specialists, physiotherapists, psychologists, and occupational therapists, to provide comprehensive care.

Making a diagnosis, decision making and reasoning
What red flags would need to be checked or excluded in assessing Sam’s pain? If Sam was older, or taking long-term steroid medication, would this raise any other considerations or concerns?
What characteristics and aetiological factors of the pain are important to consider when deciding which treatments are likely to be effective?
What socio-economic factors might influence Sam’s decision-making around treatment options?

Red Flags to Check or Exclude in Assessing Sam’s Pain

When assessing chronic back pain, it’s essential to identify any red flags that may indicate serious underlying conditions. These include:

1. Severe or Progressive Neurological Deficits:
   • Symptoms such as leg weakness, numbness, or loss of bowel or bladder control (e.g., cauda equina syndrome).
2. History of Trauma:
   • Recent significant trauma or minor trauma in patients with osteoporosis, which may indicate fractures.
3. Unexplained Weight Loss:
   • Could be a sign of malignancy or systemic disease.
4. Age Over 50:
   • Higher risk of serious conditions like malignancy or osteoporotic fractures.
5. History of Cancer:
   • Increased risk of metastatic disease.
6. Persistent Fever:
   • May indicate an infection, such as osteomyelitis or discitis.
7. Use of Intravenous Drugs or Immunosuppression:
   • Higher risk of infections.
8. Night Pain or Pain at Rest:
   • Suggestive of malignancy or infection.
9. Long-Term Use of Steroids:
   • Increased risk of osteoporotic fractures or avascular necrosis.

Additional Considerations for Older Patients or Those on Long-Term Steroid Medication

1. Osteoporosis:
   • Higher risk of vertebral fractures, especially in older patients and those on long-term steroids.
2. Avascular Necrosis:
   • Steroid use increases the risk of avascular necrosis of the femoral head or other bones.
3. Increased Risk of Infections:
   • Immunosuppression due to steroids raises the risk of infections, including spinal infections.
4. Degenerative Changes:
   • Age-related degenerative changes like spinal stenosis or spondylolisthesis are more common in older patients.

Characteristics and Aetiological Factors of the Pain to Consider

1. Location and Radiation:
   • Localized pain vs. radicular pain can suggest different underlying causes (e.g., disc herniation for radicular pain).
2. Onset and Duration:
   • Sudden onset vs. gradual onset; acute vs. chronic pain.
3. Nature of Pain:
   • Mechanical (worse with activity, better with rest) vs. inflammatory (worse at rest, better with movement).
4. Associated Symptoms:
   • Presence of neurological symptoms, systemic symptoms (fever, weight loss), or other signs (e.g., morning stiffness suggesting inflammatory arthritis).
5. Aggravating and Alleviating Factors:
   • Helps in differentiating between mechanical and inflammatory causes and in guiding treatment.
6. Response to Previous Treatments:
   • Effectiveness of past treatments can provide clues about the underlying cause and guide future management.

Socio-Economic Factors Influencing Sam’s Decision-Making

1. Financial Constraints:
   • Cost of treatments, including medications, physical therapy, and alternative therapies. Unemployment might limit access to certain treatments or insurance coverage.
2. Access to Healthcare:
   • Availability of services and specialists, particularly if relying on public healthcare systems or if there are geographic barriers.
3. Social Support:
   • Family and community support systems can influence adherence to treatment plans and the ability to attend appointments or follow through with recommendations.
4. Employment Status:
   • Being unemployed can lead to increased stress and affect mental health, which in turn can influence pain perception and management. It may also affect motivation and ability to engage in certain therapies, such as exercise programs.
5. Educational Background:
   • Understanding of chronic pain and treatment options might vary, influencing the decision-making process and adherence to treatment plans.
6. Cultural Beliefs and Attitudes:
   • Cultural attitudes towards pain, medications, and alternative therapies can affect preferences and decisions regarding treatment options.

