Curriculum standards
Knowledge guides
LG 23: Pain and dependence
Key presentations and conditions
Advanced Trainees will have a comprehensive depth of knowledge of these presentations and conditions.
Less common or more complex presentations and conditions
Advanced Trainees will understand these presentations and conditions.
Advanced Trainees will understand the resources that should be used to help manage patients with these presentations and conditions.
Epidemiology, pathophysiology, and clinical sciences
Advanced Trainees will have a comprehensive depth of knowledge of the principles of the foundational sciences.
Investigations, procedures, and clinical assessment tools
Advanced Trainees will know the scientific foundation of each investigation and procedure, including relevant anatomy and physiology. They will be able to interpret the reported results of each investigation or procedure.
Important specific issues
Advanced Trainees will identify important specialty-specific issues and the impact of these on diagnosis and management, and integrate these into care.
Presentations
- Acute pain in the opioid tolerant patient in inpatient and outpatient settings
- Chronic pain with cannabis dependence
- Chronic pain with opioid dependence
- Chronic pain with other dependence, such as:
- alcohol
- methamphetamine
- Chronic pain with overdose / toxicity, due to substances such as:
- analgesics
- opioids
- sedating medicine
For each presentation and condition, Advanced Trainees will know how to:
Synthesise
- recognise the clinical presentation
- identify relevant epidemiology, prevalence, pathophysiology, and clinical science
- take a comprehensive clinical history
- conduct an appropriate examination
- establish a differential diagnosis
- plan and arrange appropriate investigations
- consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
- provide evidence-based management
- prescribe therapies tailored to patients' needs and conditions
- recognise potential complications of disease and its management, and initiate preventative strategies
- involve multidisciplinary teams
Consider other factors
- identify individual and social factors and the impact of these on diagnosis and management
Presentations
- Pain in palliative care patients with opioid and/or other substance dependencies
For each presentation and condition, Advanced Trainees will know how to:
Synthesise
- recognise the clinical presentation
- identify relevant epidemiology, prevalence, pathophysiology, and clinical science
- take a comprehensive clinical history
- conduct an appropriate examination
- establish a differential diagnosis
- plan and arrange appropriate investigations
- consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
- provide evidence-based management
- prescribe therapies tailored to patients' needs and conditions
- recognise potential complications of disease and its management, and initiate preventative strategies
- involve multidisciplinary teams
Consider other factors
- identify individual and social factors and the impact of these on diagnosis and management
Epidemiology
- Determinants of opioid use for chronic pain
- Differences between current International Classification of Functioning, Disability and Health (ICF) and Diagnostic and Statistical Manual of Mental Disorders (DSM) regarding problematic opioid use
- Harms associated with prescribed medications for chronic pain
- Population patterns of prescribing opioids and other high risk
- Prevalence of chronic pain, and chronic pain with co-occurring substance use disorders
- Role of industry in promotion of non-evidence based treatments
Pathophysiology and clinical sciences
- Biopsychosocial approach to understanding and managing chronic pain
- Cannabis and cannabinoids and chronic pain – efficacy and risks
- Central sensitisation in the development and maintenance of chronic pain
- Common analgesics, including:
- efficacy and risks
- evidence around opioid efficacy and harms in chronic pain
- full opioid agonists
- pharmacology of opioids and other analgesics
- Gabapentinoids, tricyclics, and other medications for neuropathic pain, including:
- hyperalgesia and neurobiology of nociceptive systems and anti-nociceptive homeostasis
- methadone, oral
- neurobiology and pharmacology
- neuropathic
- nociceptive
- Opioid / Analgesic stewardship, specifically the universal precautions in opioid prescribing, such as good prescribing practice
- Opioids and pain, specifically:
- buprenorphine sublingual tablets
- pain experience and behaviours
- risk factors for development of dependence in pain patients
- tolerance and withdrawal – biology of neuroadaptation
- types of pain and underlying neurobiology
Rationale
- The increased risk of harm in long-term use of opioids in the management of non-cancer pain, including:
- death
- dependence
- hyperalgesia
- loss of function
- toxicity
Investigations
- Effects of age on test performance of investigations, particularly specificity
- Risks and benefits of imaging in the evaluation of chronic pain
Measures
- Clinical outcome measures
- Discharge planning, including reviewing and rationalising analgesics, and appropriate handover to primary care
- Evidence-based interventions
- Opioid risk tools
- Standard withdrawal measures
Acute pain
- Acute pain management in the opioid tolerant person
- Options for continuation / modification of opioid pharmacotherapy in context of acute pain in hospital settings
- Pharmacological approaches for acute pain in inpatient and community settings
- Switching opioids from one type to another, such as from normal route to IV
- Working with acute pain services
Palliative care
- Advocacy for patients with substance use disorders to receive good palliative care
- Efficacy of opioids in palliative care setting
- Handover issues
- Managing opioids in long-duration palliative care patients
- Modification of opioid replacement treatment in palliative care patients
- Multidisciplinary approaches
- Working with palliative care professionals
Chronic pain
- Awareness of guidelines for opioid prescribing in chronic non-cancer pain
- Cannabis and cannabinoids risks and benefits
- De-identifying documents for potential allied health professionals to use if unable to access a multidisciplinary chronic pain service, such as:
- exercise physiologists
- occupational therapists
- physiotherapists
- psychologists
- Deprescribing – benefits, indications, and risks
- Educating patients, and reaching a common understanding of their situation
- Gabapentioids, tricyclics, other antidepressants, and anticonvulsants
- Multidisciplinary rehabilitation principles
- Non-pharmacological approaches to chronic pain, including:
- cognitive behavioural therapy (CBT)
- mindfulness-based treatments
- Online sources of information for patients on non-pharmacological approaches to chronic non-cancer pain (CNCP)
- Patients on opioid substitution treatment prescribed additional opioids or sedating medications by other health practitioners
- Pharmacological approaches to CNCP
- Prescribe therapies tailored to patients’ needs and conditions
- Procedural / Interventionist approaches to CNCP
- Recognise potential complications of disease and its management, and initiate preventative strategies
- Switching to opioid pharmacotherapy
- Working with chronic pain specialists
Synthesis and management considerations
- Aberrant medication use
- Advise regarding evidence-based management options, considering patient wishes, underlying diagnoses, and associated risks
- Consider developmental history, life experience, and co-occurring mental disorders in understanding patients’ circumstances
- Consider legal measures where capacity is diminished and other options have been exhausted
- Coordinate a multidisciplinary and sometimes multi-agency response
- Develop a therapeutic partnership with patients, and uphold their autonomy
- Functional assessments
- Historical use of all substances to relieve pain, including signs of iatrogenic opioid dependence, such as:
- alcohol
- benzodiazepines
- cannabis
- long-term prescribing of high-dose opioids and inability to tolerate deprescribing
- Past documentation
- Systems-based approach involving families, whānau, and/or carers, where relevant