Chronic pain, biopsychosocial model, opioid prescribing guidelines, tapering, referral

Definition / Overview

• Chronic pain and opioid dependence represent two distinct but frequently overlapping clinical presentations in Australian general practice.
• Effective management requires not only clinical skill but also fluency with the Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) frameworks that fund this care.
• Under-utilisation of available billing items disadvantages patients by limiting access to multidisciplinary support, and exposes GPs to medico-legal risk by failing to document the structured care these patients require.

For billing purposes, the key distinction is:

• Chronic non-cancer pain (CNCP): persistent pain lasting beyond three months, not primarily driven by active malignancy
• Opioid dependence: a substance use disorder characterised by compulsive use, tolerance, and withdrawal, often managed through opioid substitution therapy (OST)

Both conditions qualify for a range of MBS-funded structured care items, and opioid dependence also involves specific PBS authorities and state-based prescribing authorities.

MBS Items for Chronic Pain Management

GP Chronic Condition Management Plans

The cornerstone of chronic disease management in general practice applies equally to chronic pain:

Practical tips:

• A GPCCMP (965) can be prepared directly, with allied health referred at the same visit; a separate team care arrangement is not required
• For chronic pain, the GPCCMP enables direct referral of up to five allied health sessions per calendar year (items 10950-10970) to providers such as physiotherapists, psychologists, and exercise physiologists
• Document the specific functional goals in the plan, not just the diagnosis; vague plans are poor medico-legal practice
• Item 967 review should assess progress against documented goals, adjust the plan, and confirm ongoing eligibility

Chronic Disease Management Allied Health Items

Under a GPCCMP, patients with chronic pain access:

• Up to five sessions per calendar year across all allied health types combined.
• Patients may access additional psychology sessions via the Better Access pathway (see below) concurrently, but the clinical need must be documented separately.

Mental Health Treatment Plans for Co-morbid Depression/Anxiety

Chronic pain is strongly associated with depression, anxiety, and PTSD. The Better Access scheme applies when a diagnosable mental health condition is present:

• Under the Better Access scheme, patients can access up to 10 individual psychology sessions per calendar year (six initially, then review for further four).
• For complex conditions including chronic pain with significant mental health burden, this is often insufficient; document clearly and advocate for patients needing additional care.

Prolonged Consultation Items

Complex chronic pain patients frequently require extended consultations for medication review, opioid tapering discussions, or care coordination:

Do not time-truncate consultations to bill a lower item: bill for the time and complexity actually delivered, with documentation to match.

MBS Items for Opioid Dependence

Opioid Treatment Programs and Structured Care

• Opioid dependence is classified as a chronic condition and qualifies for a GPCCMP in the same way as other chronic diseases.
• However, it also involves specific state-regulated frameworks for OST prescribing (methadone, buprenorphine, buprenorphine-naloxone).

Items applicable to opioid dependence management:

Opioid Substitution Therapy: Prescribing Authority

OST in Australia is regulated at both Commonwealth (PBS) and state/territory level. GPs must hold specific authority to prescribe OST in their jurisdiction:

• State/territory authority: varies by state; most require completion of an accredited training program and a permit or authority to prescribe Schedule 8 opioid treatment medications
• PBS authority prescriptions: methadone and buprenorphine-naloxone (Suboxone) and buprenorphine (Subutex, Sublocade) require PBS Authority approval
• Streamlined vs telephone authority: buprenorphine-naloxone maintenance has a streamlined authority (write on script); initiation of new patients or dose changes above threshold often require telephone or online authority

Key OST PBS considerations:

Initiating OST in general practice:

1. Confirm opioid dependence (ICD-10 criteria; COWS score if in mild withdrawal)
2. Complete state-mandated training and hold relevant prescribing authority
3. Discuss and document informed consent including risks, supervised consumption requirements, and urine drug screening
4. Start buprenorphine-naloxone at 4-8 mg (sublingual) once mild-moderate withdrawal confirmed (COWS ≥8) to avoid precipitated withdrawal
5. Stabilise dose over days to weeks; usual maintenance 8-24 mg/day
6. Arrange supervised dispensing through community pharmacy; document takeaway dose progression

Medication Reviews in Opioid Dependence

Home Medicines Review (HMR) and Residential Medication Management Review (RMMR):