Clinical management and therapeutic reasoning
What non-opioid pharmacological treatments can be considered to manage chronic pain? 
What options could you consider to manage Sam’s back pain, and how might these change depending on how the symptoms evolve over the coming weeks and months?
If Sam were an older person in a residential aged care facility, would this influence management decisions and/or therapeutic options?
What if Sam were a sedentary 30 year old?
At what point would you consider referral to a specialist pain service?

Non-Opioid Pharmacological Treatments for Chronic Pain

1. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs):
   • Examples: ibuprofen, naproxen, diclofenac.
   • Useful for pain with an inflammatory component. They reduce inflammation and provide analgesia.
2. Acetaminophen (Paracetamol):
   • Effective for mild to moderate pain. It has a safer profile compared to NSAIDs, especially in patients with gastrointestinal or cardiovascular risks.
3. Antidepressants:
   • Tricyclic Antidepressants (TCAs): amitriptyline, nortriptyline.
   • Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs): duloxetine, venlafaxine.
   • Effective for neuropathic pain and chronic musculoskeletal pain. They help modulate pain pathways and improve mood and sleep.
4. Anticonvulsants:
   • Examples: gabapentin, pregabalin.
   • Useful for neuropathic pain by stabilizing nerve activity.
5. Topical Agents:
   • Topical NSAIDs: diclofenac gel.
   • Capsaicin cream: used for neuropathic and musculoskeletal pain.
   • Provide localized pain relief with minimal systemic side effects.
6. Muscle Relaxants:
   • Examples: cyclobenzaprine, tizanidine.
   • Help alleviate muscle spasms and associated pain.

Management Options for Sam’s Back Pain

1. Initial Management:
   • Medication: Start with NSAIDs and acetaminophen, considering the balance between effectiveness and safety.
   • Physical Therapy: Focus on strengthening exercises, flexibility training, and posture correction.
   • Education: Teach Sam about the importance of staying active and proper body mechanics.
2. Evolving Symptoms:
   • Persistent Pain: Consider adding antidepressants or anticonvulsants if there is a neuropathic component.
   • Chronic Pain: Use of TCAs or SNRIs for additional pain relief and to address any coexisting mood disturbances.
   • Non-Pharmacological Therapies: Increase the emphasis on cognitive-behavioral therapy (CBT), mindfulness, and stress management techniques.

Management Adjustments Based on Specific Contexts

1. Older Person in a Residential Aged Care Facility:
   • Medication Considerations: Use caution with NSAIDs due to risks of gastrointestinal, renal, and cardiovascular side effects. Prefer acetaminophen as the first-line treatment.
   • Fall Risk: Be cautious with medications that can cause sedation or dizziness, such as TCAs and muscle relaxants.
   • Multidisciplinary Approach: Involve physiotherapists, occupational therapists, and geriatricians in the management plan.
   • Non-Pharmacological Interventions: Emphasize physical therapy, fall prevention strategies, and pain management techniques that do not rely heavily on medications.
2. Sedentary 30-Year-Old:
   • Lifestyle Modifications: Encourage regular physical activity, ergonomic adjustments at work, and a structured exercise program.
   • Behavioral Interventions: Focus on CBT and other psychological approaches to address any underlying psychosocial factors contributing to pain.
   • Medication: Similar pharmacological options as initially described, with a focus on non-opioid medications.

Referral to a Specialist Pain Service

1. Indications for Referral:
   • Inadequate Pain Control: Persistent pain despite optimal pharmacological and non-pharmacological management.
   • Complex Pain Syndromes: Presence of neuropathic pain, mixed pain syndromes, or other complex conditions requiring specialized interventions.
   • Functional Impairment: Significant impact on daily functioning, work, or quality of life that cannot be managed effectively at the primary care level.
   • Multidisciplinary Needs: When a comprehensive, multidisciplinary approach involving pain specialists, physiotherapists, psychologists, and other experts is required.
   • Medication Management: Need for advanced pharmacological strategies or interventional procedures that exceed primary care capabilities.

