Aust Fam Physician
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Chronic pain is a common presentation to general practice. ⋯ The mind, emotions and attention play an important role in the experience of pain. In patients with chronic pain, stress, fear and depression can amplify the perception of pain. Mind-body approaches act to change a person's mental or emotional state or utilise physical movement to train attention or produce mental relaxation. They are occasionally used as a sole treatment, but more commonly as adjuncts to other therapies. Mind-body approaches include progressive muscle relaxation, meditation, laughter, mindfulness based approaches, hypnosis, guided imagery, yoga, biofeedback and cognitive behavioural therapy. Studies have shown that mind-body approaches can be effective in various conditions associated with chronic pain, however levels of evidence vary. Group delivered courses with healthcare professional input may have more beneficial effects than individual therapy. General practitioners are well placed to recommend or learn and provide a range of mind-body approaches to improve outcomes for patients with chronic pain.
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Maximising the effectiveness of your appointment system in general practice has the potential to connect patients and clinicians for timely care and create a sustainable working environment. ⋯ Five common appointment strategies have emerged through the work of the Australian Primary Care Collaboratives: open access, book on the day, supersaturate, carve out and advanced access systems. All these systems have advantages and disadvantages and may suit different practices depending on their contexts and populations. It is helpful to measure how effective the current practice approach is in dealing with delay and delivering satisfaction. Specific approaches such as 'appointment golf' and 'jeopardy doctor' may help improve system functioning. Practices should make intentional choices about their appointment system to meet the needs of their patients, staff and clinicians.
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Opioids have a critical, time-limited role in our management of acute and terminal pain and an open-ended role in our management of opioid dependency. They also have a use in the management of chronic non-cancer pain. ⋯ For chronic non-cancer pain, the evidence base for the long-term use of opiates is mediocre, with weak support for minimal improvements in pain measures and little or no evidence for functional restoration. Much research and professional education in this field has been underwritten by commercial interests. Escalating the prescribing of opioids has been repeatedly linked to a myriad of individual and public harms, including overdose deaths. Many patients on long-term opioids may never be able to taper off them, despite their associated toxicities and lack of efficacy. Prescribers need familiarity with good opioid care practices for evidence-based indications. Outside these areas, in chronic non-cancer pain, the general practitioner needs to use time and diligence to implement risk mitigation strategies. However, if a GP believes chronic non-cancer pain management requires opioids, prescribing must be both selective and cautious to allow patients to maintain, or regain, control of their pain management.
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Chronic refractory dyspnoea is defined as breathlessness daily for 3 months at rest or on minimal exertion where contributing causes have been treated maximally. Prevalent aetiologies include chronic obstructive pulmonary disease, heart failure, advanced cancer and interstitial lung diseases. ⋯ Dyspnoea is mostly multifactorial. Each reversible cause should be managed (Level 4 evidence). Non-pharmacological interventions include walking aids, breathing training and, in chronic obstructive pulmonary disease, pulmonary rehabilitation (Level 1 evidence). Regular, low dose, sustained release oral morphine (Level 1 evidence) titrated to effect (with regular aperients) is effective and safe. Oxygen therapy for patients who are not hypoxaemic is no more effective than medical air. If a therapeutic trial is indicated, any symptomatic benefit is likely within the first 72 hours.
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Neuropathic pain (NP) may result from a lesion, disease or dysfunction of the somatosensory system (peripheral or central nervous system). Examples include diabetic polyneuropathy, postherpetic and trigeminal neuralgias, spinal cord injury pain and painful radiculopathy. While general population surveys in the United Kingdom and France indicate a prevalence of 7-8%, information is scant in Australia, as the existence of NP may be subsumed within the diagnostic label of the associated condition.