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GPs need a different approach to chronic pain



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