Preventive and population health
If Sam were an Aboriginal or Torres Strait Islander, how might this affect your treatment decisions? What assumptions, biases and prejudices might arise for clinicians in caring for Sam and the pain symptoms?
How might chronic pain be affecting Sam’s mood and psychological wellbeing?
How might the pain affect Sam’s social relationships and capacity to find work?

Treatment Considerations for Aboriginal or Torres Strait Islander Patients

Cultural Sensitivity and Awareness

1. Cultural Competence:
   • Understand and respect cultural beliefs and practices related to health and pain management. Engage with Sam in a culturally sensitive manner.
   • Consider involving Aboriginal Health Workers or Liaison Officers to facilitate communication and ensure cultural safety.
2. Holistic Approach:
   • Emphasize a holistic approach to pain management, considering the physical, emotional, social, and spiritual aspects of health.
   • Incorporate traditional healing practices if Sam expresses interest, and ensure these are integrated into the overall treatment plan.
3. Access to Care:
   • Be aware of potential barriers to accessing healthcare, such as geographic isolation, transportation issues, and socioeconomic factors.
   • Provide information about available resources and support services, and consider referral to community-based programs.
4. Trust and Communication:
   • Build trust through respectful and clear communication, ensuring Sam feels heard and valued.
   • Avoid medical jargon and provide explanations in a way that is easy to understand.

Assumptions, Biases, and Prejudices

1. Stereotyping:
   • Avoid making assumptions based on ethnicity. Treat Sam as an individual and avoid generalizing based on cultural background.
   • Be aware of implicit biases that might affect clinical judgment and strive to provide equitable care.
2. Bias in Pain Perception:
   • Recognize that biases may exist regarding the expression of pain and pain tolerance in Aboriginal and Torres Strait Islander peoples. Ensure that pain assessments are thorough and based on objective criteria.
3. Prejudice and Stigma:
   • Be mindful of the potential for prejudice and stigma related to socioeconomic status, substance use, and historical trauma. Address these issues with sensitivity and without judgment.

Psychological and Social Impact of Chronic Pain on Sam

Mood and Psychological Wellbeing

1. Depression and Anxiety:
   • Chronic pain can lead to or exacerbate depression and anxiety. The constant pain and its impact on daily life can contribute to feelings of helplessness, hopelessness, and frustration.
   • Regularly assess Sam’s mental health using validated screening tools and provide appropriate referrals for psychological support or counseling.
2. Stress and Coping:
   • Managing chronic pain, especially in the context of significant life stressors (e.g., caring for a sick family member), can increase stress levels and affect coping mechanisms.
   • Consider interventions such as cognitive-behavioral therapy (CBT), mindfulness-based stress reduction, and other psychological therapies to help Sam manage stress and develop healthy coping strategies.

Social Relationships and Employment Capacity

1. Impact on Social Relationships:
   • Chronic pain can strain social relationships, leading to social isolation, reduced participation in social activities, and difficulty maintaining personal relationships.
   • Encourage Sam to engage with support groups or community resources that provide social support and opportunities for interaction.
2. Employment Challenges:
   • Chronic pain may limit Sam’s ability to work, especially in physically demanding roles. This can lead to financial stress, reduced self-esteem, and a sense of loss of identity or purpose.
   • Provide guidance on workplace accommodations, vocational rehabilitation services, and exploring alternative employment options that are less physically demanding.

Overall Approach

1. Multidisciplinary Care:
   • Consider a multidisciplinary approach involving healthcare professionals from different fields, including physical therapists, psychologists, social workers, and pain specialists.
   • Develop a comprehensive, personalized care plan that addresses Sam’s physical, psychological, and social needs.
2. Regular Follow-Up and Support:
   • Schedule regular follow-up appointments to monitor Sam’s progress, adjust the treatment plan as needed, and provide ongoing support and encouragement.
   • Ensure that Sam feels supported and empowered throughout the treatment process, reinforcing the importance of active participation in managing chronic pain.

