Dr T Semple RAH PMU October 2010

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 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 ?






Are PMU getting the most appropriate referrals ?






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


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


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


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….


• 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



• Drugs of Dependency Unit (DASSA subbranch) reviews all S8 opioid prescriptions (35000/month)



• Drugs of Dependency Unit (DASSA subbranch) reviews all S8 opioid prescriptions (35000/month)

• Authority for S8 prescriptions provided upon application unless contraindicated


• 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




managing CNMP

“Improving management of people with chronic pain and opioid dependence “ RACP 2008




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…


• Younger patients• Vague diagnosis• Lack of access to alternative options• High levels of distress • History of dependency

Catch 22………

Documents

Dr T Semple RAH PMU October 2010