Pain management for GPs: the 4 Ps of assessment, four pillars of treatment and the 6 As of opioid review — plus an AF update

Part 1 — Pain

Pain and rehabilitation specialist (rehab physician) running the pain program at Southport Private. She introduces herself, but the name is unintelligible in the transcript (“I’m Haitian e…”), so no name is given here. She is identified by role only.

Part 2 — Atrial fibrillation

Electrophysiologist, introduced in the transcript as “Ben Hansen” (name as captured by speech recognition — spelling unverified). He has moved to an AF-only clinic and now works at Pindara five days a week.

Audience

GPs ask about opioid contracts, doctor shopping, workers’ compensation, fees, how long patients must be in sinus rhythm before stopping anticoagulation, CHA₂DS₂-VASc for device-detected AF, and a teenager with congenital heart block (Speakers 2–4, 6–8; unnamed). No sponsor or disclosure statement was captured.

Session context

Otter title Pain Management Seminar · id kPkhpVJVlHt83YKcy0fk-xg1Fs0 · ~50 min, recorded 21 March 2026 2:05 pm AEST (same CPD day as the aortic stenosis, PE, anorectal and gynaecology talks). Pain talk ~0:00–25:40; AF talk ~27:00–49:00. Slides and handouts aren’t in the recording.

Key messages for GPs

• Assess with the 4 Ps: Pain type, Past history and pathology, Performance and function, and Psychological health.
• A thin strip of pain down the leg, often to the foot, suggests a radicular (neuropathic) cause. Diffuse leg pain is more likely sacroiliac, hip or musculoskeletal.
• Before amitriptyline or a gabapentinoid, weigh liver and cardiac disease and age. Patients describe a “cloud above their head” that affects thinking and raises falls risk.
• Treat with four pillars — physical, psychological, pharmacological and procedural — within a biopsychosocial-spiritual view. Procedures are often reached for first; they shouldn’t be the only plan.
• Review opioids with the 6 As: Activity, Analgesia, Adverse effects, Aberrant behaviour, Affect, and Appropriate documentation. Ticking these in the notes gives you something to rely on if you are audited.
• Opioids can have a role when function is better and the dose is stable (e.g. tramadol 50 mg each morning in a working patient, as spoken).
• AF: be confident starting a NOAC; work up with FBC, kidney/liver bloods, TFTs and echo; 10% weight loss works about as well as an antiarrhythmic drug (as stated); treat OSA; less alcohol is better.
• PFA makes ablation quicker and safer without changing the target (pulmonary vein isolation). Some low-risk patients may stop anticoagulation after a durable, successful ablation.

Southport Private: mental health, rehab and pain under one roof

• Southport Private houses mental health, rehabilitation (the rehab service moved there; site name garbled) and the new pain program.
• The program sits there because psychology and mental health support are on site. Many pain patients need this, and the speaker said other local private hospitals she works with don’t have mental health beds.
• It is a Ramsay mental health space. Psychiatrists tend to send acute mental health admissions elsewhere (destination garbled).
• The service also takes patients with functional neurological disorder (FND), which she mentioned as a referral option, although she said FND patients do less well from a pain and rehab point of view. (This section is heavily garbled.)

Assessment: the 4 Ps

• P1 — Pain: nociceptive, neuropathic or nociplastic. Usually clear from how the patient describes it (next section).
• P2 — Past medical history and pathology: GPs are already good at this. Remember liver disease, cardiac disease and age before starting amitriptyline or a gabapentinoid. Patients describe a “cloud above their heads” that can affect cognition and falls risk.
• P3 — Performance and function: as a rehab physician she always asks, “How is this pain affecting your lifestyle?” If function is falling, set a goal for it. Otherwise the downward spiral follows: social isolation, deconditioning, job loss, depression and poor sleep.
• P4 — Psychological / mental health: anxiety, depression and PTSD are common. If there isn’t time to explore this in a 15-minute consult, she is happy to see the patient.

Reading the pain: nociceptive, neuropathic, central

Management: four pillars and the whole person

1. Physical: physiotherapy, plus non-drug options such as ice packs and similar aids for low back pain (some device names are garbled).
2. Psychological: mood, sleep and contributing comorbidities. A history of PTSD means the patient is already hypervigilant, with high sympathetic drive, and will feel more pain.
3. Pharmacological: what most people reach for.
4. Procedural: she does procedures too. They often get done faster than the other pillars, and patients can fixate on them and miss the whole picture.

