Transcript Reworking the interface

Reworking the interface between primary care
and multidisciplinary pain centres : the Adelaide
experience
Dr T Semple
RAH PMU
October 2010
1. The problem
2. South Australian Collaborative Pain Project
3. Outcomes of SACoPP
4. Ongoing activities
5. The future
Chronic Pain in South Australia – South Australian
Health Omnibus Survey 2006
Currow 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
Chronic Pain in South Australia – South Australian
Health Omnibus Survey 2006
Currow 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......
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
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 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)
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
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 ?
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 ?
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 ?
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...”
GP prescribing in Australia
Nissen et al Brit J Clin Pharmacol 2001
83% of referrals to Royal Brisbane Hospital multidisciplinary
pain clinic already prescribed opioids at presentation
Pethidine Injection 100mg, 1998-2005 per 10,000 Population
per 10,000 population
60.00
Year 1998
50.00
Year 1999
40.00
Year 2000
Year 2001
30.00
Year 2002
Year 2003
20.00
Year 2004
Year 2005
10.00
0.00
NSW
VIC
QLD
SA
WA
TAS
State
Positive changes in prescribing...
ACT
NT
Methadone 10mg, 1998-2005 per 10,000 Population
per 10,000 population
250.00
Year 1998
200.00
Year 1999
Year 2000
Year 2001
150.00
Year 2002
Year 2003
100.00
Year 2004
Year 2005
50.00
0.00
NSW
VIC
QLD
SA
WA
State
TAS
ACT
NT
Kapanol 100mg, 1998-2005 per 10,000 Population
per 10,000 population
70.00
Year 1998
60.00
Year 1999
Year 2000
50.00
Year 2001
40.00
Year 2002
30.00
Year 2003
Year 2004
20.00
Year 2005
10.00
0.00
NSW
VIC
QLD
SA
WA
State
TAS
ACT
NT
per 10,000 population
Oxycontin Tablets 80mg, 2001 - 2005 per 10,000 Population
45.00
40.00
35.00
Year 2001
30.00
Year 2002
25.00
Year 2003
Year 2004
20.00
Year 2005
15.00
10.00
5.00
0.00
NSW
VIC
QLD
SA
WA
TAS
ACT
State
Rapid uptake of new high-dose formulations
NT
ATTACHMENT 1 - South Australian oxycodone consumption
Oxycodone Consumption
140000
120000
Grams
100000
80000
60000
40000
20000
0
83
9
1
85
9
1
87
9
1
89
9
1
91
9
1
93
9
1
95
9
1
97
9
1
99
9
1
01
0
2
03
0
2
05
0
2
07
0
2
09
0
2
Prior to commencing opioids….
Australian Pain Society Guidelines 1997
• Clarify diagnosis
• Non-opioid pharmacotherapy eg TCA and/or gabapentinoids
• Exercise regimens
• Psychological assessment / therapy
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.....”
SA government regulatory model for S8 opioids
• Long term S8 opioid prescriptions under controlled
Substances Act 1984 (SA) – “authority” required if < 70yrs
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)
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
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
Authorities for long-term opioid prescription
for CNCP for patients < 70yrs
• \s
\s
\s
\s
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
So what now ?
South Australian Collaborative Pain Project
2005-2008 (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)
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”
GP resource document
based on “Frequently Asked
Questions on Opioids”, Uni
Wisconsin 2001, heavily
modified
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
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 +++
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
Flow 0n from SACoPP...
