Supervisor Modules

Teaching session worksheet

What is covered during Registrars’ Out-of-practice training?

This is a large module. You may choose to run this over two teaching sessions depending on the depth of your exploration.

Block Release Sessions in chronic pain are held for Basic and Advanced Term Registrars. This tutorial is an opportunity to consolidate and build on some of this learning in a local setting. It would be useful to ask your registrar if they have attended the Block Release sessions and discuss any pertinent aspects or issues.

Below is a list of the learning objectives from these Block Releases.

Management of Chronic Pain Advanced Term Block Release

Objectives

• Develop an assessment approach to Chronic Pain
• Understand pharmacological management of Chronic Pain
• Understand the role of Allied Health in the management of Chronic Pain
• Understand the role of non-pharmacological interventions in the management of Chronic Pain
• Understand the role of Pain Clinics

Prescribing Narcotic Analgesia Advanced Term Block Release

Objectives

• To understand the PBS criteria for prescribing drugs of dependence
• Introduction to the SA Controlled Substances Act
• To understand the implication of the SA Controlled Substances Act on prescribing drugs of dependence
• To understand process of prescribing drugs of dependence within the framework of the PBS and the SA Controlled Substances Act
  

Why are we talking about chronic pain?

Chronic pain is common and is experienced by up to 20% of the Australian population. Many of these patients manage their pain themselves, but up to 5% have what is considered severe pain that interferes with their life and function. These patients are difficult to treat as drug treatments have a limited role and the patient needs to be educated to manage their pain themselves. This takes time, which may be an extra challenge for the practitioner.

Management includes active physiotherapy, psychological therapies, basic lifestyle change and education regarding the appropriate use of medication. Patients are often looking for a cure and practitioners, who are trained with the medical model, where cure is the aim, may find it difficult to accept that these patients suffer from a chronic disease that can be managed but not cured. These patients can be demanding and it can be difficult to differentiate between the patient who has chronic pain and the one who may be using chronic pain as an excuse to obtain opioids.

It is important to acknowledge that making small changes to the patent’s pain experience can result in large changes to their general wellbeing and function.

Chronic pain can be difficult to teach because of its complexity. In this module we have tried to tease out key questions that will provide a framework to assist structured discussion.

Key Questions

1. What makes chronic pain and its management different from acute pain?

• When does pain become chronic?
• Have you seen a patient with an acute pain problem who you were worried from the beginning would develop chronic pain?
• What might trigger your suspicions this is occurring?

2. When shouldn’t I prescribe drugs?

3. Are there any co-morbidities that might lead you to have concerns about drug prescription?

4. If I use drugs, which ones should I use and how?

Discuss which of these drugs you would use and when you would use them. What sort of dosage and dose regimen would you use?

Non-steroidals
Paracetamol
Benzodiazepines
Anti-depressants
Anti-epileptics
Short acting opioids
Long acting opioids

One of the difficulties for registrars when seeing patents with chronic pain could be that they feel a reluctance to alter existing management plans of long standing patients when the Registrars will be moving practice in a few months time. This may lead to feeling they have a care-taker role rather than an active management role. How does your current Practice manage the issue of chronic pain patients seeing different practitioners? What happens when their regular GP is away and they present to the registrar requesting drugs of dependence?

Discuss how these issues might be managed in your Practice.

5. How do I access good allied health support?

Discuss your experience in referring in your local area. Who have you referred to and what outcomes have you seen?

How can General Practice care plans be used for chronic pain?
Look at what templates are available in your practice for care plans and identify which one may be the most useful.

6. How do I manage the consultations?

Reflect on the patient you identified in the pre-session worksheet.

• How did they make you feel?
• Were there any time issues that arose? If so, how did you address these?
• Did you identify any broader contextual issues that were affecting this patient’s chronic pain experience? How did you address those?
• Do you recall any special language that you have found useful in speaking with chronic pain patients?

At this stage you may like to do a simple role play practising educating a patient about the impact of their psychosocial situation on their chronic pain. For example a conversation with someone who has just had their Workcover claim rejected and his or her pain has suddenly worsened.

Think about the importance of self-care when managing chronic pain.

• Why is self-care important?
• What sort of effect might chronic pain patients have on you in the longer term?
• How do you debrief after you have had a difficult consultation?

7. How do you identify the patients that may be drug seeking?

What can you do if you have this suspicion?
What resources have you used in the past?

We suggest you read this together now:

Read Sherman (1991). MJA.

Who instantly springs to mind? You may wish to share your experience of this patient and how you managed them.

8. When should I refer to a specialist pain unit?

Make a list together of specific triggers that would lead you to refer to a specialist pain unit. Compare this list with the one found in Goucke (2003) in Box 4.

Consider the patient discussed before. Do you think they would benefit from referral? If so, why? If not, why not?

What can the chronic pain unit offer to the GP and to the patient? What can the pain unit do that the GP cannot?

9. How do I maintain hope?