How to introduce the Pain Toolkit to patients
An excellent video by Dr. Frances Cole giving a step-by-step guide as to how to introduce the Pain Toolkit.
Assessment - Identifying patients with complex pain.
It can be useful to use the two questions below to help identify more complex pain.
During the past month, has it often been too painful to do many of your day-to-day activities?
During the past month, has your pain been bad enough to often make you feel worried or low in mood?
If the individual answers yes to both questions then using the Persistent Pain Cycle tool to guide a fuller assessment and care planning over the next consultation or two.
A collaborative person centred approach focused on the individual’s physical, emotional and life issues is starting point.
This can identify factors likely to predict persistent pain, disability and distress.
Factors linked to increased pain related disability
- Body Symptoms: higher pain intensity or longer pain duration; multi-site pain; higher physical disability.
- Moods: depression; anxiety including Post Traumatic Stress Disorder; Anger and perceived injustice; low confidence to self manage.
- Cognitions: catastrophic thinking patterns about pain experience; self perceived poor health.
- Behaviours: passive coping; on-going pursuit of cure “quick fix”.
- Look for with the patient for their stress factors that contribute or worsen the stress of pain.
Non modifiable factors
- Age, Sex, Cultural background.
- Socio-economic background.
- Injury or interpersonal violence/trauma.
- Heritable factors.
A useful tool is the Persistent Pain Cycle tool which helps both clinicians and patients explore currently the way pain is affecting the person and their life in many ways. It helps shift the conversation for some patients from a “seek, fix and cure” to a more “cope, control and manage” approach. This applies to those with emerging risk of persistent pain where using the Start Tool and the identified psychosocial factors means taking an active approach in enabling the person to:
- Build fitness and confidence.
- Reduce focus on pain itself.
- Maximise function and aspects of life such as work, study.
The Patient Health Questionnaire (PHQ-9) is also a useful tool for assessing depression. The LWP service can accept patients with moderate depression (Score of 14 and below) but as there is no clinical psychology support are unable to mange patients with more severe depression (those who score 15 and above).
Using consultation time
It can be very difficult in the short consultation to identify when pain is already or becoming a major health problem. Many patients are managing their pain and their health well and we do not want to over-medicalise them. However, there are many who will require additional help to support them to minimise the risks of long-term pain.
Experienced GP’s share that several consultations are needed. These then gives continuity and emphasis on empathy, therapeutic relationship and coaching / supporting self-management which makes the difference to patient outcomes. Research evidence from patients say exactly the same thing and it leads to up to 50% reduction in GP consultations and attendance in the long term.
Dr Tim Williams a GP and Community Pain Specialist from Sheffield has developed video called ‘Top Ten Tips for Primary Care Management’ to support GP’s & Health care professionals. Tim’s tips are to help the GP when seeing patients with pain, which can be seen here:
Dr Williams has also produced a hand out for GP’s explaining his tips.
What is persistent pain?
This is a “tricky” condition to explain to patients, as changes in the pain nerve system function are multiple. These include:
- Increase sensitivity of pain receptors in skin, muscles, joints and other areas.
- “Windup” process of multiplication of the messages at the spinal cord dorsal horn area.
- Loss of synchronisation of neural process in the brain to handle pain messages effectively. Loss of inhibition of pain messages input into brain i.e. the descending spinal nerve inhibition.
The Explain Pain leaflet is a good resource to give patients, to help them understand why pain persists. It and can be downloaded here.
A useful video to recommend to the patient is the “Understanding Pain: What to do about it in less than five minutes?” It is has a very simple messages about how pain works, and what to do about it. Many clinicians have found viewing this resource themselves is informative. It is useful as it enables a common and clear understanding between clinician and patient of the faulty neural processing system problems in persistent pain. It can form a common consistent language to help manage the complexity of pain.
Within the patient section of this site are same video links so patients can see to learn more about processing problems of faulty pain systems. Here is a useful video based explanation about faulty pain systems by Lorimer Moseley ‘Body in mind - the role of the brain in chronic pain’,
Aspects of pain management in primary care
- Focus on self-management using Pain Toolkit with patients is crucial.
- Share consistently core messages about maintaining and building fitness.
- Reducing or stopping smoking.
- Healthy eating (Mediterranean diet).
- Key self management skills including, pacing activities, setting fitness, activity, relaxation and fun goals.
Management of course also includes:
- Trial of useful medication options to reduce some of the pain experience.
- Regular medication reviews including reviewing medication’s actual use, timing, dosage etc.
- Assessing and managing moods, depression, anxiety, anger and others including drug treatment and/or talking therapies referral or link to counselling service. Bereavement /grief at loss of self identity and struggling to find / develop new sense of self can benefit from talking therapies such as counselling.
- Setback support and planning; acceptance setbacks happen and support robust plans to self manage can be crucial to reduce their severity and duration and use of health care.
A useful resource to guide management of persistent pain is the Ten Top Tips summary by GP Dr Tim Williams who has special interest in managing pain.
Below are links to Neuropathic medication information approved by Greater Manchester Medicines Management Group (GMMG)
- GMMMG Neuropathic Pain Guidelines.
- Neuropathic pain tool for GP’s and Patients.
- Pain medication and injections.
- Analgesic formulary GMMMG.
- New Drug Recommendations.
- NHS Choices.
Information prior to initiating strong opioids for professionals and patients:
Patient Information Leaflets (PIL's)
- Patient Leaflet Amitriptyline
- Patient Leaflet Gabapentin Rapid Titration
- Patient Leaflet Gabapentin Slow Titration
- Patient Leaflet Nortriptyline
- Patient Leaflet Pregabalin Fast Titration
- Patient Leaflet Pregabalin Slow Titration
Visual resources to show patients
Pain & Self-Management Videos for patients (these are really good short engaging videos to show or signpost patients to)
- 3 Minutes to Think About Chronic Pain.
- 23 and 1/2 hours: What is the single best thing we can do for our health?
- 24 Hour Fitness - 23 and 1/2 Hours.
- Back Pain.
- Expert Patients Programme Manchester.
- Pain Toolkit animated version.
- The Expert Patients Programme - a brief introduction.
- The single most important thing you can do for your stress (good video to show in the service if minimising stress is a goal).
- Understanding Pain: What to do about it in less than five minutes?
- Understanding Pain: What to do about it in less than ten minutes? (ideal for young people)
- Whats the best diet, heathy eating.
- What is the Single Best Thing You Can Do to Quit Smoking? (good video to show in the service if stopping smoking is a goal).