Sharing responsibility for ‘intractable’ pain patients: a role for a community pain nurse
Pain expert Professor Harald Breivik considers a common dilemma
around the long-term clinical responsibility for difficult pain cases
and proposes a community pain nurse as a possible solution
Q. Who should care for 'intractable' pain patients in the long term? Pain specialists or primary care?
Scenario
A 45-year-old man has mostly neuropathic pain after trauma to the left side of his head, caused by glass from a broken window cutting nerves and soft tissue in the temporal and frontal areas, leaving criss-crossed scars in an area about 15cm x 10cm.About two years after the injury, his general practitioner (GP) referred the patient to our pain clinic, asking for help to control the patient’s complex pain condition. He had been on escalating dosages of oral strong opioids, namely a 12-hour controlled release opioid and a faster-onset, shorter-duration opioid for ‘breakthrough pain’. The patient had been prescribed diazepam 15mg three times daily for an unclear anxiety disorder about 10 years before the injury. The patient claimed that his pain was not relieved. He was unable to perform his job as a teacher.
At the pain clinic, hypo- and hypersensory signs supported the diagnosis of neuropathic pain that was always present, but with fluctuating intensity, often up to 8/10 on the numerical rating scale. The pain score was brought down to about 6/10, briefly, by the high doses of strong opioids.
After considerable efforts by the pain team, his situation became stable and his pain scores were mostly down to 4–5/10 on a regimen of methadone 20mg three times daily and pregabalin 150mg three times daily instead of the diazepam. He began meeting a psychologist regularly for cognitive therapy for his anxious state.
After about 18 months, whilst receiving his drugs once weekly from the pharmacy, he was able to return to work part-time, but was exhibiting drug-seeking behaviours that required a ‘firm hand’ to control. He was discharged by the pain clinic back to the care of his GP, who was unhappy with the extra burden this would mean for his practice.
If patients like this one stay at pain clinics 'forever', this will eventually make it difficult to offer new pain patients appointments within a reasonable timeframe. Conversely, if the GP is/or feels he is not qualified to treat, or does not have the motivation or time for these patients, whatever is accomplished at the pain clinic will rapidly be wasted.
What is the solution to this everyday dilemma?
In this scenario, the GP was unhappy with the extra burden the pain patient would have on his practice
A. This is a
common problem. Pain patients, like this one, can fall back to
uncontrolled drug consumption and a chaotic social and working life. In
my experience, about one in 10 of those who are offered and remain on
long-term opioids for opioid-sensitive pain end up becoming ‘difficult’
pain patients. Most of these can be helped by a strict regimen, provided
their pain is opioid-sensitive. There is constant pressure from
patients whose pain is borderline opioid-sensitive to keep escalating
the dosage in order to obtain more pain relief. The ideal course in
these patients is to taper and discontinue the opioid. Often, this
approach fails and the patient ends up feeling misunderstood, receiving
unhelpful therapy. Some of them may even resort to buying illegal drugs.
This type of failed patient, who has already received considerable attention from the pain clinic, needs help from an addiction medicine specialist. Pain patients may not accept a recommendation from a pain specialist that they should see an addiction medicine physician. Even the patient’s GP might be unhappy, perhaps believing that such patients do not belong among people labelled ‘truly addicted’.
The following plan can sometimes work: The pain clinic invites the patient’s GP, an addiction medicine specialist and the patient to a joint conference. This may be a step towards finding common ground and convincing the patient to accept such treatment with the GP as his primary contact. The pain clinic will offer to keep contact and plan to see the patient every four to six months for follow-up. In addition, there is the ability to communicate by telephone as needed. This is important for the GP and the patient in order to maintain mutual respect and confidence, ideally continuing the helping attitude shown at the pain clinic.
The alternative is that the patient remains in the pain clinic as a regular customer ‘forever’. That is not ideal, as it will eventually result in case overload and inability of the clinic to function as a helpful referral centre for GPs.
A study carried out at the pain centre of Rigshospitalet, Copenhagen, Denmark has shown that the expense of employing a community pain nurse is balanced by cost savings resulting from less healthcare utilisation among patients who are followed up by the nurse, compared with controls.1 The same same research group also reported in another study that patients followed-up by a nurse from the pain centre used less opioids, had better physical function and less bodily pain two-years after discharge from the pain centre, than those who did not receive the nurse follow-up.2
These positive data provide a rationale for the role of a community pain nurse in the scenario described above.
This type of failed patient, who has already received considerable attention from the pain clinic, needs help from an addiction medicine specialist. Pain patients may not accept a recommendation from a pain specialist that they should see an addiction medicine physician. Even the patient’s GP might be unhappy, perhaps believing that such patients do not belong among people labelled ‘truly addicted’.
The following plan can sometimes work: The pain clinic invites the patient’s GP, an addiction medicine specialist and the patient to a joint conference. This may be a step towards finding common ground and convincing the patient to accept such treatment with the GP as his primary contact. The pain clinic will offer to keep contact and plan to see the patient every four to six months for follow-up. In addition, there is the ability to communicate by telephone as needed. This is important for the GP and the patient in order to maintain mutual respect and confidence, ideally continuing the helping attitude shown at the pain clinic.
The alternative is that the patient remains in the pain clinic as a regular customer ‘forever’. That is not ideal, as it will eventually result in case overload and inability of the clinic to function as a helpful referral centre for GPs.
Community pain nurse
Another possible solution to this difficult dilemma is to establish a service based at the pain clinic using a community pain nurse who interfaces between the hospital and the GP – similar services have been used for years in other disciplines such as diabetes management.A study carried out at the pain centre of Rigshospitalet, Copenhagen, Denmark has shown that the expense of employing a community pain nurse is balanced by cost savings resulting from less healthcare utilisation among patients who are followed up by the nurse, compared with controls.1 The same same research group also reported in another study that patients followed-up by a nurse from the pain centre used less opioids, had better physical function and less bodily pain two-years after discharge from the pain centre, than those who did not receive the nurse follow-up.2
These positive data provide a rationale for the role of a community pain nurse in the scenario described above.
References
- Sørensen J, Frich L. European Journal of Pain 2008;12(2):164–171.
- Frich LM, Sorensen J, et al. Pain Management Nursing 2012;13(4):223–235.
- The treatment options described in this case scenario are based on the global literature and the long clinical experience of the author. Not all the medications listed are licensed for use in the settings described and physicians should consult the relevant SPCs prior to prescribing
Date of preparation: October 2014; MINT/PAEU-14001
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