Reworking the interface between primary care and multidisciplinary pain centres : the Adelaide experience
Dr T Semple RAH PMU
October 2010
1. The problem
2. South Australian Collaborative Pain Project
3. Outcomes of SACoPP
4. Ongoing activities
5. The future
Chronic Pain in South Australia – South Australian Health Omnibus Survey 2006
Currow et al. AustNZ J Public Health.2010;34(3)
• Whole of population, face-to-face, 2973 interviewed
• Prevalence of chronic pain 17.9%
• Severe pain interfering severely with activity 5%
• Associated with lower educational level and currently not working
Chronic Pain in South Australia – South Australian Health Omnibus Survey 2006
Currow et al. AustNZ J Public Health.2010;34(3)
• Whole of population, face-to-face, 2973 interviewed
• Prevalence of chronic pain 17.9%
• Severe pain interfering severely with activity 5%
• Associated with lower educational level and currently not working
75000 with severe CNCP......
Chronic pain and the “waiting list disease”
Canadian Pain Society Taskforce. M Lynch et al. Pain 136, 2008
Systemic review of relationship between waiting list time for specialist pain review, QOL and outcomes
• Some deterioration from 5 weeks
• After 6 months, medically unacceptable deterioration in physical and psychological health
Waiting in Pain : APS interim report 2010 Hogg M, Gibson S, Helou A, Degabriele J
South Australian data• 2418 individuals with non-urgent persistent pain assessed
per annum at multidisciplinary pain centres
Waiting in Pain : APS interim report 2010 Hogg M, Gibson S, Helou A, Degabriele J
South Australian data• 2418 individuals with non-urgent persistent pain assessed
per annum at multidisciplinary pain centres
• Waiting time mean 205.5 days (national mean 143 days)
Waiting in Pain : APS interim report 2010 Hogg M, Gibson S, Helou A, Degabriele J
South Australian data• 2418 individuals with non-urgent persistent pain assessed
per annum at multidisciplinary pain centres
• Waiting time mean 205.5 days (national mean 143 days)
• PMU input to approximately 10,000 individuals direct/indirectly per annum
Waiting in Pain : APS interim report 2010 Hogg M, Gibson S, Helou A, Degabriele J
South Australian data• 2418 individuals with non-urgent persistent pain assessed
per annum at multidisciplinary pain centres
• Waiting time mean 205.5 days (national mean 143 days)
• PMU input to approximately 10,000 individuals direct/indirectly per annum
Can PMU function with unworkable waiting lists ?
Waiting in Pain : APS interim report 2010 Hogg M, Gibson S, Helou A, Degabriele J
South Australian data• 2418 individuals with non-urgent persistent pain assessed
per annum at multidisciplinary pain centres
• Waiting time mean 205.5 days (national mean 143 days)
• PMU input to approximately 10,000 individuals direct/indirectly per annum
Are PMU getting the most appropriate referrals ?
Waiting in Pain : APS interim report 2010 Hogg M, Gibson S, Helou A, Degabriele J
South Australian data• 2418 individuals with non-urgent persistent pain assessed
per annum at multidisciplinary pain centres
• Waiting time mean 205.5 days (national mean 143 days)
• PMU input to approximately 10,000 individuals direct/indirectly per annum
What level of CNCP care are the other 55,000 receiving , if anywhere ?
Burden of CNCP for Australian general practice
• BEACH GP encounters (Sand abstract 127, 2008-09) – 19.6% attending suffered CNCP– GP satisfaction 2.4 ( scale 1 highly satisfied, 5 highly dissatisfied)– Patient satisfaction 2.5
• SACoPP GP focus group – estimated 25% patients, 25% workload– “not rewarding, not satisfying” in 75% of GPs
“I don’t even refer because your waiting lists are so long...”
GP prescribing in Australia
Nissen et al Brit J Clin Pharmacol 2001
83% of referrals to Royal Brisbane Hospital multidisciplinary pain clinic already prescribed opioids at presentation
Pethidine Injection 100mg, 1998-2005 per 10,000 Population
0.00
10.00
20.00
30.00
40.00
50.00
60.00
NSW VIC QLD SA WA TAS ACT NT
State
per
10,
000
po
pu
lati
on
Year 1998
Year 1999
Year 2000
Year 2001
Year 2002
Year 2003
Year 2004
Year 2005
Positive changes in prescribing...