Professionalism
When you first read the case study, did you make any subconscious assumptions about Sam’s gender or sex? Would your first impression of the situation be different if Sam’s gender was different to what you assumed? How might your perception of Sam’s gender impact (intentionally or unintentionally) your assessment, treatment and risk management decisions? 
What assumptions about socio-economic status, occupation, dress/clothing appearance and perceived health literacy might affect a clinician’s management decisions in caring for people with chronic pain?
What thoughts, emotions and concerns arise for you when someone presents asking for analgesics? How might these internal responses potentially affect the consultation with Sam?

Assumptions about Sam’s Gender and Their Impact

Subconscious Assumptions about Gender

• When reading the name “Sam,” I might have made subconscious assumptions about gender, as “Sam” can be a name for any gender.
• Reflecting on whether I assumed Sam to be male or female is important, as it highlights the need to be conscious of implicit biases.

Impact of Gender Perception on Assessment and Treatment

1. Pain Perception and Expression:
   • There may be biases in how pain is perceived and expressed by different genders. For example, there might be a stereotype that women are more likely to express pain or that men’s pain might be underreported.
2. Treatment Decisions:
   • Gender can affect the likelihood of prescribing certain medications. For example, women may be less likely to receive strong opioids for pain management compared to men.
   • Consideration of gender-specific conditions that may affect back pain, such as endometriosis in women.
3. Risk Management:
   • Assessing risk factors for opioid misuse might be influenced by gender. For instance, there might be a bias to think men are more likely to misuse opioids.

Assumptions about Socio-Economic Status, Occupation, and Appearance

1. Socio-Economic Status:
   • Assumptions about socio-economic status can affect perceptions of access to resources, adherence to treatment, and overall health management.
   • There may be biases toward prescribing more affordable treatments to those perceived as having lower socio-economic status.
2. Occupation:
   • Assumptions about the physical demands of Sam’s previous occupation as an events organizer might influence the emphasis on physical therapy or ergonomic interventions.
3. Dress/Clothing Appearance:
   • Appearance might lead to assumptions about Sam’s lifestyle, health literacy, or adherence to treatment plans.
   • Clinicians might subconsciously tailor their communication style and treatment recommendations based on perceived health literacy.

Internal Responses to Requests for Analgesics

1. Thoughts and Emotions:
   • When someone presents asking for analgesics, there might be immediate concerns about potential opioid misuse, dependence, or drug-seeking behavior.
   • Feelings of caution or skepticism might arise, influenced by the current climate of opioid misuse concerns.
2. Impact on Consultation:
   • These internal responses can lead to a more guarded approach, potentially affecting rapport and trust-building with the patient.
   • It might result in a more thorough and possibly more intrusive questioning about pain history and medication use, which could be perceived as distrustful by the patient.

Strategies to Mitigate Biases and Improve Consultation

1. Self-Awareness and Reflection:
   • Regularly reflecting on one’s own biases and assumptions can help mitigate their impact on clinical decisions.
   • Seeking feedback from colleagues and participating in training on cultural competence and implicit bias can be beneficial.
2. Patient-Centered Approach:
   • Focus on individual patient experiences and needs rather than relying on stereotypes or assumptions.
   • Ensure that pain assessments are comprehensive and based on objective criteria.
3. Clear and Compassionate Communication:
   • Use open-ended questions to gather detailed information about the patient’s pain and its impact on their life.
   • Show empathy and understanding, validating the patient’s experiences and concerns.
4. Collaborative Decision-Making:
   • Involve the patient in the decision-making process, discussing the risks and benefits of various treatment options.
   • Provide education about the potential risks of opioids and explore alternative pain management strategies together.

General practice systems and regulatory requirement
What are the different legal and professional obligations when prescribing opioids for cancer pain and non-cancer pain?
Where can you find reliable information about Sam’s previous prescriptions?

