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Reworking the interface between primary care and multidisciplinary pain centres : the Adelaide experience. Dr T Semple RAH PMU October 2010. The problem South Australian Collaborative Pain Project Outcomes of SACoPP Ongoing activities The future.

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Dr T Semple RAH PMU October 2010


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    1. Reworking the interface between primary care and multidisciplinary pain centres : the Adelaide experience Dr T Semple RAH PMU October 2010

    2. The problem • South Australian Collaborative Pain Project • Outcomes of SACoPP • Ongoing activities • The future

    3. Chronic Pain in South Australia – South Australian Health Omnibus Survey 2006Currow et al. AustNZ J Public Health.2010;34(3) • Whole of population, face-to-face, 2973 interviewed • Prevalence of chronic pain 17.9% • Severe pain interfering severely with activity 5% • Associated with lower educational level and currently not working

    4. Chronic Pain in South Australia – South Australian Health Omnibus Survey 2006Currow et al. AustNZ J Public Health.2010;34(3) • Whole of population, face-to-face, 2973 interviewed • Prevalence of chronic pain 17.9% • Severe pain interfering severely with activity 5% • Associated with lower educational level and currently not working 75000 with severe CNCP......

    5. Chronic pain and the “waiting list disease” Canadian Pain Society Taskforce. M Lynch et al. Pain 136, 2008 Systemic review of relationship between waiting list time for specialist pain review, QOL and outcomes • Some deterioration from 5 weeks • After 6 months, medically unacceptable deterioration in physical and psychological health

    6. Waiting in Pain : APS interim report 2010 Hogg M, Gibson S, Helou A, Degabriele J South Australian data • 2418 individuals with non-urgent persistent pain assessed per annum at multidisciplinary pain centres

    7. Waiting in Pain : APS interim report 2010 Hogg M, Gibson S, Helou A, Degabriele J South Australian data • 2418 individuals with non-urgent persistent pain assessed per annum at multidisciplinary pain centres • Waiting time mean 205.5 days (national mean 143 days)

    8. Waiting in Pain : APS interim report 2010 Hogg M, Gibson S, Helou A, Degabriele J South Australian data • 2418 individuals with non-urgent persistent pain assessed per annum at multidisciplinary pain centres • Waiting time mean 205.5 days (national mean 143 days) • PMU input to approximately 10,000 individuals direct/indirectly per annum

    9. Waiting in Pain : APS interim report 2010 Hogg M, Gibson S, Helou A, Degabriele J South Australian data • 2418 individuals with non-urgent persistent pain assessed per annum at multidisciplinary pain centres • Waiting time mean 205.5 days (national mean 143 days) • PMU input to approximately 10,000 individuals direct/indirectly per annum Can PMU function with unworkable waiting lists ?

    10. Waiting in Pain : APS interim report 2010 Hogg M, Gibson S, Helou A, Degabriele J South Australian data • 2418 individuals with non-urgent persistent pain assessed per annum at multidisciplinary pain centres • Waiting time mean 205.5 days (national mean 143 days) • PMU input to approximately 10,000 individuals direct/indirectly per annum Are PMU getting the most appropriate referrals ?

    11. Waiting in Pain : APS interim report 2010 Hogg M, Gibson S, Helou A, Degabriele J South Australian data • 2418 individuals with non-urgent persistent pain assessed per annum at multidisciplinary pain centres • Waiting time mean 205.5 days (national mean 143 days) • PMU input to approximately 10,000 individuals direct/indirectly per annum What level of CNCP care are the other 55,000 receiving , if anywhere ?

    12. Burden of CNCP for Australian general practice • BEACH GP encounters (Sand abstract 127, 2008-09) • 19.6% attending suffered CNCP • GP satisfaction 2.4 ( scale 1 highly satisfied, 5 highly dissatisfied) • Patient satisfaction 2.5 • SACoPP GP focus group • estimated 25% patients, 25% workload • “not rewarding, not satisfying” in 75% of GPs “I don’t even refer because your waiting lists are so long...”

    13. GP prescribing in AustraliaNissen et al Brit J ClinPharmacol 2001 83% of referrals to Royal Brisbane Hospital multidisciplinary pain clinic already prescribed opioids at presentation

    14. Positive changes in prescribing...

    15. Rapid uptake of new high-dose formulations

    16. Prior to commencing opioids…. Australian Pain Society Guidelines 1997 • Clarify diagnosis • Non-opioid pharmacotherapy eg TCA and/or gabapentinoids • Exercise regimens • Psychological assessment / therapy

    17. Prior to commencing opioids…. Australian Pain Society Guidelines 1997 • Clarify diagnosis • Non-opioid pharmacotherapy eg TCA and/or gabapentinoids • Exercise regimens • Psychological assessment / therapy “Perverse MBS and PBS incentives encourage early use of opioid therapy in general practice rather than other options.....”