Methadone 10mg, 1998-2005 per 10,000 Population
0.00
50.00
100.00
150.00
200.00
250.00
NSW VIC QLD SA WA TAS ACT NT
State
pe
r 1
0,0
00
po
pu
lati
on Year 1998
Year 1999
Year 2000
Year 2001
Year 2002
Year 2003
Year 2004
Year 2005
Kapanol 100mg, 1998-2005 per 10,000 Population
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
NSW VIC QLD SA WA TAS ACT NT
State
per
10,
000
po
pu
lati
on Year 1998
Year 1999
Year 2000
Year 2001
Year 2002
Year 2003
Year 2004
Year 2005
Oxycontin Tablets 80mg, 2001 - 2005 per 10,000 Population
0.00
5.00
10.00
15.00
20.00
25.00
30.00
35.00
40.00
45.00
NSW VIC QLD SA WA TAS ACT NT
State
per
10,
000
po
pu
lati
on
Year 2001
Year 2002
Year 2003
Year 2004
Year 2005
Rapid uptake of new high-dose formulations
ATTACHMENT 1 - South Australian oxycodone consumption
Oxycodone Consumption
0
20000
40000
60000
80000
100000
120000
140000
Gra
ms
Prior to commencing opioids….
Australian Pain Society Guidelines 1997
• Clarify diagnosis
• Non-opioid pharmacotherapy eg TCA and/or gabapentinoids
• Exercise regimens
• Psychological assessment / therapy
Prior to commencing opioids….
Australian Pain Society Guidelines 1997
• Clarify diagnosis
• Non-opioid pharmacotherapy eg TCA and/or gabapentinoids
• Exercise regimens
• Psychological assessment / therapy
“Perverse MBS and PBS incentives encourage early use of opioid therapy in general practice rather than other options.....”
SA government regulatory model for S8 opioids
• Long term S8 opioid prescriptions under controlled Substances Act 1984 (SA) – “authority” required if < 70yrs
SA government regulatory model for S8 opioids
• Long term S8 opioid prescriptions under controlled Substances Act 1984 (SA) – “authority” required if < 70yrs
• Drugs of Dependency Unit (DASSA subbranch) reviews all S8 opioid prescriptions (35000/month)
SA government regulatory model for S8 opioids
• Long term S8 opioid prescriptions under controlled Substances Act 1984 (SA) – “authority” required if < 70yrs
• Drugs of Dependency Unit (DASSA subbranch) reviews all S8 opioid prescriptions (35000/month)
• Authority for S8 prescriptions provided upon application unless contraindicated
SA government regulatory model for S8 opioids
• Long term S8 opioid prescriptions under controlled Substances Act 1984 (SA ) – “authority” required if < 70yrs
• Drugs of Dependency Unit (DASSA sub-branch) reviews all S8 opioid prescriptions (35000/month)
• Authority for S8 prescriptions provided upon application unless contraindicated
• Frequent DDU recognition of poor rationale for opioid prescription and requirement to seek pain specialist opinion = significant PMU workload burden
Authorities for long-term opioid prescription for CNCP for patients < 70yrs
• \s \s \s \s
S8s in SA for non-cancer pain
SA 2010 data• 7000 authorities per 1.5million population (> 1 in 250)• In some regional centres, 1 in 100 patients
This excludes long-term Panadeine Forte, Tramadol and other compound analgesics
So what now ?
South Australian Collaborative Pain Project2005-2008 (SACoPP)
Key stakeholders– Drugs and Alcohol Services South Australia (DASSA)– RAH and FMC Pain Management Units– RACGP and South Australian Divisions General Practice
Funding (~ $200,000)– Intergovernmental Committee on Drugs (supporting
Ministerial Committee on Drug Strategy)– Industry Product Sponsors (Mundipharma and Janssen-Cilag)
SACoPP goals
• Improve inappropriate use of opioids and reduce diversion
• Provide educational resource on opioid prescription
• Up-skill pain management capacity in community amongst interested GPs by PMU “internships”
GP resource document based on “Frequently Asked Questions on Opioids”, Uni
Wisconsin 2001, heavily modified
GP attachments to PMUs
• ~ 52 hrs attendance, usually 1-2 sessions/week• Reimbursed @SADI rates $120/hr• 12 GPs enrolled (9 urban, 3 rural)• Attachments focusing on
– optimising referrals – team care and working with pain-trained allied health– management of complex patients– current thinking with pharmacotherapy– integrating pharmacological and non-pharmacological therapies– pain management program options
Outcomes – GP feedback
• More confident/appropriate use of opioids in CNCP• Recognition of aberrant behaviours• Earlier use of regulatory intervention/addiction medicine
services• Advice to GP colleagues• Assessment/management of GP-referred patients• Potential involvement with future community-based pain
services
Relationships between pain medicine and general practice strengthened +++
Outcomes – rural example
Clare Medical Centre• 2 GPs attended RAH PMU• Developed clinic-based Pain Program• Employed mental health-trained practice nurse as case
manager• Community OT with pain experience• Visiting psychiatrist with regular FMC PMU sessions• Access to heated indoor pool for group exercise session• Represented ACRRM at National Pain Summit
Flow 0n from SACoPP...
