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Presentation: Delivering pain management in a rural setting

Codeine up-scheduling workshop, Melbourne, 28 November 2017

16 January 2018

For further information about changes to medicines containing codeine, see the Codeine information hub.


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  • Presented by: Dr Malcolm Hogg, Royal Melbourne Hospital and Head of Pain Services, Melbourne Health
  • Presented at: TGA workshop: Codeine up-scheduling, 28 November 2017
  • Presentation summary: This presentation gives an overview of delivering pain management in a rural setting.


Delivering pain management in a rural setting: the why and how

Dr Malcolm Hogg
Royal Melbourne Hospital and Head of Pain Services
Melbourne Health

TGA workshop: Codeine up-scheduling, 28 November 2017

We're very happy, well we've got a lot of people with some rural experience and very happy but Malcolm's going to just make a couple of points. We'll also address these in the panel because I know Pene and others are working in in this area too. But I've just asked Malcolm to say a few words, then we 'll go into… I know everyone's getting either hungry or tired.

Well, we could do that. And then we'll go into, so if you do stand up for a sec, please do. And then we'll go into a little panel. We 'll just see for how long, and if we break up, we won't be offended if you wander off because you've got other commitments and I know there's big commutes. So, I've just asked Malcolm to say a few things and then we 'll go into a panel.

So, my interest in this comes from, I was born in a rural area but then I also do both some consultancy work at Ballarat Hospital, and I run a telehealth service with Mildura, Horsham and Hamilton.

And so, there's quite a bit out there and I just want to pick out some key points. There 's the pain cohort in the rural area is higher proportion of men. They're at higher risk of motor vehicle accident, work-related accidents and suicide as a population as a whole. And they have a high rate of back pain. So, the group that I see are often high opioid using people with chronic back pain but they remain active. And my perspective is, they 're less disabled in that they're doing stuff, they're taking tablets and they're doing stuff because their country men.

The second thing is about the model of care and this is comes from the National pain strategy document, but also the New South Wales group, and they talk about really building up community care, including pharmacists and population health. So, some self-efficacy work, some education work, primary health care networks with pharmacy input prior to sending up to specialist care and tertiary care in multidisciplinary pain centres such as where I would work. And this is a problem in community Regional Health because both the population health is lower, so self-efficacy and health literacy, generally the primary health care is in patches excellent, but in other areas can be quite deficient, particularly in remote areas, and then access to these services are very limited, hence the role for telehealth.

So, Ballarat has 250,000 people. We set up a small pain clinic and essentially, we were then inundated. Ballarat pain clinic now has a four-year waitlist. And essentially when you look at some of the other things and the population, we should be dealing with five to six hundred patients a year if we were to match the city services, the population and activity. But instead, we're seeing about a hundred new with 1.1 medical specialists. So, one day a fortnight. Just not enough for the population so they are under serviced from population but this is all we can get out of Ballarat health services. There is a pain program and allied health input and so they need a new model of care to direct it to that so that the medical person just sees those that are needed to be seen or managed. And there's a big push for opioid permits because to me there's a lot of opioid prescribed patients out in rural areas that need permits and higher doses.

They did a pilot with the Victorian persistent pain outcome collaboration. We did a trial of Royal Melbourne, Caulfield and Ballarat. We had great difficulty recruiting patients, great difficulty getting the systems right, but we did not show that there was a deficiency. They still got benefit when they used these questionnaire studies from the service. So, the patients aren't resistant to change, it's actually that health systems are resistant to implementing the services that are required.

There are a number of funding models: rural health outreach fund. I'm going to go past this. This is the regional map from the government. So very remote is RA,5 remote is RA4 and then RA3, and that is implied in the telehealth program. So the telehealth came in, MBS funded. There was an on-board incentive which is now gone and basically, you get your normal item number plus 50%. So, I do a pain consult, I get $128 dollars which is added on to about $200 and then you get 75 or 85 percent of that.

So, for us running it in a public pain clinic, it was really difficult and we were averaging $650 income which wasn't covering our costs. So, my hospital has now gone, we don't like Medicare clinics in a public hospital because we can't cover our costs. And so business cases tipped to run a Medicare clinic is fallen away. And same thing if you're going to do bulk billing in rural areas as a specialist. It's not sustainable, even with 50 percent encouragement.

There has been some statewide incentives and recently we've done one with Health Direct, and so we're using a Health Direct platform which I'll talk about shortly. But pain medicine, and I think drug and alcohol, is really suitable, as is psychiatry is really suitable for telehealth, because you don't have to really examine the patient. You need to talk to them and you need to educate them and you need to engage the GP and the local providers. So, when we do run a telehealth clinic, we do it with either a GP or nurse practitioner in the region. And that works well. But it works better as a paid session or funded through a state system that it is through a Medicare system.

And this is a MBS assessment and it 's mostly been taken up by physicians. Very little has been taken by pal care and pain medicine. Anaesthesia is another thing. Pre-admission clinics or big hospitals are now starting to do telehealth. So the wrong groups are using telehealth than what we need.

So, I'm going to go through. Health directors the one that's won out. It's a federally government supported thing; it's now encrypted. It's fantastic. Most of it we have still use Skype which has some federal government approval to use but it's not encrypted so it's not very secure. But most GPS want to use Skype. We are transitioning them all onto Health Direct.