Legal and Professional Obligations When Prescribing Opioids

Cancer Pain vs. Non-Cancer Pain

Cancer Pain

1. Legal Obligations:
   • Less Restrictive Prescribing: Opioids can be prescribed more liberally for cancer pain, reflecting the need for effective pain relief in palliative care settings.
   • PBS Guidelines: The Pharmaceutical Benefits Scheme (PBS) in Australia allows for a more streamlined process for prescribing opioids for cancer pain. The prescribing doctor must ensure that the patient’s condition meets the criteria set out by the PBS.
2. Professional Obligations:
   • Pain Relief Priority: Focus on providing adequate pain relief to improve the patient’s quality of life.
   • Documentation: Document the rationale for opioid use, pain assessments, and any dose adjustments. Regularly review and update treatment plans.
   • Informed Consent: Discuss the benefits and risks of opioid use with the patient and their family, ensuring they understand and consent to the treatment plan.
   • Regular Monitoring: Conduct regular follow-ups to assess pain control, side effects, and any signs of opioid misuse.

Non-Cancer Pain

1. Legal Obligations:
   • More Restrictive Prescribing: Stricter regulations govern opioid prescriptions for non-cancer pain to mitigate risks of misuse, dependence, and addiction.
   • PBS Guidelines: The PBS has specific criteria for prescribing opioids for non-cancer pain. This includes ensuring that opioids are only prescribed when other treatments have failed and that the patient meets the necessary clinical guidelines.
2. Professional Obligations:
   • Comprehensive Assessment: Conduct a thorough assessment of the patient’s pain, including its cause, duration, and impact on function.
   • Non-Opioid Alternatives: Explore and document the use of non-opioid pain management strategies before initiating opioid therapy.
   • Risk Assessment: Evaluate the patient’s risk for opioid misuse, including history of substance abuse, mental health conditions, and social factors.
   • Documentation and Monitoring: Document the treatment plan, rationale for opioid use, and agreements with the patient. Implement regular monitoring for efficacy, side effects, and signs of misuse.
   • Opioid Agreements: Use treatment agreements that outline the terms of opioid use, including adherence to prescribed dosages and regular follow-ups.
   • Informed Consent: Ensure the patient is fully informed about the potential risks and benefits of opioid therapy.

PBS Guidelines for Opioid Prescriptions

For Cancer Pain:

• Streamlined Authority Codes: Opioids for cancer pain can be prescribed using streamlined authority codes, simplifying the process.
• Clinical Justification: The prescriber must document the clinical justification for opioid use, ensuring it aligns with PBS criteria.
• No Dose Restrictions: There are generally no dose restrictions for opioids prescribed for cancer pain under the PBS.

For Non-Cancer Pain:

• Trial of Other Therapies: Patients must have tried and failed other pain management options before opioids are prescribed.
• Specific Indications: Opioids must be prescribed for specific indications, such as severe chronic pain unresponsive to other treatments.
• Authority Required: An authority prescription is often required, meaning the prescriber must seek approval from Medicare to prescribe the opioid.
• Dose Limits: There are often dose limits and requirements for regular reviews to assess the ongoing need for opioid therapy.
• Duration of Therapy: The PBS guidelines typically outline the expected duration of opioid therapy, emphasizing the need for regular reassessment and potential tapering.

Reliable Sources for Information About Sam’s Previous Prescriptions

1. Prescription Monitoring Programs (PMPs):
   • Description: State or national electronic databases that track prescriptions for controlled substances.
   • Usage: Check the PMP for records of all controlled substance prescriptions filled by Sam. This can provide information about the prescriber, the pharmacy, dosage, and dates.
2. Electronic Medical Records (EMRs):
   • Description: Digital versions of patients’ paper charts maintained by healthcare providers.
   • Usage: Access Sam’s medical history, including previous prescriptions, through EMRs used by past healthcare providers or current practice.
3. Pharmacy Records:
   • Description: Records maintained by pharmacies detailing prescriptions filled for patients.
   • Usage: Contact pharmacies where Sam has filled prescriptions to obtain records of previous medications, including opioids.
4. Previous Healthcare Providers:
   • Description: Doctors or healthcare facilities that have previously treated Sam.
   • Usage: With Sam’s consent, request medical records from previous providers to review past prescriptions and treatment plans.
5. Patient-Reported Information:
   • Description: Information provided by the patient regarding their medication history.
   • Usage: Ask Sam to provide details about previous medications, dosages, and prescribing doctors. Verify this information with other sources when possible.

