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Managing pain 2019

The management of chronic pain is an important issue

Photo credit: iStock / Getty Images Plus / Benjavista

Dr Zaid Hirmiz GP

Musculoskeletal (MSK) Lead for NHS South Eastern Hampshire CCG, NHS Southampton City CCG and NHS Fareham and Gosport CCG

Dr Zaid Hirmiz, a GP and musculoskeletal lead, explains how new pathways for chronic pain can improve patient self-reliance and reduce opioid use.

“The management of chronic pain is an important issue,” says Dr Zaid Hirmiz, Musculoskeletal Lead for NHS South Eastern Hampshire CCG, NHS Southampton City CCG and NHS Fareham and Gosport CCG. Chronic pain can lead to absence from work, poor mental health and other social issues; we need better pathways to treat it.

Patients with chronic pain often have to attend multiple appointments. Dr Hirmiz envisages an integrated system, where the patient is referred just once, to the persistent pain team. This team is led by allied health professionals – such as physiotherapists and occupational therapists – and has access to input from rheumatology, orthopaedics and mental health (not currently available at all pain clinics).

The team would make use of symptom questionnaires and group therapy. The aim is to help the patient to manage their pain rather than continue what is often a futile search for a ‘cure’. In this way, the patient can become more self-reliant and opioid use may reduce.

Be careful when prescribing opioids

Dr Hirmiz uses opioids for some patients with chronic pain but always looks at the cause, being careful not to over-prescribe. An opioid may be appropriate for a patient with severe osteoarthritis, but less so for a patient with fibromyalgia where there needs to be more evidence about the effectiveness of opioids for these patients.

Southampton CCG have an innovative scheme whereby a pharmacist sees patients who are at risk of opioid dependency and support to reduce their opioid use. This involves working closely with GPs, introducing self-management ideas and resources and involving other agencies (including substance misuse).

Healthcare professionals should share their learnings around pain management

“Education is key” says Dr Hirmiz, who is keen for primary care guidance and education to be rolled out widely, alongside revised musculoskeletal (MSK) pathways based on solid evidence.

In his part of the UK, several CCGs are working together, and he has taken part in the NHS 2030 leadership programme, which aims to share good practice country-wide.

In some areas, pain team clinicians can offer advice and guidance to GPs before a referral is made.

What else can help?

Each CCG has a medicines management team; these teams can audit opioid use, to make GPs and patients more aware of the problem of high dose and /or long-term use. Dr Hirmiz feels that we need a fundamental shift in the way we think about patients on long-term opioids.

Keeping registers of these patients and inviting them for an annual review – specifically about their opioid use – would help to focus the mind of both the doctor and the patient, so that the NHS and patients continue to gain from the benefits of opioids while reducing the risks.

“For my patients, I recommend self-management tools (such as the NHS 24 MSK app), which provides them with exercises. The aim of the exercises is to help them to move normally and safely.”

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