So, what's the access for rural areas? When we did this study on waiting in pain, 0.05 percent versus 0.174 out of urban and rural areas. So, access to pain services is a essentially a third of what it is in the city, and so therefore we need to use the GPS to a greater extent. And there's also this concern about prescribing, and when I wrote this slide, this hadn't come through. So, this is the Atlas which came out in 2015, looking at variation in healthcare, and this is number of opioid scripts per capita. And so, there's a ten times variability if you lived in Boroondara council versus if you lived in Edenhope. So, you got out of western Victoria ten times the prescribing of opioids compared to Hawthorn.

And not only that is that there's a variability based on socio economics. So, on the right-hand side here, you've got very remote areas which is actually low. So, Arnhem Land is low because you just got no doctors in Arnhem Land. So, there's no opioid scripts per capita, but in rural areas, if you're in a low socio-economic, your variability was higher. The ability to get an opioid script was higher, and this is shown in American Studies as well. There's a link between socio economics and distress levels in opioids, and at higher socioeconomics, you have less opioid prescribing.

And then this is major cities. So, high socio-economic group in the major cities is here, and so you're prescribing around 25,000 scripts per 100,000 population versus low socio-economic in rural areas, you're up here. So, to me these are the two big factors.

And then when you look at the rural areas, I believe there 's this socio-economic drift out of Melbourne along the train lines, the hamlets around Ballarat, Bendigo, out to Horsham, down to Geelong to Warrnambool, that's where people who are on high-dose opiates on disability pension… they might be burned out addicts, they might be chronic pain patients, they can't afford to live in Melbourne. They find a caravan out in the rural areas, and so that in part, explains higher prescribing in the rural areas. But the other part is, I believe, is explained by low access to services, low access to valid health input.

Now, we're also being compared to America and a lot of this concern is being driven by America. And I'm not sure, I worked in America medically and it's a different health care system, it's a different culture. And so, if you look at the prescribing and the opioid dosing versus, and the deaths, it's really three times Australia when you look at it per capita. It 's the same thing with car accidents, they're about double per capita, because they don't have to wear seatbelts, they can drive at whatever speed they want, they're idiots on the road. So, they've got a higher death rate, but they have a higher problem with opioids, and they have a higher amount related to non-medical prescription. So, 50% misuse. So, they've got a different misuse group and cohort. I just make that point because it's possible that the rural population is different to the city population based on this sort of socioeconomic access.

And they tell me that heroin is very hard to get in the rural areas. It sort of comes from on the boats and so it spreads out from Port Melbourne, so the access to heroin is in a circle from Port Melbourne --- conceptually. So, in rural areas, it 's prescription misuse.

This is nationally, wait time is not as bad as what everyone says. This is 55 days but I think the wait time for rural areas is more difficult and that's where the concept of linking intercity service can be really important. People still respond with allied health programs. I'm going to move past this. And then cannabis to me is the other concern. I think there's a cannabis market out in the rural areas.

Any other comments or questions? I do actually have a colleague who is a rural doctor? Any other rural medical people here? Great, so I 'd love your insight, all your commentary based on that. Do you have any comments specifically?

I think what you 've said is right.  It 's cheap to live, particularly in Queenstown in Tasmania. A mining community, very cheap accommodation, and we had a very high incidence of prescription Oxycontin users. Hillbilly heroin users down there.

Fiona is from Daylesford. Any comments, Fiona?

I 'd say the same thing. Areas of the state that might seem very appealing for a cozy weekend but actually when you live there, there 's quite an enormous underclass of underprivileged people who often have lots of mental health issues, lots of dual diagnosis stuff. And then it might not even be like accessing the pain clinic in Melbourne, it's actually getting them there as well. Like the logistics of getting someone who is in pain to travel that distance, and it's expensive.

They're in pain and just the continuity of care.

I think what you said also parallels the codeine story. Because you look at places and I haven 't got any figures for this, but in my travels around the state, but Bairnsdale, Shepparton, Mildura, very heavy uses of ibuprofen codeine. Your outer suburbs of Melbourne, similar, but the CBD is very heavy, but the ordinary suburbs, and I won 't mention any names, the usage seems to be much lower. So, it would tend to parallel what you've said about the schedule of opiods.

Yes. So, the three main areas are the Latrobe area, western Victoria and there 's that pocket that extends up into Mildura. So that little border there between New South Wales and South Australia, Victoria is a high opioid use area.

So, we had a codeine forum in Warragul last week and the comments that keep coming up over and over again is the lack of availability of a pain service. [Inaudible]

So, conceptually, what we argue with the argument is that Geelong has a tertiary service that should capture that area as at Royal Melbourne. We try to do telehealth into that region. I think St Vincent's should do that region, I think Caufield should do that reason. We want the government to say that models good. You've got a tertiary, a secondary and a community thing, and we're going to fund you to provide liaison works and a telephone link-up, early triage for people in your section. So, if I get a referral from Latrobe, I send it to Caulfield, and I think that's giving or empowering both the community areas to say, I want to link with the tertiary service and that they're funded to support me.

But at the moment, we're not funded very well. We're taking in locals, generally in preference, although I'm doing a few telehealth links to specific areas. Does that make sense? It's what we're looking for at advocacy perspective. We haven't quite got a statewide pain plan yet but I think we'll get one out of this issue. Won't we John?

We hope. I mean it's quite as I said at the very beginning, the whole codeine thing is certainly, I guess it's done two things. It's raised the profile of pain management and pain management services and challenges at large. It's also raised a number of issues and I can't say too much at the moment, but we are closely looking at some bigger issues related to S8 opioids, I mean, while some of the patterns are different between us and the US, we certainly sit in between the US and Europe, for example, in whether you look at any of the statistics on deaths, on usage and so forth. And sadly, we often follow the US a few years behind, so it's really put the spotlight on those two issues on codeine proper.

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