Steps to Access Information

1. Register and Use PMPs:
   • Ensure registration with the local or national Prescription Monitoring Program.
   • Regularly check the PMP before prescribing opioids to verify Sam’s prescription history.
2. Integrate EMRs:
   • Use EMRs to access and document Sam’s medication history.
   • Collaborate with other healthcare providers to share and obtain comprehensive medical records through EMR systems.
3. Request Pharmacy Records:
   • With Sam’s consent, contact pharmacies to obtain detailed records of prescriptions filled.
4. Coordinate with Previous Providers:
   • Obtain Sam’s consent to request medical records from previous healthcare providers.
   • Review these records for insights into past pain management strategies and medication use.
5. Document and Monitor:
   • Maintain accurate records of all obtained information.
   • Continuously monitor and update Sam’s prescription history to ensure safe and effective pain management.

Procedural skills
Could acupuncture be an effective option to consider? What evidence is there to support acupuncture? Is learning to deliver acupuncture for chronic pain something you could consider?

The evidence suggests that acupuncture can be an effective treatment for chronic back pain, providing pain relief and functional improvement. While the quality of studies varies, the consistent findings across multiple systematic reviews and meta-analyses support its use as part of a comprehensive pain management strategy.

1. Systematic Review and Meta-Analysis (2013):
   • Source: Vickers, A. J., et al. (2012). “Acupuncture for chronic pain: individual patient data meta-analysis.” Archives of Internal Medicine, 172(19), 1444-1453.
   • Findings: This large meta-analysis included data from 29 randomized controlled trials (RCTs) and concluded that acupuncture is effective for the treatment of chronic pain, including back pain. The study found a significant difference between acupuncture and sham acupuncture, suggesting that acupuncture has specific effects beyond placebo.
2. Cochrane Review (2013):
   • Source: Furlan, A. D., et al. (2005). “Acupuncture and dry needling for low back pain.” Cochrane Database of Systematic Reviews, Issue 1. Art. No.: CD001351.
   • Findings: This review included 35 trials with over 2,800 participants and found that acupuncture provides better pain relief and functional improvement than no treatment or sham treatment for chronic low back pain. However, the review also noted that the quality of evidence was variable and called for more high-quality RCTs.
3. Systematic Review and Meta-Analysis (2017):
   • Source: Yuan, Q. L., et al. (2015). “Acupuncture for musculoskeletal pain: a meta-analysis and meta-regression of sham-controlled randomized clinical trials.” Scientific Reports, 5, 11613.
   • Findings: This review included 12 RCTs and found that acupuncture significantly reduced pain intensity and improved functional outcomes in patients with chronic musculoskeletal pain, including low back pain. The study highlighted the role of acupuncture as a beneficial adjunct therapy.
4. Systematic Review (2020):
   • Source: Nielsen, A., et al. (2019). “The effects of acupuncture for the treatment of chronic low back pain: a systematic review and meta-analysis.” American Journal of Physical Medicine & Rehabilitation, 98(2), 173-184.
   • Findings: This review analyzed data from 16 RCTs and concluded that acupuncture is associated with significant improvements in pain and functional outcomes for patients with chronic low back pain. The authors emphasized that acupuncture can be considered as part of a multidisciplinary approach to pain management.
5. Clinical Practice Guidelines:
   • Source: The American College of Physicians (ACP) and the American Pain Society (APS) Clinical Practice Guidelines recommend acupuncture as a treatment option for patients with chronic low back pain.
   • Findings: The guidelines, based on a comprehensive review of the literature, suggest that acupuncture is moderately effective for chronic low back pain and can be used alongside other non-pharmacological therapies.

