What I did before
Chronic pain is under-recognized and under-treated. It affects people of all ages, races and socioeconomic class and there are many different types of chronic pain. In Canada, one in five people suffer daily from chronic pain. Our patients with chronic pain have unique and complex needs often needing longer office visits. It can be very challenging to help patients to navigate the health care system. As a family physician it was difficult to discuss issues in a systematic, integrated and holistic way within a short office visit. Given our heavy patient loads and current billing paradigms, family physicians are challenged to meet the educational needs of chronic pain patients as pain education and self-management training takes a lot of time.
What changed my practice
Two websites have changed my practice.
1) The www.PainBC.ca website has changed my practice because it provides options beyond medications. It is a one stop website with BC resources, ideas and methods to help support patients outside of our office. By downloading the pain toolbox from the website I feel I’m better able to engage and support my patients in the management of their chronic pain. Some suggested goals of referring patients to this resource include:
- Engaging people living with pain in a self-management paradigm that allows them to begin learning the process of taking back their life. The website provides information on specialized health care providers, and community, government, and academic partners.
- Providing education for people living with pain, their family friends and other health care providers
- Facilitating our office visits to become more productive by providing referral and reference resources.
2) The People in Pain Network (PIPN) (http://www.pipain.com) hosts an online pain self-management course called the Pain Toolkit for people who can’t get to one of the face to face programs available or who have done a program but want more information. The PIPN online course can be a great resource for those who cannot attend in person support group sessions. Many patients find it helpful for ongoing help after they have completed a program either in the community or at a hospital or private pain clinic (via WBC for instance). The website also provides information on pain support meetings and upcoming webinars and broadcasts about chronic pain.
What I do now
The key for the busy family physician is providing the information above in manageable chunks and approach care plan negotiation in partnership with our patients.
Now, with all of my patients with chronic pain, in addition to providing referrals, investigations, specialist consults, and medication changes and renewals; I can offer education and self-management resources. I negotiate with patients the agenda to discuss self-management during regular monthly follow-up appointments which is important for pharmaco-vigilance and a encouraging a systematic comprehensive approach to care. One of my patients reminded me that it’s important to match this intervention to where they are personally in the stages of change. Patients need to be ready to change prior to introducing this concept, to even suggest some homework and book series of follow up visits.
For patients who are in the action phase of change and want to start an online pain management course, I am now recommending patients look at the PAIN TOOLKIT course at http://bcpaintoolkit.pipain.com/. This is a simple online guide on principles of self-management for patients with chronic pain. Another method to identify patients who would benefit from this resource is to ask some screening questions. Dr. Squire has found the following screening questions helpful to identify patients who might benefit from being referred to the online pain tool kit course. She often asks, “Who is on their team? How do they use pacing in their life (to manage pain)? (When managing their own chronic pain) What do they know about prioritizing and/or What relaxation skills do they use?” If patients don’t know the answer to these questions or if they agree they could use some help in one of the areas, this indicates that a review the principles of self-management that the Pain toolkit teaches would be helpful.
The second step I am beginning to recommend or demonstrate to patients showing them how to access the PAIN TOOLBOX at Painbc which has an extensive list of topics to discuss at subsequent visits and community resources to attempt to access to support pain self-management. The Personal Toolbox of Pain solutions, which was created by Drs. Squire, Williamson, Lau, Gromala and Pearson, has helped me change the way I think about organizing my chronic pain visits. Using the Toolbox, I instantly have a potential list of topics I can divide into manageable chunks and prioritize topics for future visits. It is important to carefully review each topic with patients during a one on one visit. If not, I’ve found simply giving your patient the website can be overwhelming and patients may not actually follow through unless the family physician leads the way.
For example, I would say, “Here is a list of important topics we could cover over subsequent visits. Which topics do you want to prepare for and read prior to our next visit?”
- Pain self-management and pain education courses
- Improving sleep
- Changing your mind and changing your pain
- Mind body medicine for pain relief
- Getting help-support for people with pain and disability
- Exercise and Progressive Activity
- Lifestyle changes
By recommending the pain toolkit as a guide to the approach to self-management in chronic pain and the pain toolbox as a resource for dealing with the issues that affect chronic pain, the busy family physician can make a visit less about prescription refills and more about building new coping skills. The visit can be made more efficient and effective by setting the ground rules early with the patient on dealing with one or two of the topics for each visit. Moreover, inviting the patient to become part of a support group can be an important therapeutic goal of encouraging them to explore external supports. An example of what is available on the Pain BC Website is a link to the BC Chronic Pain Self Management Program . This program is a local peer taught self-management program where patients can sign up via www.coag.uvic.ca/cdsmp or 1-866-902-3767. Finally, the PainBC website also provides lists of chronic pain multidisciplinary clinics and specialized care at painbc.ca/content/pain-clinics-and-services which can be helpful in explaining and arranging for the long term plans with patients.
In closing, for physicians managing patients with chronic pain, nothing can replace common clinical sense and it is vitally important to practice the principles of pharmacovigilance. It is essential that we are all aware of and try to implement some of the recommendations of the Canadian Guidelines for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain nationalpaincentre.mcmaster.ca/opioid which can be a guide for dealing with our patients.