Exclusive The NHS England clinical director for prescribing has said he no longer refers patients to pain clinics because they end up on even higher strength opioids.
Speaking at Pulse Live, Professor Anthony Avery, who is also a GP and professor of primary health care at Nottingham University, said a different approach with less emphasis on drugs is needed.
He was responding to a question from a member of the audience at the event, who asked how GPs should manage patients who have been put on ever-increasing numbers of painkillers when they have sent them to a pain clinic.
‘I personally have largely stopped referring to pain clinics,’ he said. ‘You write to them and you say “we’re looking for a holistic approach, we’re not looking for an increase in medications”, but often they still end up prescribing higher strength opioids.’
He added: ‘It seems awful that we’ve been almost hoodwinked into believing that they work [for long-term non-cancer pain] for the last 20 years and have carried on prescribing them and increasing the doses of them.
‘In relation to pain clinics, I think we need a different approach with less emphasis on drugs and a more holistic approach which focuses on helping people to live well with pain.’
Earlier this month, guidance from NHS England said GPs should offer alternatives including psychotherapy, sleep clinics and social activities or clubs before prescribing addictive painkillers.
An action plan, published following the 2019 review by Public Health England, which found one in four adults were prescribed medications associated with dependence, including opioids, benzodiazepines and antidepressants, said reducing prescribing required a ‘whole-system’ approach and the development of new services with personalised and innovative support for those at risk of withdrawal or dependence.
But data from NHS England shows GPs and pharmacists have already helped cut opioid prescriptions by 450,000 in under four years.
The framework, which tasks the whole of the NHS with tackling the problem said where appropriate GPs should offer social prescribing, health coaching, peer support as well as psychotherapy before prescribing a potentially addictive medicine.
The framework also asks commissioners to provide services for patients who wish to stop taking addictive medicines.
And it states to help reduce prescribing in the first place: ‘Systems should ensure that alternative treatment options are available and that prescribers are aware of them.’
Regular audits should be done of prescribing for all adult patients to support GPs and clinical pharmacists to provide patients with a personalised review of their medicines and make a shared decision about whether a change in treatment is needed.
NICE guidelines published last year on safe prescribing and withdrawal management for addictive drugs said GPs should provide regular reviews for patients on drugs for chronic pain.
For some a dose reduction rather than complete withdrawal may be a more realistic approach, NICE said and if there is more than one medicine, this should be done in stages.
READERS' COMMENTS [13]
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I have long had little faith in pain management clinics
I have had several patients become addicted to opiates after they were wrongly started on them for chronic pain by pain clinics.
I never refer to them now, I am able to do a much better job of pain management myself.
Personally I would close these departments and reallocate the funds to primary care, where we can manage chronic pain much more effectively at a fraction of the cost
I fully agree with the experience of Prof Avery; as a fellow Nottinghamshire GP, I have found patients are not given the high quality, holistic and specialist pain management at the community pain clinic. These are complex patients, who are often being mismanaged by an overstretched service, with little or no holistic or psychological support, or any senior medically-qualified, oversight. Pain services in our region, as with a number of other services, has been recommissioned into the community, cut price, and with little leadership from the ICB.
I haven’t referred to pain clinics for some time. Chocolate teapot.
But the prof is missing the point.
Opiates are singularly useless for chronic pain because of their pharmacodynamics. Rapid down regulation of opiate receptors means rapid tolerance with dependence. Due to this opiates will always rapidly stop working and need dose increase forever.
Neuropathic agents don’t cause tolerance so they can actually work.
I have had very good effect with amitryptiline, gabapentinoids, duloxetine.
You start low, you taper up. if not working at optimal tolerated dose you taper back down and stop.
It’s all about the follow up.
And GPs can do f/u a lot better than any OP clinic. Better still if we were funded properly.
To denounce all meds for chronic pain is as dumb as thinking opiates can ever work long term.
Holistic? Yes it they work but often patients have tried other things themselves.
It may be that some of the benefit of these neuropathic agents is the effect on mood/emotion/anxiety but it they work what is the issue.
Functional mri shows emotional centres light up most in chronic pain not sensory areas of brain.
I thought the evidence was that anti depressants don’t cause dependence.
Also for prof and some of you.
When you have lived the lives of some of these chronic pain patients come back and extol the virtue of meditation and social clubs.
Living in cloud cuckoo land.
If they work use them. if they don’t taper them off.
The key is f/u.
Prof would be best placed lobbying NHSE to find primary care properly and give us the funding for social prescribers and well being coaches so we can have more receptionists and GP appts.