Royal Australian College of General Practice SA chapter gets involved...
Pain-GPs enrol RACGP – SA branch appoints coordinator
• SA Pain Education Group formed to develop educational modules
• RACGP-National Faculty of Specific Interests includes pain management (GP-si)
• National Network of Pain Management initiated
Enrolling SA Health in CNCP
GP Plus Model of Care – SA Health
• Aimed at bridging the gap between tertiary hospital-based services and primary care
• Increasing capacity of primary care sector to respond to chronic conditions
• Differ from GP Super Clinics by use of state health funding to provide allied health and nurses with chronic disease management skills
GP Plus Elizabeth lobbied to include CNCP services – develops Central Northern Integrated Pain Service (CNIPS) concept
Penny Westhorp, Project Manager, CNAHS GPwSI Pain Management
Generic GP Plus Model: “Collaborative Corridor”
• Supervising specialist• Treating medical staff:
– GPwSIs– Trainee GPwSIs– Other medical trainees?
• Specialist allied health • Treating staff take history, organise tests, draft
diagnosis, consult with specialist• Specialist checks with patient, modifies diagnosis &
suggests Rx plan• Treating staff reviews tests with consultant, delivers
diagnosis, writes Rx plan, checked and signed by specialist, sends to referring GP
Co-ordinated Pain Services System B Lau. Brit Columbia Pain Initiative 2008
• Graded Healthcare• Regional Multi-disciplinary pain centre hubs • Navigation of services: BC Website/Pain Hotline• Integration of electronic information systems
C Hayes Hunter integrated Pain Service
June 2009 Penny Westhorp, Project Manager, CNAHS GPwSI Pain Management 42
Central Northern Central Northern Integrated Pain ServiceIntegrated Pain Service
TREATMENTCNIPS auspicing allied health treatment to patients in collaboration with GP’s treatment and management plans
PATIENT & CARER EDUCATIONCommunity pain information to people living with pain at 2 or 3 levels eg.:
Understanding painMoving with painLiving with painRefer to or use Stanford Chronic Disease Self Management Program Evidence for programs indicates: must be group program;
must include experienced pain CBT practitioners; CBT underpins all; must include activities, pacing etc; must include exercise and ‘doing’ not just talking
GP EDUCATIONre CNIPS & pain mgtReferral Guidelines
ALLIED HEALTH EDUCATIONre CNIPS, specialist pain management, self-management
support & ongoing education opportunities
COMMUNITY MDT ASSESSEMENTCommunity based Pain Ax clinics at each GP Plus:RAH PMU SPECIALIST
Ax & RxTertiary level pain interventions
TRIAGE at PMU: including triggers to refer to DASSA
Use electronic reminders for Ax and Rx visits
(contracted) allied health Ax
MENTORING, SUPERVISION, CASE CONFERENCING,GPwSI in Training Placements
GPwSI Ax
Internal referral to tertiary service
PEOPLE LIVING WITH PAIN
Pts own GP
Gp AxMedication prescription
Education
Referrals
Management plans:
GMPM, EPC, TCA, MHP
Referral for AH Rx
Ongoing management and overview
PATIENT & CARER EDUCATIONCommunity pain information to people living with pain at 2 or 3 levels eg.:
Understanding painMoving with painLiving with painRefer to or use Stanford Chronic Disease Self Management Program
GP EDUCATIONre CNIPS & pain mgtReferral Guidelines
Evidence for programs indicates: must be group program; must include experienced pain CBT practitioners; CBT underpins all; must include activities, pacing etc; must include exercise and ‘doing’ not just talking
ALLIED HEALTH EDUCATIONre CNIPS, specialist pain management, self-management support & ongoing education
opportunities
COMMUNITY MDT ASSESSEMENTCommunity based Pain Ax clinics at each GP Plus:
RAH PMU SPECIALIST Ax & Rx
Tertiary level pain interventions
TRIAGE at PMU: including triggers to refer to DASSA
Use electronic reminders for Ax and Rx visits
(contracted) allied health Ax
MENTORING, SUPERVISION, CASE CONFERENCING,GPwSI in Training Placements
GPwSI Ax
DASSA:Ax & consultation liaison service; report to CNIPS Ax clinic & pts own GP
TREATMENTCNIPS auspicing allied health treatment to patients in collaboration with GP’s treatment and management plans
Organisations offering pain related support: eg. Arthritis Foundation, Diabetes Assoc, SA Health Stanford online etc groups
RACGP Pain training
Allied Health Pain training
Internal referral to tertiary service
Rx feedback to GPs
Ax feedback Letter framed to assist construction of GP plans
GP referral to CNIPSusing Referral Guidelines
Pt Requests GP for referral for increased Ax and Rx
Suggestion to pt to attend
Input via Division, meetings, email, newsletters, Referral Guidelines & Templates, F2F
Rx feedback to GPs
GP referral to AH
Central Northern Central Northern Integrated Pain Integrated Pain
ServiceService
GP Plus - realities
• Elizabeth GP Plus Pain– Not commencing until 2011– 0ne session/wk initially– Substantive input required from RAH PMU
• Marion GP Plus – FMC PMU tendering for assessment and treatment services...
