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 Management Plans and Team-Care Arrangements

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

Practical tips:

• A GPMP (721) must be in place before a TCA (723) can be created; they can be done at the same visit
• For chronic pain, the TCA enables 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 732 review should assess progress against documented goals, adjust the plan, and confirm ongoing eligibility

Chronic Disease Management Allied Health Items

Under a TCA, 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 GPMP/TCA 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 $4{-}8\,\text{mg}$ (sublingual) once mild-moderate withdrawal confirmed (COWS $\geq 8$) to avoid precipitated withdrawal
5. Stabilise dose over days to weeks; usual maintenance $8{-}24\,\text{mg/day}$
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 721/723: to coordinate multidisciplinary pain or addiction care

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 GPMP/TCA to coordinate with social work, psychology, and 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

Sources

• MBS Online (Medicare Benefits Schedule)
• PBS Schedule (Pharmaceutical Benefits Scheme)