Managing uncertainty
If prescribing opioids, what are the risk management strategies to consider to protect Sam, the community and Sam’s treating clinicians?
How might the management options be different if there is no clear aetiological diagnosis for the pain?

Risk Management Strategies for Prescribing Opioids

Protecting Sam, the Community, and Treating Clinicians

1. Comprehensive Assessment:
   • Conduct a thorough assessment of Sam’s pain, including history, physical examination, and relevant investigations.
   • Assess risk factors for opioid misuse, including history of substance use disorder, mental health conditions, and social circumstances.
2. Clear Documentation:
   • Maintain detailed records of the pain assessment, diagnosis, rationale for opioid use, and treatment plan.
   • Document informed consent discussions, including potential risks and benefits of opioid therapy.
3. Informed Consent:
   • Provide Sam with information about the potential risks and benefits of opioid therapy.
   • Discuss alternative treatment options and obtain informed consent before initiating opioids.
4. Opioid Agreements:
   • Use opioid treatment agreements that outline the terms of opioid use, including adherence to prescribed dosages, regular follow-ups, and avoiding the use of other controlled substances.
   • Include clauses about random drug testing and the importance of safeguarding medications.
5. Regular Monitoring and Follow-Up:
   • Schedule regular follow-up appointments to monitor pain control, functional outcomes, and potential side effects or signs of misuse.
   • Use tools such as the Pain Management and Opioid Risk Evaluation (PMORE) to regularly reassess risk.
6. Prescription Monitoring Programs (PMPs):
   • Utilize Prescription Monitoring Programs to track Sam’s opioid prescriptions and prevent “doctor shopping” or overprescribing.
   • Regularly review PMP data to ensure compliance with the treatment plan.
7. Dose Limitation and Tapering:
   • Start with the lowest effective dose and avoid high-dose opioid therapy when possible.
   • Develop a plan for tapering or discontinuing opioids if they are no longer effective or if risks outweigh benefits.
8. Multidisciplinary Approach:
   • Collaborate with other healthcare professionals, such as pain specialists, physiotherapists, and mental health providers, to provide comprehensive care.
   • Consider referral to a pain management clinic for complex cases or if there are concerns about opioid misuse.
9. Education on Safe Use and Storage:
   • Educate Sam on the safe use, storage, and disposal of opioids to prevent misuse by others.
   • Discuss the importance of keeping medications out of reach of children and not sharing them with others.
10. Naloxone Prescription:
    • Consider prescribing naloxone alongside opioids to mitigate the risk of overdose.
    • Educate Sam and family members on the use of naloxone in case of an opioid overdose.

Management Options Without a Clear Aetiological Diagnosis

1. Symptomatic Treatment:
   • Focus on relieving symptoms and improving function, even without a definitive diagnosis.
   • Use a multimodal approach, combining pharmacological and non-pharmacological treatments.
2. Non-Opioid Medications:
   • NSAIDs, acetaminophen, antidepressants (e.g., TCAs, SNRIs), and anticonvulsants (e.g., gabapentin, pregabalin) can be used to manage pain.
   • Consider topical treatments, such as lidocaine or capsaicin patches, for localized pain relief.
3. Non-Pharmacological Therapies:
   • Physical therapy, exercise programs, cognitive-behavioral therapy (CBT), and other psychological interventions can be effective in managing chronic pain.
   • Explore complementary therapies such as acupuncture, massage therapy, and relaxation techniques.
4. Pain Management Programs:
   • Referral to a multidisciplinary pain management program may be beneficial for patients with chronic pain without a clear diagnosis.
   • These programs often include physical, psychological, and occupational therapy components.
5. Regular Reassessment:
   • Continuously reassess the patient’s pain, functionality, and response to treatment.
   • Be vigilant for the development of new symptoms or changes that may provide clues to an underlying diagnosis.
6. Psychosocial Support:
   • Address any psychosocial factors contributing to the patient’s pain experience, such as stress, anxiety, depression, or social isolation.
   • Provide support through counseling, support groups, and community resources.
7. Patient Education:
   • Educate Sam about chronic pain, including the potential lack of a clear diagnosis and the importance of a comprehensive management approach.
   • Emphasize the role of self-management strategies and the importance of staying active and engaged in daily activities.

