The pharmacological management of pain in older Australians

Nearly all humans experience acute pain during their lives. Generally, acute pain is short lived, however, up to 20% of adults globally suffer from persistent pain. This prevalence increases with age with up to 50% of elderly people in the community setting and 80% in aged care facilities (ACFs) experiencing persistent pain. Pain, whether acute or persistent can create a significant burden and cost to the patient and society as a whole, through reduced work productivity and health care costs. In the financial year ending June 2014 analgesics (excluding anti-inflammatories) were the fifth most commonly dispensed class of drug on the Pharmaceutical Benefits Scheme (PBS) in Australia. Six of the top 50 medications on the PBS, by volume, were analgesics or anti-inflammatories. The most frequently dispensed analgesics were paracetamol (with over 6.4 million prescription), followed by paracetamol and codeine (with approximately 3.8 million prescriptions) and then oxycodone (with approximately 3.7 million prescriptions). These figures parallel research findings in Australia and other countries that have found that the consumption of analgesics, particularly opioids, for persistent pain has increased dramatically over the past decades, as a consequence of significant societal reliance on the pharmacological management of pain. With pain being so prevalent in today's society, evaluating the way in which pain is managed pharmacologically, as well as identifying quality use of medicine (QUM) issues related to its management is paramount to ensure optimal patient outcomes. In addition, increased research activity in pain management has been recommended by the National Pain Strategy [Australia] and the Royal Australasian College of Physician's Opioid Policy, with a focus on assessing attitudes to pain, risk factors for persistent pain conditions and reducing the harms associated with pain management, particularly opioids. The overarching aim of this thesis was to identify barriers to pain management and make recommendations as to how these could be overcome. Specifically, the research objectives were to: ‚Äö Observe how pain is managed pharmacologically in Australian clinical practice; ‚Äö Identify predictors for persistent postoperative pain (PPP); ‚Äö Identify QUM issues related to the management of pain; and ‚Äö Identify barriers to pain management. These research objectives were investigated through a number of complementary papers, which are described in Chapters Three to Ten. This thesis initially describes the current literature surrounding the pathophysiology and management of pain, and then goes on to detail the eight studies completed as part of this thesis, which investigate the clinical management of pain and how pain management could be improved. The thesis concludes with a discussion about the main areas where QUM issues exist in relation to the management of pain and how these issues and barriers could be overcome. The study presented in Chapter Three evaluates nearly 170 patients who underwent an operation at the Royal Hobart Hospital (RHH), the major teaching hospital in Southern Tasmania, and discusses the management of pain by patients following discharge from hospital, and the provision of advice regarding pain management provided during their admission. This study found that management of pain by patients was often characterised by underuse of analgesics despite a significant proportion of patients experiencing moderate-severe pain. Additionally this study found that the content of the advice given to patients about pain management and consistency in personnel who provided this advice was highly variable. From this study, it is clear that there is the need for significant improvement in discharge counselling to ensure that patients have sufficient knowledge to safely and adequately self-manage their pain following a hospital separation. Chapters Four and Five follow patients who underwent orthopaedic surgery or a sternotomy at the RHH for a period of 12 months to evaluate how patients manage their pain throughout this post-surgical period, the effect the pain had on their physical function, the incidence of and potential predictors of PPP and ways to improve pain management. These studies identified a number of patient factors associated with PPP, including pre-operative anxiety, pre-existing pain and younger age. Uncontrolled pain following discharge and symptoms consistent with neuropathic pain following discharge were also associated with PPP, and this is an area that could be addressed to potentially reduce PPP incidence and severity. Chapters Six and Seven retrospectively evaluated nearly 20,000 Australian patient medication reviews, to identify the prevalence of analgesic use, how analgesics were used in clinical practice and ways that pain management could be optimised. These studies found a lack of concordance between guideline recommendations and the management of pain; specifically maximum opioid doses being exceeded, concurrent use of opioids and benzodiazepines, low use of laxatives in combination with opioids and a failure to optimise use of non-opioid analgesics in patients prescribed opioids. The final three studies report on the perspectives of general practitioners' (GPs), anesthetists' and nurses' regarding enablers and barriers to optimal pain management and identify ways in which pain management could be improved. Through these complementary studies, a number of barriers to optimal pain management were identified, including: - Patient stoicism and reluctance to take analgesics; - Inadequate understanding about pain and its management by patients and health care practitioners; - Poor and variable post-surgical discharge counselling and patient resources regarding pain management; - Poor access to pain clinics and allied health professionals; - Slow hospital-GP communication following a surgical admission; - A lack of involvement of pain specialists following surgery to manage pain; - Difficulties in the identification of pain in patients with dementia in ACFs; and - Poor GP-ACF communication regarding escalation of analgesic orders. Based on this research a number of recommendations are suggested to improve the management of pain in Australia. These include: - Increased education and training about pain and its management to undergraduate, graduate and qualified health care practitioners working with patients who experience pain; - Increased patient education regarding pain, analgesics and expectations of treatment; - Improved involvement by pain specialists or the Acute Pain Service (APS) following a surgical procedure and at discharge; - Improved and consistent discharge counselling and post-discharge resources for patients who have undergone a surgical procedure; - Increased access for persistent pain patients to funded multidisciplinary services including pain clinics, psychologists and physiotherapists; and - Further research evaluating the effectiveness of the interventions suggested in this thesis, including pharmacist education of patients in GP clinics, increased patient education on surgical discharge, pain specific follow-up after surgery, and the development and validation of a PPP assessment tool. In summary, pain is currently not well managed in primary care settings by patients or GPs, and there is the need for improvement to optimise patient outcomes. Improved counselling, follow-up and management of post-discharge pain have the potential to reduce the incidence of PPP, and at a minimum, improve the quality of life (QOL) and potential for patients to participate in rehabilitation following surgical discharge. Additionally, improved GP concordance with guidelines and recommendations may allow for a reduction in harms associated with the use of opioids. These small changes in practice have significant potential to improve patient outcomes and the management of pain in Australia without the need for substantial increases in funding or policy change.