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GPs need a different approach to chronic pain

Editor’s blog

1 nigel

1 nigel

It has been labelled the ‘silent epidemic’, with some estimating that around half of the UK population is affected by chronic pain. But concerns are growing over the way these patients are being managed.

An alarming rise in the use of strong opioids has prompted calls for annual reviews of patients, with NICE, Public Health England and the BMA all encouraging GPs in the UK to move away from their long-term use.

And – as we detail in a special online investigation today – it looks like the next target will be the gabapentinoids, with the Home Office looking to make pregabalin and gabapentin controlled drugs after recent studies showed they are only effective in around half of patients – with the rest (presumably) just popping them for the opioid-like ‘buzz’.

But this change alone will not tackle a situation in which many patients are overmedicated with potent painkillers that often don’t work and are ripe for misuse.

The system colludes to pump chronic pain patients full of drugs

The enthusiasm for such analgesics can be traced back to publication in 1986 of the WHO’s ladder, which legitimised their use, as chronicled by Dr Des Spence in his Pulse blog this month. I would also argue the whole system colludes to pump chronic pain patients full of drugs, without addressing the root causes of their condition.

Indiscriminate prescribing in secondary care and A&E departments adds to the burden, with patients routinely discharged on co-codamol 30/500 after an operation. Pain clinics may be a godsend for GPs who don’t know what to do next, but patients almost inevitably end up on more potent medications as a result.

Practices are then asked to manage these patients, who end up on repeat medication scripts without reviews – the sort of situation that would not happen with diabetes or asthma as they are directly funded through the QOF.

Now, I am not saying GPs should refuse to treat any pain with pills – that would be callous and very cruel. But potent analgesics should be a stop-gap, not a sink hole. A new approach is needed for the management of chronic pain – one that does not continually default to the readily available pharmacological option.

Most GPs I speak to know drugs are not the answer, but what are they expected to do when waits for psychology, physiotherapy or occupational therapy can stretch to several months? Leave the patient with no support at all? Pain is a multifaceted and complex condition and should be treated as such, with GPs being supported to explore a multidisciplinary response and encourage better self-care, rather than having no choice but to reach for the green pad.

Primary care medication reviews should be funded, to ensure that they are not pushed to the back of the queue. The perception that a pill of any sort will solve chronic pain must be tackled. No GP will get a complaint for giving opioids, but I bet many have had complaints for saying no to them.

Every avoidable long-term analgesic prescription should be considered a failure of the system and GPs must be given the tools they need to manage chronic pain with the seriousness it deserves.

Nigel Praities is editor of Pulse


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Readers' comments (7)

  • Vinci Ho

    (1) This Gabapentinoid Crisis simply epitomised and exposed one fragility of the current NHS where patients needing more time of attention were shuffled from busy secondary care to busier primary care clinicians. Chronic pain , as we already discussed in another article, is more than upper respiratory tract infection, chest infection , gastroenteritis or even suspected cancers . Time consuming is inevitable if a proper review with some positive outcomes are desired . Yes , realistically , many are just staying on the drugs permanently. But the physical-mental-social medicine model always apply in chronic pain . Continuity of care supported by time , in my opinion , is essential. 10 minutes appointment is a joke in this context.
    (2) Alongside with tramadol , we do not seem to have learnt the lesson about all these new drugs into the market. NHS is a jewel on the crown and is particularly so in the eyes of pharmaceutical companies. Why were we so resistant to the Transatlantic trade and investment pact (TTIP)? I understand that they have good arguments about spending millions of pound in their researches and obviously need a positive reception but it does not mean a green light to exploit opportunitiscally the weaknesses of our beleaguered NHS( thanks to the good work of the government).
    (3) Do not want to point a finger solely on the academics but NICE needs to recognise their medico-legal representation and produces guidelines with more common senses , without fearing to 'disappoint' drug companies.Cockrane review in June this year is telling. Perhaps , under current crisis of GP workforce, the implication of being liberal in passing drugs for indications with unclear benefit , will simply increase our(GP) burden unnecessarily.
    (4) Without examining the current circumstances throughoutly , being strict or liberal still end up with mistakes, costly ones in this case .
    (5) Personally , I say yes to stop prescribing these drugs under current conditions we are under .

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  • we could stop them and refer everyone to the local pain clinic , our current writing time is approximately up 10 months!

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  • AlanAlmond

    How does guidance from NICE telling us NOT to prescribe paracetamol help exactly? Ok medication often doesn't help - agreed we get guidance to avoid using the medication LEAST likely to cause addiction or adverse effects. Smart that. Genius. You got my back NICE, thanks very much.

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  • I like the patients that tell me they will not take pain killers as it simply "masks"the cause of the pain.
    My standard response it that you are onto a winner.

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  • Sorry Nigel, I disagree with your conclusions on this occasion. As an experienced GP and as a sufferer of neuropathic pain myself (quite appropriately and very successfully treated with pregabalin via initial pain clinic assessments &recommendation) ,I and most GPS know these drugs are a godsend for people whose lives would otherwise be severely blighted. I am sure however that all GOs will be anxious to ensure these are not used inappropriately.
    The problem is not that these drugs do not work, though it may be an inconvenient cost that so many people may benefit from these expensive medications, rather it is that these drugs are falling into the wrong hands and are being misused. The problem is not principally one of incorrect prescribing but of a failure of medication monitoring and issue , and also illicit purchase from other sources quite apart from GP surgeries.
    The answer is not to make the correct use of these medications fall under suspicion and risk failure to prescribe where clinically appropriate what is an extremely effective treatment for neuropathic pain.
    As with all drugs we need to ensure that such medication is issued to patients whose clinical needs meet the criterion for their use, as here with gabapentinoids and Neuropathic pain.This is most often a chronic pain problem where treatment of necessity becomes long term and I am concerned by suggestions I have read elsewhere on this topic that issues should be short term only. I cannot agree that long term ongoing treatment of chronic ongoing pain should be considered in any way a prescribing 'failure' but rather as meeting a clinical need.
    What is required is for the issued amounts and frequency of the medication ,which will usually be predictable and stable, to be agreed with the patient and monitored subsequently such that any misuse should become apparent. If it takes the drug being reclassified as a scheduled drug in order to do this reliably then I am not against this so long as deserving patients are not excluded...we should not throw the baby out with the bath water.
    Obviously, any GP role changes here will have a limited effect where these medications are obtained illicitly for the sole purpose of misuse from other sources.

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  • A good balanced article.
    Give me forty minutes with every chronic pain patient and I'm sure I could get a lot of them to reduce or stop a lot of their medication. Problem is in the real world we have 10 minutes and these are usually patients with multiple complex problems and most would not even see polypharmacy as one of their problems.

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  • absolutely needs to be properly funded through QoF/LCS.

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