Episode 24: Opioids special #2: Non-pharmacological management options for chronic non-cancer pain

Voiceover:

Welcome to the NPS MedicineWise podcast, helping health professionals stay up to date with the latest news and evidence about medicines and medical tests.

Dr Jill Thistlethwaite:
Welcome to all listeners. I'm Jill Thistlethwaite, I'm a GP and medical advisor at NPS MedicineWise, and I have a special interest in communication skills, education, and shared decision-making. The management of chronic non-cancer pain is a complex area. NPS MedicineWise has been running a program for health professionals and consumers on opioids and chronic non-cancer pain for some time now. And in this podcast, we'll be focusing on the non-pharmacological options for chronic non-cancer pain. To discuss this topic, I'm joined by Dr Tania Gardner and Sarah Fowler. Tania, would you like to say a few words about yourself?

Dr Tania Gardner:
Thanks for having me. I'm a senior physiotherapist practicing out of St. Vincent's Hospital with the Department of Pain Medicine, and also have a role in CRUfAD, and I was involved in the development of our online pain management program, Reboot Online. I've also done my PhD and I'm also interested in communication, patient motivation, and goal setting.

Dr Jill Thistlethwaite:
Thank you, Tania, and welcome. And, Sarah, would you like to say a few words about yourself?

Sarah Fowler:
Hi, thank you for having me. My name is Sarah. I've been a consumer advocate for quite a few years now and I work quite a lot with Painaustralia. I was diagnosed when I was about 13 or 14, and I've had my pain symptoms for about 10 years now.

Dr Jill Thistlethwaite:
Thank you, Sarah. So, Sarah, I know you've used a number of different management strategies for your pain over those 10 years, including opioids at some points. Can you tell us a little bit more about your story and the management of your pain?

Sarah Fowler:
Yes, so my pain started, normally after an injury or illness, it would progressively get worse and continue through most of my lower half of my body, and my GP would do multiple tests, and that was when I would be on your typical pain medication, including opioids at times. Because I was so young, they probably avoided them a little bit more, which probably benefited my treatment. But sometimes they were necessary and it took quite some time, but I would progressively use less typical pain medication by moving to different types of pain medication that is more neurological-based but primarily doing physical therapies, and mindfulness, using TENS machines, or hydrotherapy, different types of techniques, even meditation at times. So, using all those different skills and some cognitive behavioural therapy to try and change things on the long-term so that I could then progressively move away from my typical short-term acute-based pain medicine.

Dr Jill Thistlethwaite:
Thanks, Sarah. You've mentioned quite a few different options there. How did you get involved in those and learn how to use them successfully?

Sarah Fowler:
The first time I had a severe sort of lapse in my chronic pain health, I was misdiagnosed quite a few times, and actually, my physiotherapist started to give me different pain alternative treatments. Because I didn't have a diagnosis, there wasn't necessarily medication that I could be treated with but that's when I started hydrotherapy because I was in a wheelchair. That sort of gave me the ability to start movement again. And then again, my physiotherapist and my GP started recommending other options for me. And I often tried different things with various success, knowing sometimes from other groups like online and those sorts of things that it works best for different people. Some just worked better than others, depending on my situation, I think.

Dr Jill Thistlethwaite:
Tania, from your perspective, we know about the difficulties with opioids and the harms that they can cause. What do you think are effective alternatives to these medicines?

Dr Tania Gardner:
Yes, so you're correct in regards to the harm of opiates. And I think one of the difficult things for health professionals is when we are presented with a person who experiences chronic pain is that we want to try and fix it. So, we can't do that and we can't do that with opiates. We know that. So, there are lots of other different strategies that you can use to manage pain. And I think as we start to see more patients having to be deprescribed opiates, it's important that we tell our patients or persons with chronic pain there's lots of other tools that they can be using apart from the opiates. And these things include cognitive behavioral therapy, mindfulness, relaxation, meditation, and movement. Pacing is really important. So, that's the strategy where we pace activity either throughout the day or throughout the week, activity scheduling.