• Challenge of engaging with generic chronic disease – focussed allied health and nursing practitioners
Rural and regional pain issues – the burden of distance
Rural outreach - Whyalla
Population 25000, rural city with heavy industry / subsidized housing 400km from Adelaide
Minimal medical specialist supportSignificant “area-of-need” GP workforce
Rural outreach - Whyalla
Population 25000, rural city with heavy industry / subsidized housing 400km from Adelaide
Minimal medical specialist supportSignificant “area-of-need” GP workforce
• High burden of pain• 4-fold higher long-term opioid prescription rate• High PMU referral rate• DNA rate problematic• Pain management plan implementation limited
Whyalla outreach plan
• Successful application for MSOAP funding 2006• Initial 2-day visits bimonthly, then 8 single day visits
annually• RAH PMU referral - waiting list triage
– first visit in Whyalla usually– follow-up either Whyalla or RAH if complex
• GP education sessions via Division, ready direct telephone access
• RAH PMU referral/triage form added to each GP “medical director”
• Allied health liaison
Whyalla outcomes - positives
Increased local CNCP management capacity
• Allied health – increased use of local exercise/hydrotherapy groups
• Increased use of case management items for anxiety/depression with local psychology
• More active GP management – increased “pain ownership”
• Reduced high dose opioid prescribing for higher risk individuals
Whyalla outcomes - negatives
Increased recognition of CNCP undertreatment leads to...
• Increasing referral load
• Difficulties of sustainability by RAH PMU
• Annual funding model – state/federal cost-shifting exercise
• Demand from GPs in other regional centres
What next ?
“Improving management of people with chronic pain and opioid dependence” RACP 2008
“Attempts to improve CNMP must always have general practice at their centre”
“Improving management of people with chronic pain and opioid dependence” RACP 2008“Attempts to improve CNMP must always have general
practice at their centre”
Key recommendation 2.– GPs and their professional organisations to accept
ownership of CNMP – Attractive and effective programs to train GPs in
managing CNMP
“Improving management of people with chronic pain and opioid dependence” RACP 2008
“Attempts to improve CNMP must always have general practice at their centre”
Key recommendation 2.– GPs and their professional organisations to accept
ownership of CNMP – Attractive and effective programs to train GPs in
managing CNMP
“Improving management of people with chronic pain and opioid dependence “ RACP 2008
“Attempts to improve CNMP must always have general practice at their centre”
Key recommendation 2.– GPs and their professional organisations to accept
ownership of CNMP – Attractive and effective programs to train GPs in
managing CNMP
Responsibility for funding GP training in CNCP.......?
June 2009 Penny Westhorp, Project Manager, CNAHS GPwSI Pain Management 57
People living with chronic non-cancer pain:Patients, family, carers
Specialist Pain Education providers: Pain Institutes, IASP,
conferences, Universities etc
Community Treatment and Education Providers:GPs, physiotherapists, psychologists, pharmacists,
other musculo-skeletal providers (chiropractors, osteopath),psychiatrists,
Arthritis Foundation, community pain education providers, etc
CNIPS Pain Ax ClinicPractitioners with Specific Interest in
Pain: GPwSI. Contracts with CBT trained
psychologist/s, physiotherapists as required
Central Northern Integrated Pain Service:
High level specialist Ax & Rx RAH PMU
Patient Education Program
CPE, support, mentoring of pain professionals
Trends in SA opioid prescription for chronic pain 1984 - 2006
Caution commencing opioids in…
Australian Pain Society Guidelines 1997
• Younger patients• Vague diagnosis• Lack of access to alternative options• High levels of distress • History of dependency
Catch 22………