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
Enrolling SA Health in CNCP
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
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
Co-ordinated Pain Services System
B 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
C Hayes Hunter integrated Pain Service
GP EDUCATION
ALLIED HEALTH EDUCATION
re CNIPS & pain mgt
Referral Guidelines
re CNIPS, specialist pain management, self-management
support & ongoing education opportunities
PATIENT & CARER EDUCATION
Central Northern
Integrated Pain Service
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
Evidence for programs indicates: must be group program;
Disease Self Management 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
RAH PMU SPECIALIST
Ax & Rx
Tertiary level pain interventions
Community based Pain Ax clinics at each GP Plus:
GPwSI Ax
allied
health Ax
(contracted)
Internal referral to tertiary
service
MENTORING, SUPERVISION, CASE CONFERENCING,
GPwSI in Training Placements
TREATMENT
June 2009
CNIPS auspicing allied health treatment to
patients in collaboration with GP’s treatment
Penny Westhorp, Project Manager, CNAHS
and management plans
GPwSI Pain Management
42
PEOPLE LIVING WITH PAIN
Pts own GP
Gp Ax
Medication
prescription
Input via Division,
meetings, email,
newsletters, Referral
Guidelines &
Templates, F2F
Education
Suggestion to pt to
attend
Referrals
GP EDUCATION
ALLIED HEALTH EDUCATION
re CNIPS & pain mgt
Referral Guidelines
re CNIPS, specialist pain management, selfmanagement support & ongoing education
opportunities
PATIENT & CARER EDUCATION
Central Northern
Integrated Pain
Service
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
Evidence for programs indicates: must be group
Disease Self Management Program
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
TRIAGE at PMU:
GP referral to CNIPS
using Referral Guidelines
Management
plans:
GMPM, EPC,
TCA, MHP
Referral for AH
Rx
Ongoing
management
and overview
including triggers to refer to DASSA
Use electronic reminders for Ax and Rx visits
COMMUNITY MDT ASSESSEMENT
Ax feedback Letter
framed to assist
construction of GP
plans
RAH PMU SPECIALIST
Ax & Rx
Tertiary level pain
interventions
allied
health Ax
(contracted)
GPwSI Ax
Internal referral to
tertiary service
MENTORING, SUPERVISION, CASE CONFERENCING,
GPwSI in Training Placements
TREATMENT
Rx feedback to GPs
DASSA:
Ax &
consultation
liaison
service; report
to CNIPS Ax
clinic & pts
own GP
Community based Pain Ax clinics at each
GP Plus:
Rx feedback to
GPs
GP referral to AH
Organisations
offering pain
related support:
eg. Arthritis
Foundation,
Diabetes Assoc,
SA Health
Stanford online
etc groups
CNIPS auspicing allied health treatment to patients in
collaboration with GP’s treatment and management plans
RACGP Pain
training
Allied Health
Pain training
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
Rural and regional pain issues – the burden of
distance
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
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
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
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
Whyalla outcomes - 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
What next ?
“Improving management of people with chronic
pain and opioid dependence” RACP 2008
“Attempts to improve CNMP must always have general practice
at their centre”
“Improving management of people with chronic
pain and opioid dependence”
RACP 2008
“Attempts to improve CNMP must always have general practice
at their centre”
Key recommendation 2.
– GPs and their professional organisations to accept
ownership of CNMP
– Attractive and effective programs to train GPs in
managing CNMP
“Improving management of people with
chronic pain and opioid dependence” RACP 2008
“Attempts to improve CNMP must always have general practice
at their centre”
Key recommendation 2.
– GPs and their professional organisations to accept
ownership of CNMP  
– Attractive and effective programs to train GPs in
managing CNMP
“Improving management of people with
chronic pain and opioid dependence “ RACP 2008
“Attempts to improve CNMP must always have general practice
at their centre”
Key recommendation 2.
– GPs and their professional organisations to accept
ownership of CNMP  
– Attractive and effective programs to train GPs in
managing CNMP 
Responsibility for funding GP training in CNCP.......?
Community Treatment and Education Providers:
GPs, physiotherapists, psychologists, pharmacists,
other musculo-skeletal providers (chiropractors,
osteopath),psychiatrists,
Arthritis Foundation, community pain education providers,
etc
CNIPS Pain Ax Clinic
Practitioners with Specific Interest in
Pain: GPwSI.
Contracts with CBT trained
psychologist/s, physiotherapists
as required
CPE, support,
mentoring of pain
professionals
Patient Education Program
Central Northern
Integrated Pain Service:
High level specialist
Ax & Rx RAH PMU
People living with chronic non-cancer pain:
Patients, family, carers
June 2009
Penny Westhorp, Project Manager, CNAHS
GPwSI Pain Management
Specialist Pain
Education providers:
Pain Institutes, IASP,
conferences,
Universities etc
57
Trends in SA opioid prescription for chronic
pain 1984 - 2006
Caution commencing opioids in…
Australian Pain Society Guidelines 1997
•
•
•
•
•
Younger patients
Vague diagnosis
Lack of access to alternative options
High levels of distress
History of dependency
Catch 22………