    18. SA government regulatory model for S8 opioids • Long term S8 opioid prescriptions under controlled Substances Act 1984 (SA) – “authority” required if < 70yrs

    19. SA government regulatory model for S8 opioids • Long term S8 opioid prescriptions under controlled Substances Act 1984 (SA) – “authority” required if < 70yrs • Drugs of Dependency Unit (DASSA subbranch) reviews all S8 opioid prescriptions (35000/month)

    20. SA government regulatory model for S8 opioids • Long term S8 opioid prescriptions under controlled Substances Act 1984 (SA) – “authority” required if < 70yrs • Drugs of Dependency Unit (DASSA subbranch) reviews all S8 opioid prescriptions (35000/month) • Authority for S8 prescriptions provided upon application unless contraindicated

    21. SA government regulatory model for S8 opioids • Long term S8 opioid prescriptions under controlled Substances Act 1984 (SA ) – “authority” required if < 70yrs • Drugs of Dependency Unit (DASSA sub-branch) reviews all S8 opioid prescriptions (35000/month) • Authority for S8 prescriptions provided upon application unless contraindicated • Frequent DDU recognition of poor rationale for opioid prescription and requirement to seek pain specialist opinion = significant PMU workload burden

    22. Authorities for long-term opioid prescription for CNCP for patients < 70yrs • \s \s \s \s

    23. S8s in SA for non-cancer pain SA 2010 data • 7000 authorities per 1.5million population (> 1 in 250) • In some regional centres, 1 in 100 patients This excludes long-term Panadeine Forte, Tramadol and other compound analgesics

    24. So what now ?

    25. South Australian Collaborative Pain Project2005-2008 (SACoPP) Key stakeholders • Drugs and Alcohol Services South Australia (DASSA) • RAH and FMC Pain Management Units • RACGP and South Australian Divisions General Practice Funding (~ $200,000) • Intergovernmental Committee on Drugs (supporting Ministerial Committee on Drug Strategy) • Industry Product Sponsors (Mundipharma and Janssen-Cilag)

    26. SACoPP goals • Improve inappropriate use of opioids and reduce diversion • Provide educational resource on opioid prescription • Up-skill pain management capacity in community amongst interested GPs by PMU “internships”

    27. GP resource document based on “Frequently Asked Questions on Opioids”, Uni Wisconsin 2001, heavily modified

    28. GP attachments to PMUs • ~ 52 hrs attendance, usually 1-2 sessions/week • Reimbursed @SADI rates $120/hr • 12 GPs enrolled (9 urban, 3 rural) • Attachments focusing on • optimising referrals • team care and working with pain-trained allied health • management of complex patients • current thinking with pharmacotherapy • integrating pharmacological and non-pharmacological therapies • pain management program options

    29. Outcomes – GP feedback • More confident/appropriate use of opioids in CNCP • Recognition of aberrant behaviours • Earlier use of regulatory intervention/addiction medicine services • Advice to GP colleagues • Assessment/management of GP-referred patients • Potential involvement with future community-based pain services Relationships between pain medicine and general practice strengthened +++

    30. Outcomes – rural example Clare Medical Centre • 2 GPs attended RAH PMU • Developed clinic-based Pain Program • Employed mental health-trained practice nurse as case manager • Community OT with pain experience • Visiting psychiatrist with regular FMC PMU sessions • Access to heated indoor pool for group exercise session • Represented ACRRM at National Pain Summit

    31. Flow 0n from SACoPP...

    32. Royal Australian College of General Practice SA chapter gets involved... Pain-GPs enrol RACGP – SA branch appoints coordinator • SA Pain Education Group formed to develop educational modules • RACGP-National Faculty of Specific Interests includes pain management (GP-si) • National Network of Pain Management initiated

    33. Enrolling SA Health in CNCP

    34. GP Plus Model of Care – SA Health • Aimed at bridging the gap between tertiary hospital-based services and primary care • Increasing capacity of primary care sector to respond to chronic conditions • Differ from GP Super Clinics by use of state health funding to provide allied health and nurses with chronic disease management skills GP Plus Elizabeth lobbied to include CNCP services – develops Central Northern Integrated Pain Service (CNIPS) concept

    35. Generic GP Plus Model: “Collaborative Corridor” • Supervising specialist • Treating medical staff: • GPwSIs • Trainee GPwSIs • Other medical trainees? • Specialist allied health • Treating staff take history, organise tests, draft diagnosis, consult with specialist • Specialist checks with patient, modifies diagnosis & suggests Rx plan • Treating staff reviews tests with consultant, delivers diagnosis, writes Rx plan, checked and signed by specialist, sends to referring GP Penny Westhorp, Project Manager, CNAHS GPwSI Pain Management

    36. Co-ordinated Pain Services SystemB Lau. Brit Columbia Pain Initiative 2008 • Graded Healthcare • Regional Multi-disciplinary pain centre hubs • Navigation of services: BC Website/Pain Hotline • Integration of electronic information systems

