Managing the continuum between pain and dependency in general practice

Advocacy for improved management of pain has contributed to the escalation of prescription opioid analgesic (POA) use in the West over the last two decades. In the USA, the most commonly prescribed class of medication is now the opioids [1]. While they are essential for acute or terminal pain, there is limited evidence for their safety or efficacy in chronic non-malignant pain (CNMP) [2], and population studies indicate that POAs do not seem to improve key outcomes such as: pain relief, quality of life or functional capacity [3]. POA safety and efficacy studies have excluded those with past opioid use disorders, yet half of those with this diagnosis will move onto chronic opioid therapy (COT) [4]. This commentary [5] calls for increased scrutiny for those with CNMP and follows similar calls by medical indemnity insurers and Departments of Health. The class of drug responsible for most medication-related notifications is now opioids, second only to vaccinations. Such medico-legal incidents may leave doctors exposed to civil, criminal and disciplinary proceedings, including punitive damages, such as removal of prescribing rights or deregistration [6]. Such calls for increased clinical diligence for general practitioners (GPs), to do with a major part (19.6%) of all their encounters [7], are likely to fall on deaf ears. GPs are already feeling over-burdened with workload, time and financial pressures. This is particularly so in rural Australia where workforce shortages have resulted in salaries being offered (Hamzeh N, 2010, personal communication) guaranteeing over double the average rural salary [8]. To help cover these labour costs requires an intense focus on time management. Public funding for general practice offers equal payment for consultations of between 5 and 19 min. Mindful of this, the chairman of the Australian Medical Association Council of General Practice, Brian Morton, has commented ‘Medicare rewards quick throughput’ [9]. A recent opinion piece in a free GP newspaper advised supervisors of GP registrars to teach that it is ‘entirely reasonable’ to simply provide a script if requested, and to leave any personal or preventative matters to the annual check-up. ‘Anything beyond that is a waste of time and money’ [10]. Currently COT surveillance is problematic, with a detection rate of only 13.9% of misusers in pain management centres [11]. Screening for dependency can be experienced by GPs as imposing judgment, threatening the therapeutic relationship and disruptive to the normal patterns of work and cooperation [12]. GPs may fear finding an addiction, which many are unprepared to treat [1]. Because of these time and financial pressures, the difficulty of detecting problematic opioid use and the lack of prescriber confidence in treating addiction GPs are left on the horns of a dilemma. So, what should GPs do? GPs need to explain COT is no panacea, with an improvement in pain and function levels found in only 26% and 16% of cases, respectively [13].These modest benefits of COT need to be balanced against the risks such as sleep apnoea [14], opioid-induced hyperalgesia, unintentional fatal or non-fatal overdoses [15], diversion and addiction.The prevalence of addiction in COT has been estimated in various studies as 0–7.7% in cancer patients and 0–50% in non-cancer patients [16]. General practitioners have been called to implement universal precautions (UPs) [2,17].The concept of UPs was developed after the advent of HIV/AIDS in order to reduce the risk of the transmission of infection. They described minimum standards of care for all patients, regardless of their perceived or confirmed infectious status. Introducing UPs for CNMP would systematise attention to the dimension of dependency in the use of COT. Rather than reserving harm minimisation strategies for those with confirmed POA abuse, doctors would systematically be assessing pain and addictive disorders along a continuum [17].They would prepare for an exit strategy at initiation of a POA trial. They would manage the nuances of any adverse drug-related behaviours (ADRBs) as routinely as they currently manage cardiac risk factors.This would normalise flexibility in the degree of supervision and structuring for all opioid treatments. Pain is frequently part of the presentation of opioid dependency and withdrawal. Deciding on a management approach becomes more challenging when a commonly agreed definition of pain notes, ‘if people regard their experience as pain and if they report it in the same ways as pain caused by tissue R E V I E W