And it's really a combination of these tools that helps manage pain the best way. Often, I'll describe to my patients that we're really trying to teach them or give them a tool bag or tool belt for them to have lots of different chores that they can choose on a particular day or a particular time that is useful. And I think Sarah mentioned the fact that different things worked at different times, and that's really common. It's a really individual sort of approach that we need to take, but there's lots of different strategies that people can use.

Dr Jill Thistlethwaite:
So, when you are having the conversation with a person with chronic pain, and you mention these alternatives, Tania, I presume that some people are quite skeptical to begin with. So, what do you discuss with them about the evidence?

Dr Tania Gardner:
Yes, so there's very good evidence now that this multidisciplinary approach is the best way to manage pain long-term. We also have the good evidence in regards to the effectiveness or the poor effectiveness of opiates and the harms as well. So, it's about showing them that the opiates are harmful and that we do have other strategies that actually work long-term. It's about discussing the different types of pain, acute versus chronic, and sort of teaching them the effectiveness of those different tools in those different phases as well.

Dr Jill Thistlethwaite:
So, Tania has mentioned the multidisciplinary team approach to this chronic pain management. And, Sarah, which health professionals have you been involved with in your journey and how did you access those professionals?

Sarah Fowler:
The start of my journey primarily [involved] my GP and physiotherapist. And when I got worse again a few years later, I ended up at the Randwick Children's Hospital where I was eventually admitted to the pain clinic there which had multidisciplinary team. And it meant that I had access to a really wide, wide variety. So so many specialists, including physiotherapists [specialising] in pain, and psychologists, and psychiatrists, and you name it, they were there, and it meant that they could really tackle a problem from all areas at once.

Dr Jill Thistlethwaite:
Did you ever find sometimes that you were a bit overwhelmed by the number of people involved in your care?

Sarah Fowler:
Yes, very much so. I would have been maybe 13 [years old] and there were many, many doctors in the room, all listening to my story at once which was so, so beneficial, but also a little bit daunting to have so many professionals listening to me, particularly when I was quite young. But the whole process was really supportive and it really makes you feel like you have a team of people that want to help you. So, even though it was a little bit daunting, it was a really beneficial process. I always say that it was the start of my pain journey. It was really the start of my recovery being there and having all those professionals helping me at once.

Dr Jill Thistlethwaite:
Tania, as a physiotherapist, what's your special expertise in the non-pharmacological management that you would recommend to people in Sarah's position?

Dr Tania Gardner
So, I guess as a pain physiotherapist, I'm looking at the whole person. So, I'm looking at not just their musculoskeletal system, which is what physios have got an expertise in, but I'm also looking at their relationship with movement, the thoughts and mood associated not just with movement and function, but what's happening with that person in their life. And so, I'm tying all of those different aspects together. In regards to movement, we know that any movement is going to be helpful with chronic pain. So, you can do specific exercises. You can do general cardiovascular exercises, body movements, Tai Chi. There's a whole variety of research out there showing us that all these different types or modes of exercise are effective in helping to manage chronic pain. And so, it's really about choosing what movement you enjoy doing, what movement's going to fit into your lifestyle.

And that's really up to the patients. So, it's about listening to them and listening to what they want to be doing. But with that is pacing. So, pacing's a really important strategy that we try and use. That's where you slowly and gently increase the amount of movement that you do. So, we don't want to be pushing that pain system too hard or too fast because it will respond with stress or increased pain. So, we want to gently improve the amount of movement you do. And then also thinking about pacing your activities so that you're spreading your activities across a week or across a day, depending on your schedule.

So, in terms of movement and that physio approach, that's what I would be doing, and then combining that or embedding all the different other aspects of what that person is bringing in terms of their mood, their thoughts, their function, and what's happening in their life as well. And my particular focus is on patient-led goal setting. It's important to really ask the person what their life is like with pain, what do they want to improve in their life, and work towards what that person's goal is. So, it's not a black and white answer, I'm afraid. It's quite an individual approach for everybody that walks through the door.

Dr Jill Thistlethwaite:
You mentioned there about communication and both of us have an interest in that. What are the strategies for keeping all these different people who are working with the patient to help manage the pain, the strategies for communication amongst the team so that everybody knows what's happening and is up to date, including the patient?

