Optimal Pain Treatment Interventions (OPTIons): Providing early access to a specialist multidisciplinary pain service for people injured at work

OPTIons (Comprehensive Early Intervention) Assessment: Participants in the intervention cohort will undergo a comprehensive 5-hour assessment by a multidisciplinary team including a clinical psychologist, physiotherapist and pain specialist, at one of the Pain Management Clinics (PMC) involved in this study. This assessment determines specific treatment needs, as well as intensity. Participants will then be allocated to commence one of three levels of pain management programs, dependent on their Örebro score, use of opioids and time off work (see 'Triage Rules' below). All decisions regarding suitability for the various levels of intensity need to be flexible and assessed on a case by case basis, using the criteria as a guide rather than as absolute specifications. The underlying principle is to match the patient’s needs with the type of program. Triage rules for High, Medium, Low intensity program, following multidisciplinary assessment: • High intensity: Örebro >/= 50 with: opioid use >90 days (>60 mg morphine equivalent dose); or high complexity as determined by ePPOC scores; or polypharmacy use • Medium intensity: Örebro >/= 50 with: opioid use >20 days (<80 mg morphine equivalent dose); or not prescribed opioids but have not returned to work after 12 weeks; or referred from low intensity intervention as needing additional support • Low intensity: Örebro >/= 50 with: no opioids or regular medications and/or returned to work or off work for <12 weeks Treatment: The pain management programs will be carried out as per standard practice (see Components of Pain Management Programs, below). OPTIONS Pain Management Programs Description: • The High intensity program involves attending a multidisciplinary program five days a week for three weeks (about 105 hours contact). Workers will be encouraged to return to work (RTW) in the weeks following the program. • The Medium intensity program involves attending a multidisciplinary program for five days in the first week and two days a week over the next two weeks (about 50 hours contact). Workers will be encouraged to RTW during the second or third week of the program. • The Low intensity program involves attending a group program for two hours a week for five weeks or up to 10 individual sessions with a clinical psychologist and physiotherapist (about 10 hours contact). Workers will be encouraged to RTW during this period. All levels of treatment involve interactive sessions, group or individual, cognitive behavioural therapy, with physiotherapy directed exercises employing CBT principles, home practice of the self-management skills and activities planned. Exercises include stretch exercises, aerobic and anaerobic exercises gradually upgraded according to pacing principles on an individual basis. Each participant will have a workbook to record his/her exercise, activity, medication use, relaxation practice, use of problem-solving skills. Attendance will be recorded for all participants by the treatment team. In addition to the treatment program, the intervention includes liaison by the PMC with the employer, via a rehabilitation provider or RTW coordinator and their GP. This will ensure a suitable return to work plan is in place for the worker to follow either during or at the completion of the treatment program. In all three programs the worker will be asked to meet with their GP during the pain treatment program to review their work capacity and to guide the return to work planning. Key Components of Pain Management Programs: Key content elements, as defined by the Agency for Clinical Innovation (ACI) in "Which patient for which program",(1) within the framework of RTW, include: • education about chronic pain • identified psychosocial barriers for returning to work • communication regarding chronic pain in the workplace • managing distress (depressed mood, anxiety, fears of re-injury or pain) • managing flare-ups in pain at work and home • applying problem solving in the workplace • pacing up activity levels and tasks in the workplace • withdrawal from analgesic medications (reduction schedule in the context of work). Medium and High intensity Pain Management Programs also have the following features: • offered within the context of a RTW plan • delivered in less than six weeks • a proficient multidisciplinary team is available to deliver the program in a coordinated, interdisciplinary manner • effective liaison and coordination with any existing service providers, workplace rehabilitation providers, employer and RTW coordinators (which may or may not need to continue as part of the treatment plan) • minimum in-house staffing complement, including: psychologist, physiotherapist (or occupational therapist/exercise physiologist), nurse (or pharmacist), pain medicine specialist (if medication withdrawal is included) • musculoskeletal expertise through skilled physiotherapists and pain medicine specialists, and consideration of any further expertise (such as rheumatology, neurology or sports physicians) as part of the detailed design planning phase 1. ACI Pain Management Network. Pain Management Programs – Which Patient for Which Program? A guide for NSW Tier 3 and Tier 2 public health facilities providing pain programs. ISBN: 978-1-74187-936-0. https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0015/205071/ACI13-015-pain-programs-2017-web.pdf