GP Toolkit

1. Display a sign explaining your opioids policy to patients.
   Click here for practice sign.
2. Register with the Prescription Shopping Information Service (PSIS).
   Register with PSIS.
3. Familiarise yourself with the Medicare items for chronic disease management to minimise remuneration pressures. 
   MBS items for chronic disease management.

1. Assess current pain using the 3-item Pain Intensity, Enjoyment of Life, General Activity (PEG) scale.
   Click here for the PEG scale.
2. Avoid providing a script at the first appointment. Use the Opioid Patient Plan to explain to patients the need for a follow-up appointment for a detailed assessment and to develop a careful treatment plan.
   Click here for the Opioid Patient Plan.
3. In rare cases you could provide a short-term script (≤ 1 week) prior to the detailed assessment.
4. Encourage patient to watch a 5 minute video about chronic pain, either in your office or when they get home.
   Click here for the video.
5. Order any tests you require and book the follow-up appointment. In the meantime you could:
   a) Check for doctor shopping with the PSIS;
   b) Contact the Chronic Pain Clinic at Orange Base Hospital. Dr Claire Sui (Pain Specialist) is very happy to discuss your patient plan with you (note: you can leave a message with the triage nurse, Gizelle Kircher). 
   c) Consider developing an active (non-opioid) pain management plan – try using a mental health plan and/or making a referral to an allied health professional (e.g. psychologist) in your area.

1. Readminister the PEG and compare with previous responses.
   Click here for the PEG scale.
2. Avoid initiating opioids for chronic non-cancer pain altogether.
3. Focus the treatment plan on active management strategies rather than reliance on opioids for pain management – try using a mental health plan and/or making a referral to an allied health professional (e.g. psychologist) in your area.
   Click here for active management strategies.
4. If you decide to prescribe opioids, expert consensus is that you should first consult a pain and/or addiction specialist if you plan to prescribe:
   - for more than 90 days
   - more than 100mg morphine-equivalent units per day;
5. For patients already using opioids, use the Opioid Patient Plan to explain the need to develop a treatment plan that is less reliant on opioid scripts. Plan to taper and cease their opioid use within 90 days.
   Click here for the Opioid Patient Plan.
6. Access the opioid rotation and dose conversion information if required.
   Opioid rotation and dose conversation information. 

1. Monitor pain progress using a standard tool such as the three item PEG.
   Click here for the PEG scale.
2. Assess changes in patient progress and outcomes against the 4 A’s: effectiveness of analgesia; impact on activities of daily living; adverse effects; and unexpected or aberrant behaviours (aberrant behaviours can be assessed using the 10-item Opioid Related Behaviours in Treatment (ORBIT) scale).
   Click here for the ORBIT scale.
3. If improvements are not observed, taper and cease opioid treatment ASAP.
4. Seek further advice from a specialist such as Dr. Rod Macqueen (Addiction Physician) or Dr Craig Sadler (Addiction Medical Specialist)  and/or refer the patient for a thorough mental health assessment (use a mental health plan and/or allied health referral).
   

Links

Hunter Integrated Pain Services (HIPS) Opioid Quick Steps (OQS).

Relevant MBS items for chronic disease management.

Information about active pain management strategies.

Video vignettes developed for the GP education session

The following 2-3 minute video vignettes of doctor-patient interactions were developed by Dr Simon Holiday in consultation with Medical Educators from General Practice Training Valley to Coast. They were used in a chronic pain education session developed for two NSW Health MHDAO-funded studies (2013-2014), one examining community-level interventions to improve GP prescribing of opioids, and the other evaluating a chronic pain intervention for GP trainees/registrars. These aimed to increase immediacy, illustrate negotiation skills and enhance group dialogue.

The first vignette involves the doctor seeing an inherited CNCP patient for the first time who requests a repeat opioid prescription (Part 1). The following two scenes (Parts 2 and 3) illustrate the development of functional goals, an opioid agreement, the implementation of monitoring/review, and dose escalation. The final scene (Part 4) demonstrates increasing aberrant behaviour.