All above true of pain clinic but I have sympathy for them . They have little alternative for quick solution. Holistic approach sound good but are they effective? Long wait to be seen in pain clinic and then referral elsewhere.
If pain clinic is combined with other services same time then it would make sense. . What do you say to patient who is in pain despite all medication? We got to ask for further help.
I like the bit about ‘the whole NHS should’ and ‘Systems should ensure…. aware of (alternative treatments)’.
I had a patient allergic to and having side effects from Tramadol. He went through withdrawal effects too as we withdrew them in primary care. Then he had to go back into hospital for an operation, and they re-prescribed Tramadol despite knowing the recent history and recorded ADR.
I had a different patient with side effects from opioids. He also had aphasia, so I spent about 2 hours ‘discussing’ the nature of his pain, side effects, and use of alternative (TCAD), and then 2 weeks titrating him to an effective dose.
I had to send him back to hospital with a specific request for an amputation, which they did not do :- but they did abruptly stop his TCAD and recommence the opioid that was completely ineffective for his pain, so he came back to us again distressed in pain and also constipated again.
Maybe we are fortunate in that our local ‘pain clinic’ is not actually, but a ‘Pain Management Programme’ instead, so they like to have patients off all drugs before they even start the programme…..
Dear All,
Eventually the penny drops, mine dropped 20 yrs ago. When they used to issue TENS machines and do other stuff they were a benefit but that has long gone, now referring to a pain clinic is a positively bad thing, just like Memory Clinics and Long Covid Clinics.
Regards
Paul C
I largely agree – over the years Big Pharma has given us valium, dothiepine, prozac, oxycodone, pregabalin, tramadol, duloxetine etc etc
but none of these pills heal a wounded soul – they just numb the spiritual pain, – the Victorians used gin and opium, which were probably no worse or better !
I worry that not only are long term opioids of little benefit, but their continued prescribing makes us the potential target of legal action.
I lost count of the numbers of patients with chronic pain whom I treated osteopathically in GP and who were then able to come off the drugs and resume their normal lives.
The drugs don’t work, but neither does telling people to just live with their pain (acceptance therapy).
Nearly all the chronic pain I’ve encountered is MSK in origin; the concepts of neuropathic pain and central sensitisation are egregiously overused – no doubt helped by pharma overmarketing of gaba agents.
Meanwhile the burden of disability from chronic pain continues to grow.
It would be helpful to hear from patients as they are the ones in pain. It can be very hard to deny them relief when they are coming to you in severe distress. There just are not the services available to offer the holistic approach and we are faced with a patient in pain and nothing to offer so its no wonder so many GPs offer opiates. We use amitript to good effect and don’t much like pregabalin which was heavily promoted and disappointing.
Dear GP,
I spoke on the phone to your patient (who you referred in 2021) today concerning their chronic back pain. I suggest you start MST and titrate up to maximum dose, ditto pregabalin if she’s still in pain. She is now discharged from Pain Clinic.
Cheerio!
Dr Pain Consultant
Scrap them
The traditional secondary care pain clinic run by anaesthetists who are expert at interventions is a small part of what a Pain pathway should look like . There should be three tiers in a Pain Pathway – Tier-1 is Primary Care, Tier-2 a Community Pain service and Tier-3 advanced interventional services usually in hospital pain clinics.
The key point is there is an alternative to drugs and needles for most people and Chronic Pain patients are not all the same – their needs vary and should be tailored to the management which should be personalised and involve active approaches not [passive interventions. Understanding what pain is remains an issue for patients and health professionals – what we were taught is not what the reality is
Some Pain Consultants and services have modernised to this approach where the pathway is bottom up not top down but far too many haven’t and where there is a long wait for first appointment and longer for second with a Consultant, of course prescriptions in Primary Care become the easy option where patients need something tonow for their pain
All commenters above need to press their ICB for a modern pain pathway but of course money isn’t available as we are spending all the money on Orthopaedic Operations where all patient by definition have chronic pain …. Have a look at http://www.flippinpain.co.uk to see what changes there are in pain science since you trained and what can be achieved with a modern approach . I am CMO to Connect Health an independent provider ( = a large GP practice in contracting) who amongst other MSK services operate Community Pain clinics in over 40 CCG areas as …. its possible and it works, there are other providers out there too but they are largely not NHS Trusts for a variety of reasons that you can all imagine see https://www.connecthealth.co.uk/?s=chronic+pain&submit=Search So don’t scrap them …..MODERNISE THE PATHWAY