• Initiated by GP referral to an accredited pharmacist
• Relevant when patient is on complex polypharmacy (OST plus benzodiazepines, antidepressants, antipsychotics)
• GP receives written report and conducts a follow-up consultation (item 900, 903)

PBS Considerations for Chronic Pain Medications

Opioid Analgesics: Authority Requirements

Strong opioids for chronic non-cancer pain require PBS authority prescriptions in most cases:

Authority prescribing principles for CNCP:

• Document the indication, failed alternatives, functional goals, and risk assessment (including PDMP check)
• Prescriptions for Schedule 8 drugs must comply with state regulations: handwritten or approved electronic format, patient's name/address, prescriber details, quantity, and repeats as permitted
• Most states require a Prescription Drug Monitoring Program (PDMP) check (e.g. SafeScript in Victoria, NarxCare in other states) before issuing Schedule 8 prescriptions

Non-Opioid PBS Items Relevant to Chronic Pain

75+ Health Assessment and Chronic Pain/Opioid Dependence

Older patients with chronic pain or long-term opioid use warrant specific considerations in the 75+ Health Assessment (MBS item 703):

• Screen for falls risk: opioids increase falls risk significantly
• Assess cognitive function (MMSE/GPCOG): opioid-related cognitive impairment
• Medication reconciliation: polypharmacy with opioids, benzodiazepines, gabapentinoids is a high-risk combination
• Document functional status and pain impact on activities of daily living
• Review appropriateness of ongoing opioid prescribing; opioid tapering may be appropriate with adequate non-pharmacological support

Item 703 can be complemented by:

• Item 900 (after HMR): to rationalise polypharmacy
• Item 965: to coordinate multidisciplinary pain or addiction care via direct allied health referral

Complications and Special Considerations

Medico-Legal and Prescribing Safety

• Informed consent documentation: for long-term opioid therapy, document the risks (dependence, overdose, cognitive effects, hormonal effects), the opioid treatment agreement, and patient goals
• Opioid treatment agreements: not mandatory but strongly recommended; document expectation of urine drug screening, single prescriber policy, and conditions for dose change
• Concurrent prescribing of opioids and benzodiazepines: the combination is the leading cause of prescription opioid overdose death in Australia; if prescribing both, document clinical justification explicitly
• Safe storage counselling: advise all patients receiving opioids on safe storage; document this advice
• Naloxone co-prescribing: PBS-subsidised naloxone (Prenoxad or Nyxoid) should be offered to all patients on high-dose opioids or OST; document the offer and patient education provided

Aboriginal and Torres Strait Islander Patients

• Access to PBS medicines under the Closing the Gap PBS Co-payment (CTG PBS) for eligible patients: reduces out-of-pocket costs for PBS medicines to zero or minimal co-payment
• Requires registration with the practice's Indigenous health program and consent
• For OST, ensure cultural safety in supervised dosing arrangements; consider liaison with Aboriginal Community Controlled Health Services (ACCHS)
• The Practice Incentive Program (PIP) Indigenous Health Incentive supports practices providing best-practice care; relevant when managing chronic pain in this population

Refugee and Migrant Health

• Newly arrived refugees may have undertreated chronic pain from prior trauma or conflict-related injuries
• Initial health assessment: MBS item 701 (refugee health assessment) within 12 months of arrival
• Interpreter services: Medicare funds interpreter use; document interpreter-assisted consultations

Long-Term Care and Monitoring Framework

Structured Review Schedule for Chronic Pain

Structured Review Schedule for Opioid Dependence (OST)

• Weekly to monthly GP reviews during dose stabilisation: bill item 23/36/44 as appropriate
• Pharmacy supervised dosing records should be available and reviewed
• Urine drug screens: document findings and clinical response; do not discharge patients solely for positive screens without clinical assessment
• Gradual reduction in supervised dosing frequency (takeaway doses) as stability is demonstrated; document decision-making
• Annual GPCCMP, with direct referral to social work and psychology, and coordination with addiction medicine

When to Refer

• Pain specialist/anaesthetist-led pain clinic: persistent CNCP not responding to multimodal management; consideration of interventional procedures
• Addiction medicine specialist: complex OST initiation, high-risk polydrug use, psychiatric comorbidity requiring integrated care
• Psychiatrist: significant co-morbid mental illness; risk of self-harm
• Emergency department: signs of opioid toxicity (respiratory rate <12/min, pinpoint pupils, reduced GCS); administer naloxone and call 000

Quick-Reference Summary Table