Opioids and chronic pain
My colleague was handing over his patients. He was middle aged and burnt out, and after decades of working full-time at the same practice was finally extricating himself from the clinic. He wasn’t sure what he would do next. Maybe locum work – the doctor’s equivalent of a gap year.
Some say doctors get the patients they deserve. Most GPs would cringe at that, but most would also concede particular patients do seem to gravitate towards particular clinicians. My burnt-out colleague was fast-talking, efficient and eager to please. He gave patients what they wanted and he didn’t ask too many questions in the process. It’s fair to say that several doctors, myself included, found his patients a little challenging. Perhaps the most challenging of the bunch was a woman with chronic pain, whom I’ll call Jenny.
I’d seen Jenny a couple of times. Often it was for something simple while my colleague was on holiday – a script for one of her 20 or so medications, an extension of her Centrelink certificate – but even during these brief visits I’d always felt mildly uncomfortable. Maybe the other doctors had felt it, too, because when my colleague asked for volunteers to take over her care, nobody dared look at him.
I’m not sure what made me do it. Perhaps it was my intolerance for uncomfortable silence, or the creeping sense that I, as one of the more junior doctors, should “take one for the team”. Maybe it was just my embarrassment that a group of professionals could act so unprofessionally. Whatever the cause, I volunteered to look after Jenny for the foreseeable future. If she’d have me.
I spent the first visit gathering a detailed history. Like most of the three million Australians with chronic pain, Jenny was female, of working age, and could trace the origins of her pain to an injury. In Jenny’s case, the injury was relatively minor but the impact on her life was devastating. Prior to the injury, she had been a busy, high-functioning, working woman. After the injury, she was lucky if she could get out of bed in the morning.
When she spoke of her past self it was with a detached, almost wistful admiration, the way others might describe a first love or a celebrity. From this I gathered two things: first, that she had long given up hope of a full recovery; and second, that she had low expectations of me and of health professionals in general. I’m ashamed to admit that, rather than sadness or indignation, I felt relief at this realisation.
At subsequent consultations, we discussed her extensive list of tablets. A few had been started by her previous pain specialist, some had been prescribed by my GP colleague, others had been initiated during short stays in hospital. During her journey through the labyrinthine health system, Jenny had collected medications like a tourist collects souvenirs: there were opioids for the pain and laxatives to treat the constipation caused by the opioids; there were antidepressants for the coexisting depression, and sedatives for the insomnia associated with the depression; there were anti-inflammatories for the chronic inflammation and antacids to protect the stomach from the damaging effects of the anti-inflammatories.
I knew my first task would be to rationalise Jenny’s medications and the prospect of this task made me ridiculously nervous. I worried Jenny had grown attached to her pills after all these years. I feared they had become pharmacological comforters for her. The reality, however, was quite the opposite. Having failed to adequately treat her symptoms, Jenny was not overly loyal to her tablets. And she was sick of the side effects. Together we drew up a plan for a slow wean off her medications. At the same time, we spoke about multidisciplinary pain management clinics. I called around, made the necessary referrals.
Over the ensuing days, I saw glimpses of what I imagined was the old Jenny. She brushed her hair, wore lipstick and dressed in brightly coloured clothing. With fewer sedatives in her system, her speech was clearer, her movements quicker. Her eyes were wide and bright. Somewhat naively, I took great comfort in these early, subtle changes. But they were fleeting. Within weeks, Jenny’s pain had rebounded and she was back to unwashed hair and faded tracksuit pants.
Jenny and I spent the subsequent months negotiating the perilous tightrope between pain relief and sedation. We waited days and weeks and months for a place in a multidisciplinary pain clinic. And for days and weeks and months we were met with radio silence. On occasion, I thought of my colleague who had escaped to the twilight zone of locum work and I felt an unprecedented and powerful longing to join him.
Eventually, in the late stages of my second pregnancy, I handed Jenny over to another colleague. Once again she went to the youngest doctor at the clinic.
Jenny was still in my thoughts, however. In the final weeks of my pregnancy, I suffered from a severe and nagging pelvic pain. Every evening I went to bed, hoping my body would undergo a magical healing overnight, and every morning I woke to the heartbreaking discovery that the pain was still there. I cooked dinner in 10-minute shifts, lying on the couch for relief between steps in the recipe, and while I lay there, staring at the ceiling and swallowing my tears, my thoughts turned to Jenny. It struck me that this must be how she had felt every day since her injury – only without the reassurance that her symptoms would end with the delivery of a baby.
When my maternity leave ended, I returned to the clinic briefly before moving to another practice. During that short time, I ran into Jenny in the waiting room. She asked about my baby and I asked about her health. I never got the opportunity to say a proper goodbye before I left.
Years later I learnt of Jenny’s untimely death, through a nurse who was still working at the clinic. The nurse wasn’t aware of the details but, knowing Jenny’s history, I couldn’t help wonder if she had become one of the more than 1500 Australians who die from accidental overdose each year.
Chronic pain affects a staggering one in five Australian adults. While it is accepted that pain should be managed in a holistic and overarching way, many patients just like Jenny wait up to a year and sometimes up to two years for appointments in public multidisciplinary pain clinics. In the meantime, these patients are left to seek care from general practitioners like me.
Nowadays, almost one-in-five GP consultations involve the management of chronic pain. In 70 per cent of these consultations, the patient walks away with a script for a medication rather than a referral. This isn’t surprising. The Medicare Benefits Schedule still favours 10-minute medicine over the complex, holistic care that a patient with chronic pain requires.
But there may be hope on the horizon. In May, a National Strategic Action Plan for Pain Management, endorsed by all Australian governments, was launched by the Health minister. Carol Bennett, the chief executive of Pain Australia, said the next step was to ensure that governments provided funding to realise the actions and agenda outlined in the plan. It is in their best interests to do so. Chronic pain costs the Australian economy $140 billion a year. About 10 million missed work days and 40 per cent of forced early retirements are reportedly due to chronic pain conditions. A 2019 Deloitte Access Economics report into the cost of pain in Australia concluded that a doubling of access to multidisciplinary care would reduce health system costs and lead to significant benefits in productivity and wellbeing.
Every so often a patient comes along who has a profound effect on me. Jenny was such a patient. Even now, when colleagues talk about the opioid crisis, it’s Jenny’s face I see – the bright-eyed, lipsticked one. The sad reality, however, is that Jenny’s story is far from unique. At any one time a significant proportion of the Australian population is suffering from daily, intractable pain. It may be too late for Jenny but investment in this long-neglected area is what the 3.4 million others like Jenny so desperately need and deserve.
This article was first published in the print edition of The Saturday Paper on Jun 26, 2021 as "In a world of pain".
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