Dr Tania Gardner:
So, first thing is to involve the patient as much as you can. Making sure that they're developing those goals, that they're developing those strategies so there's an ownership of that pain pathway, if you like, or pain journey. And then it's really important that the team, so whatever team you're in, so if you're in a tertiary clinic, we've got a team, then we meet regularly. We also have a similar direction in terms of what our ethos is and the language that we use so that the message is repeated between members. And then if you're are in primary care and you need to communicate with different professionals out there, it's really important that everyone on that team, whether it's in tertiary care or primary care, that everyone's communicating, everyone's got the same model that they're following in terms of that chronic-pain model and that multidisciplinary approach and that self-management approach, which is so important.

So, communication between professionals is really important. The language we use is also really important. So, we know that if a person goes in to see their GP or their physio, their physio might tell them that their spine is out or their disc has gone out. I'm not quite sure where their disc has gone, but patients will hear that and, of course, that's going to instill fear or uncertainty. So, the type of language that we use with our patients is also really important in thinking about what message we're actually giving them. This comes down to x-rays and other scans. So, often these reports will show us what's going on in somebody's structure, but we also know that x-rays and pain aren't correlated very well. So, it's about demystifying those reports and reassuring the patient that their body is fine, and it is their pain system that's firing off or hypersensitive, and that's what we need to be managing.

Dr Jill Thistlethwaite:
Thank you. Sarah, in terms of the information that you've received and the conversations that you've had throughout this journey, what's been some of the things that have been helpful to you in terms of communication?

Sarah Fowler:
I think that, again, that individual approach is really important. So, I'm someone who comes from a very scientific background and there's moments that I vividly remember having things explained to me in a way that I understood. And it just meant that I really felt like I knew what was happening in my body which is the scariest part of chronic pain. The scariest part is not knowing what's going on in your body, and having that explained to me in a way that I could understand, even as a 12-year-old, but also just in a language that I understood, was really important. And I think that that communication between the different parts of your team, so that they're continuing to communicate in a way with you that is really valuable to you is really, really important.

So, I think that language can be really important and also that communication between professionals because it can be very hard to repeat your story or try and remember something that one specialist said and bring it to the next specialist and tell them. It can be very draining. And I encourage all people with pain to be their own advocate and do what they can and be in control of their own health goals. But if you have that support, if other people are on your side and they're helping you with those goals, then it makes a really big difference. I think that's really important and I really agree with what Tania said.

Dr Jill Thistlethwaite:
And what do you see as the role of the GP or your GP in this whole process?

Sarah Fowler:
My GP is often, particularly if you're an outpatient, the person that brings everything together. They bring together all the specialist reports that don't really make a lot of sense but [which] you still get sent, and they bring that information together and make something more clear to you. And they can also make sure that the information is being communicated across all the different specialists. So, they're really a key communicator to the patient as well because they know the patient probably best in a lot of circumstances, but also communicating to the specialists.

Dr Jill Thistlethwaite:
And, Tania, are there any particular resources you recommend to patients that they can use to help their self-management or that give them extra information to read at home or anything like that?

Dr Tania Gardner:
Absolutely. So, I think the first one is our online pain management program called Reboot Online, which is on the THIS WAY UP platform. So, this is [a] multidisciplinary online pain program that we've adapted from our face-to-face program, and it really provides someone with eight modules, going through all of the different aspects of chronic pain and [attempts] to teach people those skills that they could be using to manage their chronic pain. So, that's a great resource, particularly for those people that can't access face-to-face programs, [for example] people who [live in] rural or regional [areas], people who've got family or work commitments that can't attend face-to-face programs. And we know in the last 12 months with COVID, we've had that extra pressure of not being able to do any face-to-face programs, so those online pain management programs like Reboot Online have been a great resource. And that's got all the information as well as those skills-based tools, a movement station, a relaxation station. So, it's really the whole shop.

Apart from that, there's a lot of great resources. The ACI, which is run by the NSW government has got a great chronic pain website with information for both patients and health professionals. So, that's a great resource that I also recommend.

Dr Jill Thistlethwaite:
And do you have any recommendations for other things for GPs around the management of chronic pain?

