Background & Aims
Chronic pain is associated with depression and anxiety (1), sleep disturbances, substance abuse(2), and an overall reduced quality of life (3). In 2018, an estimated 3.24 million Australians were living with chronic pain, resulting in a financial burden of 139.3 billion AUD (4).
Recognising the significant impact of chronic pain, the Australian Government endorsed the development of the country’s first National Strategic Action Plan for Pain Management in May 2018 (5). Limited medical education may be contributing to poor management of chronic pain. A 2018 study of medical schools in Australia and New Zealand found that, on average, 20 hours of teaching were dedicated to pain medicine across a medical degree(6).
This study aimed to get patients’ views of their doctor’s pain management knowledge and skills. It was liked to another study of undergraduate healthcare students knowledge and confidence in chronic pain management.
Methods
A focus group was established to devise survey questions to be answered by people attending pain support groups in Australia. This was based on the Pain Understanding and Confidence Questionnaire (PUnCQ) which had been developed to assess healthcare students’ knowledge and confidence in pain management. Representatives came from the Australian Pain Management Association (APMA), the Adelaide Pain Support Network (APSN) and the American Chronic Pain Association (ACPA). The survey was distributed online to gatekeepers at APMA, APSN, Arthritis Australia, Australian Pain Society, Chronic Pain Australia, Fibromyalgia Australia, MS Australia, Pain Australia, and Pain Support ACT. The survey was subsequently distributed to attendees of their voluntary organisations. Results were analysed with a pragmatic epistemological perspective, focusing on practical outcomes and real-world implications for patient care. This approach acknowledges the presence of the researchers’ values and biases.
Results
127 people with chronic pain responded to the survey. Respondents were 87.3% Female. The majority (54.3%) of patients were aged 40-59, with no patient younger than 20 years, and one patient over 80 years.
58% of patients thought their healthcare practitioner had no pain management knowledge or a little. 75% thought their GP would welcome training in chronic pain management. A large majority (86%) supported the direct involvement of chronic pain patients in medical student education. 90% saw their GP monthly or quarterly and 95% answered medication as the way their GP had been able to help their pain. Referral to physio, psychology and non medical treatments were also reported by 37 to 64% of patients. Only 6% had been referred to APMA. 63% had been referred to a pain management service.
Thematic analysis of free text comments revealed that people felt lack of empathy, clinicians didn’t believe their pain or patients felt judged. Another frequent theme was not having access to analgesic medication due to government policy, fears of addiction and that medication was ineffective.
There were favourable comments about the effectiveness of a multidisciplinary team.
Many comments mentioned that help from patient support groups, other patients and the internet had been helpful.
Conclusions
This survey confirms that many patients feel that their GP has little or no knowledge of pain management. Studies of undergraduate education on pain management have found that there is very limited teaching on pain.
Although there is increasing evidence that medication, particularly opioids have little or no benefit for people with chronic pain (7,8), medication was a prominent concern in many of the comments from respondents. The Australian Government initiatives to reduce opioid prescribing may have led to doctors cutting their patients medication down and there were comments about reduction of opioids being done too rapidly (10,11,12). It is important to help patients to get on-side with any reduction in opioid doses, with gradual reduction and support to maintain the doctor patient relationship (13).
We hope that improvement in education will improve pain management and a public health approach may also be helpful, especially with limited access to specialists (14).
References
1. Bair MJ, Robinson RL, Katon W, Kroenke K. Depression and Pain Comorbidity. Archives of Internal Medicine. 2003;163(20). https://doi.org/10.1001/archinte.163.20.2433.
2. Hser YI, Mooney LJ, Saxon AJ, Miotto K, Bell DS, Huang D. Chronic pain among patients with opioid use disorder: Results from electronic health records data. Journal of Substance Abuse Treatment. 2017;77. https://doi.org/10.1016/j.jsat.2017.03.006.
3. Pandelani FF, Nyalunga SLN, Mogotsi MM, Mkhatshwa VB. Chronic pain: its impact on the quality of life and gender. Frontiers in Pain Research. 2023;4. https://doi.org/10.3389/fpain.2023.1253460.
4. Access Economics D. The cost of pain in Australia The cost of pain in Australia Painaustralia. 2019. www.deloitte.com/au/about
5. Australian Government Department of Health. National Strategic Action Plan for Pain Management. 2019; https://www.painaustralia.org.au/static/uploads/files/national-action-plan-final-02-07-2019-wfpnnlamkiqw.pdf
6. Shipton EE, Bate F, Garrick R, Steketee C, Visser EJ. Pain medicine content, teaching and assessment in medical school curricula in Australia and New Zealand. BMC Medical Education. 2018;18(1). https://doi.org/10.1186/s12909-018-1204-4.
7. Krebs EE, Gravely A, Nugent S, Jensen AC, DeRonne B, Goldsmith ES, et al. Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain the SPACE randomized clinical trial. JAMA – Journal of the American Medical Association. 2018;319(9). https://doi.org/10.1001/jama.2018.0899.
8. Krein SL, Bohnert A, Kim HM, Harris ME, Richardson CR. Opioid use and walking among patients with chronic low back pain. Journal of Rehabilitation Research and Development. 2016;53(1). https://doi.org/10.1682/JRRD.2014.08.0190.
9. Jones, C. M. P., Day, R. O., Koes, B. W., Latimer, J., Maher, C. G., McLachlan, A. J., Billot, L., Shan, S., Lin, C.-W. C., McLachlan, H., Webb, M., Hamilton, M., Ahedi, H., Barber, A., Mak, W., Mathieson, S., Petrova, V., Bompoint, S., Shan, S., … Yang, S. C. (2023). Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomised placebo-controlled trial. The Lancet (British Edition), 402(10398), 304–312. https://doi.org/10.1016/S0140-6736(23)00404-X
10. Painaustralia Impact of opioid regulation on people living with chronic pain. https://www.painaustralia.org.au/static/uploads/files/painaustralia-impact-of-opioid-regulatory-reforms-on-people-living-with-chronic-pai-wfopkycfkmnq.pdf
11. Australian Government Department of Health and Aged Care, Therapeutic Goods Administration. Prescription Opioids: What changes are being made and why. https://www.tga.gov.au/products/medicines/prescription-medicines/prescription-opioids-hub/prescription-opioids-what-changes-are-being-made-and-why [Accessed 15th April 2024].
12. Brendan Murphy. Australia’s Chief Medical Officer responds to GP questions over opioid warning letter. newsGP. 2019. https://www1.racgp.org.au/newsgp/professional/australia-s-chief-medical-officer-responds-to-gp-q#:~:text=Australia’s%20Chief%20Medical%20Officer%20responds%20to%20GP%20questions%20over%20opioid%20warning%20letter,-Brendan%20Murphy&text=Professor%20Brendan%20Murphy%20writes%20for,intimidating’%20and%20’unpleasant’. [Accessed 10th May 2024].
13. Matthias MS, Johnson NL, Shields CG, Bair MJ, MacKie P, Huffman M, Alexander SC. “I’m Not Gonna Pull the Rug out From Under You”: Patient-Provider Communication About Opioid Tapering. J Pain. 2017 Nov;18(11):1365-1373. doi: 10.1016/j.jpain.2017.06.008. Epub 2017 Jul 8. PMID: 28690000; PMCID: PMC6219456.
14. Buchbinder, Rachellea,b,*; Underwood, Martinc,d; Hartvigsen, Jane,f; Maher, Chris G.g,h. The Lancet Series call to action to reduce low value care for low back pain: an update. PAIN 161():p S57-S64, September 2020. | DOI: 10.1097/j.pain.0000000000001869