Identifying and managing the significantly ill pat
If Sam were to later have an accidental opioid overdose, or present with symptoms and signs of opioid toxicity, how would you manage this?

Opioid Overdose

1. Initial Assessment and Stabilization:
   • Airway: Ensure the patient has a patent airway. Perform a jaw thrust if needed and consider intubation if the airway is compromised.
   • Breathing: Assess respiratory rate and effort. Provide supplemental oxygen and support ventilation if necessary. Consider bag-valve-mask ventilation if the patient is apneic.
   • Circulation: Monitor blood pressure and heart rate. Establish intravenous access and administer fluids if hypotensive.
2. Administration of Naloxone:
   • Dose: Start with an initial dose of 0.4-2 mg IV, IM, or subcutaneously. If there is no response, repeat doses every 2-3 minutes, increasing the dose as needed (up to 10 mg in total).
   • Observation: Monitor the patient closely for recurrent symptoms of opioid toxicity, as naloxone has a shorter half-life than most opioids.
3. Monitoring:
   • Vital Signs: Continuously monitor vital signs, including oxygen saturation, respiratory rate, and heart rate.
   • Level of Consciousness: Use the Glasgow Coma Scale (GCS) to monitor changes in the patient’s level of consciousness.
4. Supportive Care:
   • Provide ongoing respiratory support if needed.
   • Treat any complications such as aspiration pneumonia, pulmonary edema, or rhabdomyolysis.
5. Disposition:
   • Observation: Patients should be observed for at least 4-6 hours after the last dose of naloxone, as opioid effects can recur once naloxone wears off.
   • Admission: Consider hospital admission for patients with severe overdose, recurrent symptoms, or complications.
6. Psychosocial Support:
   • Address the underlying issues related to opioid use, including referral to addiction services or counseling.

What serious causes of back pain would warrant referring someone to the acute sector for urgent assessment? What signs or symptoms would suggest a more sinister underlying diagnosis?

Signs and Symptoms Suggesting a More Sinister Underlying Diagnosis

1. Cauda Equina Syndrome:
   • Signs and Symptoms: Severe lower back pain, bilateral sciatica, saddle anesthesia, bowel or bladder dysfunction (incontinence or retention), and lower extremity weakness or numbness.
   • Action: Immediate referral to emergency department for urgent MRI and neurosurgical consultation.
2. Spinal Infection (e.g., Discitis, Osteomyelitis, Epidural Abscess):
   • Signs and Symptoms: Severe back pain, fever, chills, night sweats, and local tenderness over the spine. Neurological deficits may be present if there is epidural abscess.
   • Action: Urgent referral for MRI and blood cultures. Initiate broad-spectrum antibiotics and consult with infectious disease and spine surgery.
3. Malignancy (Primary or Metastatic):
   • Signs and Symptoms: Persistent, non-mechanical back pain (worse at night and not relieved by rest), unexplained weight loss, history of cancer, or new-onset back pain in patients over 50.
   • Action: Urgent referral for imaging (MRI or CT) and further oncological assessment.
4. Vertebral Fracture:
   • Signs and Symptoms: Sudden onset of severe back pain following minor trauma or in patients with risk factors such as osteoporosis or long-term steroid use.
   • Action: Urgent imaging (X-ray, CT, or MRI) to assess for fractures and possible referral to orthopedic surgery.
5. Abdominal Aortic Aneurysm (AAA):
   • Signs and Symptoms: Severe, sudden-onset back or abdominal pain, hypotension, pulsatile abdominal mass.
   • Action: Immediate referral to emergency department for ultrasound or CT and vascular surgery consultation.