Pain ManageMent
An innovative project has been
helping people with chronic pain
cut their use of dependence-
forming medications. Change
Grow Live’s Robert Ralph
describes how it was done
Less pain,
more gain
O
piate medications don’t work for
chronic pain – in fact they often
make it worse. In a recent pilot
scheme in Hastings run jointly by
Change Grow Live’s East Sussex drug
and alcohol recovery service (STAR)
with local GP surgeries, 235 patients were assessed
and supported to manage their pain and wean them
from opiate medications. Sixty were fully weaned and
a further 57 reduced to a safe and sustainable level.
The results were startling. Patients who weaned
from opiates reported an average 19 per cent
improvement in their quality of life, significant
reductions in anxiety levels, improved sleep, less
constipation – and no increase in pain. Early
indications also suggest a further reduction in GP
appointments following weaning of as much as 20
per cent – a huge cost saving, especially when added
to the £31,000 per annum saved in medications.
In addition a group work programme was
developed that supported patients with a range of
self-management techniques for pain. The isolation
caused by chronic pain leads to a wide range of
problems, and the group found it useful to spend
time together connecting with others who truly
understood their issues. In fact, the core of the group
has continued to meet and, with support from
Change Grow Live (CGL), is setting up a community-
based peer support group for chronic pain sufferers.
Moderate to severe chronic pain – that is, pain
that continues for more than 12 weeks – is thought
to affect around 18 per cent of the UK population.
GPs have traditionally prescribed opiate medications
such as morphine, fentanyl, buprenorphine and
oxycodone, as it was thought that – provided they did
not over-sedate, cause overdose or other severe
reactions – it was safe and there was little else that
could be done for these patients.
A broad definition of dependence-forming
medications encompasses GABAergic medicines,
benzodiazepines and Z-drugs such as zopiclone, and
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the prescribing of these has been increasing (with the
exception of benzodiazepines). In 2000, 6 per cent of
the UK population were prescribed at least one of
these types of medicines, but by 2015 this had risen
to 9 per cent.
Hastings and Rother CCG looked at GP surgeries
locally and were able to identify those with the highest
rates of opiate prescribing. CGL were then contracted
to provide a pilot scheme alongside The Station
Practice in Hastings for one year from February 2018.
The pilot worked in two phases, with the first half
of the year a multi-disciplinary team (MDT) approach,
and the second half CGL-led with limited GP support
and expansion into a second practice. The MDT
approach showed the greatest results, but also used
the most resource. The CGL worker engaged patients
with an above 120mg morphine daily equivalent, as
well as patients prescribed polypharmacy opiates or
other DFMs.
Engagement was key – someone listening to
patients’ stories was an incredibly powerful
experience for them, as most clinical staff are usually
unable to take the time to do this. Motivational
interviewing was used to support movement towards
change, both with lifestyle and medication, and
mindfulness, TENS machines, sleep hygiene, and
referral to other agencies were also key in fully
engaging patients.
Once a week for half a day a dedicated GP was
available and MDT practice appointments were run
alongside the CGL worker – these were 20-minute slots
that allowed time for holistic interventions for a wide
range of health issues. Patients were provided with a
‘Hastings pain toolkit’ to assist with self-management
of pain and lifestyle, which included links to other
useful resources. A surgery pharmacist was also
involved to provide follow-up support and discuss
medication with patients by telephone. The MDT team
has been nominated for this year’s BMJ awards in
general practice, and has reached the final five.
During the second half of the year the CGL worker
Long-term prescription
of opiates can lead to a
faulty pain system, with
the medications starting
to ‘drive’ the pain.
was spread across two GP surgeries, carrying out the
same interventions without the MDT clinic. This
approach was less resource intensive, yet still wielded
some promising results.
Future plans – provided appropriate funding can
be secured – centre around whole-surgery
approaches, with all GPs supporting the programme,
referring to a DFM worker for assessment, and most
psychosocial and self-management of pain support
taking place in a group setting. A similar trial is due to
begin soon in Worthing, supported by CGL.
This is an often-neglected cohort of patients, who
suffer daily and are often left ‘parked’ on large doses
of opiates that have devastating long-term effects on
their life, affecting their memory and digestion,
accelerating osteoporosis, and potentially damaging
their immune systems or causing fatal overdose.
Long-term prescription of opiates can also lead to
a faulty pain system, with the medications starting to
‘drive’ the pain. But these effects can be reduced or
negated through a combination of psychosocial
support, a change in pain management techniques
and judicious use of pain relief medications. After all,
who wouldn’t want an 18-20 per cent improvement
in their overall quality of life?
Robert Ralph is dependence forming medications
lead at Change Grow Live (CGL)
May 2019 | drinkanddrugsnews | 9