Dr Tania Gardner:
The ACI website's got a great tool kit. It's got a great outline of where to go in terms of deprescribing, and then also all of the other strategies that you could recommend for your patients.

Dr Jill Thistlethwaite:
And NPS MedicineWise has some resources on our website, particularly around, as you mentioned then, deprescribing opioids, down-titration, and also having conversations with patients around some of these difficult areas because it can be, as we know, very difficult and challenging for everyone who's involved.

Dr Tania Gardner:
Exactly.

Dr Jill Thistlethwaite:
Sarah, is there anything else you'd want to say, something that we haven't touched on yet that you think's important?

Sarah Fowler:
On that conversation, definitely some of those resources can be really valuable to the consumers as well, and just thinking about giving those resources to the patients and making sure they have some reputable resources I think is really important because there is lots and lots of information on the internet and groups, and that is amazing. But having some reputable information to go to because, no matter what, your patient is definitely going to go home and Google it. So, if they're going to Google it, they might as well Google somewhere where they're going to get really beneficial information. And yes, it's really encouraging to see that NPS MedicineWise and others are engaging with consumers as well. So, those GPs are getting a consumer's perspective when they're looking at ways to reduce opioids because it can be a really daunting process, and even though it might seem easy for some, [for] the person in pain it can be really difficult. So, having that education behind it, always great, always really good.

Dr Jill Thistlethwaite:
And, Tania, anything else you'd like to say on this?

Dr Tania Gardner:
Yes I think with the deprescribing and that conversation with your patient, I think that is difficult for both the clinician and patient, and I think there's a lot of distress often associated with that deprescribing. So, it's about understanding that it is a distressing thing for patients, and being able to sit with that distress and just reassure yourself that it is what is needed to be done, but there are other tools and strategies that you can help your patient with.

The other thing I would also say is that patients need some time to process the chronic pain model. We're asking them to change their belief systems and change behavior in the long-term, and this takes a bit of time. So, we almost say that we drip feed that information to patients, and they're not always going to just hear it once and get it. You need to be drip feeding that information, repeating that information over a period of time until that patient's been able to process that, accept that model, and then be ready to change behaviour. So, you need to allow that patient to reach that point in their own time as well.

Sarah Fowler:
I really agree with that point. It is a difficult thing to process and it does take time, and it often can be difficult and overwhelming to have all that information. But, surprisingly enough, most people don't like taking the medication in the first place and you're providing them [with] an alternative that could be better. So, that should be a really positive thing for them, to empower them. You can actually do this without the medication and without those side effects. So, it can be a really positive thing. It's just sometimes a bit scary.

Dr Jill Thistlethwaite:
Sarah, can you remember that point maybe when the emphasis was not on curing your pain, if that was something that was there at the beginning of your journey to that pain management model?

Sarah Fowler:
I remember sitting down with a nurse in the hospital, and they sat down and really started to explain that pain model to me. And I was honestly relieved because I had spent years not knowing what was wrong. And even though it wasn't this perfect cure, which in medicine it normally isn't but a lot of consumers think it is, it just provided me with so much clarity in that moment, and just hope. I felt so much hope that I actually had somewhere to go and a path, and something that I could achieve. So, I was a very determined young lady, and it was actually a really good moment for me, and I still remember it so vividly. So, sometimes it's actually understanding [that] can really make a big difference.

Dr Jill Thistlethwaite:
That's such a powerful message for everyone who's listening and it's so refreshing to hear about this optimism, and that there are things that we as GPs and doctors, and other health professionals can offer other than medication. So, it's really been great to hear your conversation and your experience, and thank you, Tania, as well, for your input. So, I'd like to thank both of you today and say to listeners if you'd like to find out more about the opioids program from NPS MedicineWise or the TGA reforms, we will put some links in the podcast description for access to those. I'd also invite listeners to view our ‘If Not Opioids, Then What?’ program on the NPS MedicineWise website and to send in any questions or suggestions for future podcasts via Twitter, LinkedIn, or the NPS MedicineWise website. Thank you both.

Sarah Fowler:
Thank you for having me.

Dr Tania Gardner
Thank you.