What's happened to date?

 

Following the adoption of the Pain Summit work stream, the Faculty appointed a working group of Dr Ann Taylor, Dr Chris Barker and Dr Andy Nicolaou to lead this project.

 

The aims of the working group were:

  • To develop a consensus statement with multiprofessional colleagues that defines 'Complex Pain'.
  • To develop a simple 'early-use' screening tool and also identify standardised, valid and reliable screening tools to address 'at risk' and 'established persistent pain' groups using one system, and delineate core primary care assessment tools.
  • To prepare for NICE Quality Standards and/or Quality Outcome Framework (QOF) status and/or use of the Local Enhanced Schemes (LES).
  • To develop a Read Code for problematic/complex pain.
  • To link into the potential development of 'core standards' of pain management for primary care.
  • To delineate how the Initial Assessment and Management Map of Medicine Pathway could be used following pre-screening.
  • To identify educational resources needed.
  • To help develop the e-learning Department of Health pain resources.
  • To identify future audit processes and research agendas.

 

A multiprofessional meeting was held in April 2013 with the aim of planning the processes required and the participants needed to achieve a consensus statement for complex pain. The tool, once agreed and consulted upon, was trialled initially through a survey circulated on the Faculty's behalf by the Royal College of General Practitioners to all GPs. The survey ascertained their opinions regarding the use of a pre-screening tool.
 

The work was reported back to the House of Lords Select Committee in November 2014 and was welcomed by the members of the Committee and the patient and lay representatives present.
 

The Working Group are now working on local pilots of the screening tool.

Initial Survey:

A surveymonkey questionnaire was sent to all GPs in the UK via a link provided on the RCGP Chair's newsletter in April 2014. Participants were allowed 6 weeks to respond and the questionnaire was purposefully brief to improve participation. It is also acknowledged that this is a small sample of the total number of GPs.

 

Questions with responses as follows.

 

Currently NHS services can be reactive rather than proactive in managing people with pain. More emphasis could be placed upon a prognostic assessment identifying those with acute pain who are at risk of developing chronicity (pain related disability & distress), or people who have chronic pain and are struggling to cope with their pain.

1. Do you agree with the above statement?

No               31

Yes            317

 

2. Do you think it reflects your practice?

No             140

Yes            202

 

Strong evidence exists highlighting early appropriate management of pain can prevent chronicity. A brief pain pre-screening tool has been developed; it is designed to be quick to use and to help with decisions about whether further screening, assessment, and early management (including possible referrals) is necessary.

3. Do you think that the concept of early pre-screening for complex/problematic pain is appropriate in your day-to-day practice?

No             54

Yes            273

 

The development of this pre-screening tool for problematic/complex pain has evolved from work that has been undertaken in depression screening (Arroll et al 2003). In this context, if the clinician considers depression may be present yet undiagnosed s/he asks the patient two questions. If a positive response was gained to both, the patient then completes a validated diagnostic tool to establish whether depression is present.

4. Are you familiar with this depression pre-screening tool? If yes, do you use it in practice?

No                                        101     

Yes - don't use                  120

Yes - do use                      103

 

Problematic/complex pain is defined as ‘Any pain associated with, or with the potential to cause, significant disability and/or distress’. It has been shown that a number of key discriminating factors exist in the identification of chronicity associated with pain. (Linton et al, Mallen et al.)   The following two questions include many of these key factors:

  • ‘Over the past two weeks has pain been bad enough to interfere with your day to day activities?’
  • ‘Over the past two weeks have you felt worried or low in mood because of this pain?’

 

Evaluating:

  • Pain duration                                      ‘..past two weeks..’
  • Pain intensity                                       ‘..pain been bad enough..’
  • Level of pain related disability            ‘..day-to-day activities..’         
  • Level of pain related distress               ‘..worried or low in mood..’   

 

5. Do you think the two pre-screening questions are worded appropriately? Yes/No

If no, please indicate below how you would rework them:

Use these as they stand                210

Use these subject to change         43

 

5.a. Would you be willing to use these questions in your practice? Yes/No

5.b. Is there anything you would like to see added/amended? Yes/No

Free text box for comments:

 

210 participants answered ‘use these questions as they stand’

43 answered ‘use these questions subject to change’

37 answered ‘not use these screening questions at all’

And 58 did not respond to question 5.

 

Of the 43 that responded ‘use these questions subject to change’, 40 commented further.

Of the 37 who responded ‘not use these screening questions at all’, 25 commented further.   

 

Key themes emerging from the comments provided for both options were very similar:

  • Language and cultural barriers to questions
    • with a subtheme of adapting the wording (especially in regards to the second question and the word ‘worried’)
  • Require further understanding of managing patients and their pain
    • Subthemes – lacking access to appropriate services, lack of knowledge/training in chronic pain (e.g. ‘The issue is not detecting these patients but having appropriate mdt services with psychological input to refer to…we are increasingly being asked to identify conditions without services being available’,  ‘I would really value some training in chronic pain from the RCGP’)
  • Require further understanding of the evidence-base for the 2Qs
    • including usefulness of the 2Q’s
    • the suitability of the two-week timeframe
    • the preferable use of the holistic/narrative approach and open-ended questions
    • having an awareness of the 2Qs but using it as a guide and adapting format

The only difference in themes which emerged from the comments of those that answered ‘not use these screening questions at all’ seem to focus on:

  • Lacking capacity and time to ask the 2Qs (‘I think the questions are excellent. The issue is finding the time to be proactive!’, ‘We have enough to do without this sort of box ticking’)

 

Thanks to Hannah Traynor (Psych Asst – Southport & Ormskirk NHS Trust) for Q5 thematic analysis

Back to main A2Q page