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:
- 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