    37. C Hayes Hunter integrated Pain Service

    38. GP EDUCATION re CNIPS & pain mgt Referral Guidelines ALLIED HEALTH EDUCATION re CNIPS, specialist pain management, self-management support & ongoing education opportunities Central Northern Integrated Pain Service • PATIENT & CARER EDUCATION • Community pain information to people living with pain at 2 or 3 levels eg.: • Understanding pain • Moving with pain • Living with pain • Refer to or use Stanford Chronic • Disease Self Management Program Evidence for programs indicates: must be group program; must include experienced pain CBT practitioners; CBT underpins all; must include activities, pacing etc; must include exercise and ‘doing’ not just talking TRIAGE at PMU: including triggers to refer to DASSA Use electronic reminders for Ax and Rx visits COMMUNITY MDT ASSESSEMENT Community based Pain Ax clinics at each GP Plus: RAH PMU SPECIALIST Ax & Rx Tertiary level pain interventions (contracted) allied health Ax GPwSI Ax MENTORING, SUPERVISION, CASE CONFERENCING, GPwSI in Training Placements Internal referral to tertiary service TREATMENT CNIPS auspicing allied health treatment to patients in collaboration with GP’s treatment and management plans Penny Westhorp, Project Manager, CNAHS GPwSI Pain Management

    39. PEOPLE LIVING WITH PAIN GP referral to CNIPS using Referral Guidelines Ax feedback Letter framed to assist construction of GP plans GP referral to AH Internal referral to tertiary service Rx feedback to GPs Rx feedback to GPs • Pts own GP • Gp Ax • Medication prescription • Education • Referrals • Management plans: • GMPM, EPC, TCA, MHP • Referral for AH Rx • Ongoing management and overview GP EDUCATION re CNIPS & pain mgt Referral Guidelines ALLIED HEALTH EDUCATION re CNIPS, specialist pain management, self-management support & ongoing education opportunities Input via Division, meetings, email, newsletters, Referral Guidelines & Templates, F2F Organisations offering pain related support: eg. Arthritis Foundation, Diabetes Assoc, SA Health Stanford online etc groups • PATIENT & CARER EDUCATION • Community pain information to people living with pain at 2 or 3 levels eg.: • Understanding pain • Moving with pain • Living with pain • Refer to or use Stanford Chronic • Disease Self Management Program Central Northern Integrated Pain Service Suggestion to pt to attend Evidence for programs indicates: must be group program; must include experienced pain CBT practitioners; CBT underpins all; must include activities, pacing etc; must include exercise and ‘doing’ not just talking Pt Requests GP for referral for increased Ax and Rx DASSA: Ax & consultation liaison service; report to CNIPS Ax clinic & pts own GP TRIAGE at PMU: including triggers to refer to DASSA Use electronic reminders for Ax and Rx visits COMMUNITY MDT ASSESSEMENT Community based Pain Ax clinics at each GP Plus: RAH PMU SPECIALIST Ax & Rx Tertiary level pain interventions (contracted) allied health Ax GPwSI Ax RACGP Pain training MENTORING, SUPERVISION, CASE CONFERENCING, GPwSI in Training Placements Allied Health Pain training TREATMENT CNIPS auspicing allied health treatment to patients in collaboration with GP’s treatment and management plans

    40. GP Plus - realities • Elizabeth GP Plus Pain • Not commencing until 2011 • 0ne session/wk initially • Substantive input required from RAH PMU • Marion GP Plus • FMC PMU tendering for assessment and treatment services... • Challenge of engaging with generic chronic disease – focussed allied health and nursing practitioners

    41. Rural and regional pain issues – the burden of distance

    42. Rural outreach - Whyalla Population 25000, rural city with heavy industry / subsidized housing 400km from Adelaide Minimal medical specialist support Significant “area-of-need” GP workforce

    43. Rural outreach - Whyalla Population 25000, rural city with heavy industry / subsidized housing 400km from Adelaide Minimal medical specialist support Significant “area-of-need” GP workforce • High burden of pain • 4-fold higher long-term opioid prescription rate • High PMU referral rate • DNA rate problematic • Pain management plan implementation limited

    44. Whyalla outreach plan • Successful application for MSOAP funding 2006 • Initial 2-day visits bimonthly, then 8 single day visits annually • RAH PMU referral - waiting list triage • first visit in Whyalla usually • follow-up either Whyalla or RAH if complex • GP education sessions via Division, ready direct telephone access • RAH PMU referral/triage form added to each GP “medical director” • Allied health liaison

    45. Whyalla outcomes - positives Increased local CNCP management capacity • Allied health – increased use of local exercise/hydrotherapy groups • Increased use of case management items for anxiety/depression with local psychology • More active GP management – increased “pain ownership” • Reduced high dose opioid prescribing for higher risk individuals

    46. Whyallaoutcomes - negatives Increased recognition of CNCP undertreatment leads to... • Increasing referral load • Difficulties of sustainability by RAH PMU • Annual funding model – state/federal cost-shifting exercise • Demand from GPs in other regional centres