She often draws a person with four parts — biological, psychological, social and spiritual. Usually only the biological part is being addressed. Without a whole-person approach, things decline. “Sometimes there is no problem to fix.”

Opioid review: the 6 As

Patients sometimes tell her, “My GP won’t prescribe opioids.” She acknowledged the medicolegal risk of continuing to prescribe for the wrong person as doses climb. She offered this framework to help GPs decide, and to document, whether to prescribe or decline:

• Activity is “the carrot”: if doses keep rising and the patient is still in bed all day, you can say the opioids aren’t helping.
• Analgesia: no benefit means the wrong drug, or pain that doesn’t respond to opioids — stop escalating.
• Function wins: if a stable low dose keeps someone working and living despite pain — “why not?”

Early run-out, contracts and doctor shopping

• Run out at two weeks on a one-month supply? Ask what else has been tried. She said there is no single right answer. Her approach: move to a staged supply — seven days at a time — and explain that if it happens again she may stop prescribing. “They might not like you, but you have to be fair.”
• Opioid contract: an audience member said they always use one before starting an opioid, stating the patient will get it only from that doctor. Another said they look up dispensing history and can see doctor shopping. (Editor’s note: in Queensland this is the QScript real-time prescription-monitoring system; the system wasn’t named in the recording.)
• “We’re told to de-escalate”: a GP raised the teaching that opioids do nothing in chronic pain. The speaker agreed opioids have a role when the patient meets the criteria above — functioning, keeping their job, dose not climbing. Otherwise look for something that works, to keep the opioid burden low. Some patients arrive saying, sarcastically, “My doctor sent me to take me off the drugs.”

The two-week inpatient pain program

• Who: patients with private health insurance that covers a pain program. Workers’ compensation patients are accepted for assessment, though she finds workers’ comp insurers don’t like to fund the program.
• Cost: the specialist assessment gap is about $100, deliberately, so that patients who don’t want to engage don’t take up appointments. In the program, the patient pays only their hospital excess (around $500, depending on the fund) — nothing day to day.
• Format: 14-day inpatient program with an education session every day: the biology of chronic pain, central sensitisation and how the nervous system has changed. Patients can ask questions, so they don’t leave thinking “they told me it’s all in my head”.
• Team: OT, psychology and physio, each taking about six patients at a time. Patients may see them twice a day. Afterwards they are linked to ongoing services.
• Pain as identity: for some patients, pain has become who they are, so taking it away is frightening. Psychology support is needed at the start and afterwards.
• Wait: was ~3 months. With new clinics added it is now ~5–6 weeks. Urgent: phone her and she will see them sooner.

Part 2: AF — anticoagulate, work up, modify risk

• Be confident starting anticoagulation. Stroke is the worst outcome of AF. AF strokes tend to be large (clot from the left atrial appendage blocking large brain vessels). The risk of starting a NOAC is low, and “the worst thing — you stop it.”
• It also helps the EP: cardioversion needs three weeks of anticoagulation beforehand. Without it, a transoesophageal echo is needed to exclude left atrial clot.
• GP work-up: FBC, kidney and liver function bloods (abbreviation garbled), thyroid function and an echo.
• Weight: losing 10% of body weight (e.g. 100 kg → 90 kg) is “as good as me putting you on an antiarrhythmic drug” (as stated; data largely from Adelaide and Melbourne).
• Obstructive sleep apnoea: diagnose and treat (CPAP). He also mentioned recent data on a newer drug class reducing OSA (drug name garbled; possibly the weight-loss injections).
• Alcohol: “It’s not a moral thing… the science is, the less you drink,” the less AF.

Pulsed-field ablation: same target, safer energy

• Mechanism of AF: heart muscle sleeves spiral 4–5 cm up the pulmonary veins and trigger and maintain AF. Ablation makes a ring of scar where they join the atrium, electrically isolating the veins.
• History: James Cox’s surgical maze (cutting and re-sewing the atrium) worked but was very invasive. Radiofrequency catheters drew a ring point by point. The cryoballoon froze the vein ostium (the speaker had done well over 1000).
• Thermal energy is non-specific: the phrenic nerve is injured in ~2% of cryo cases and usually regrows over about a year. The rare atrio-oesophageal fistula was catastrophic: “most people who got it died”. His figures were roughly 1 in 1000 burn-throughs and about 1 in 2000 deaths (as spoken).
• PFA: an electric field of the right strength, duration and frequency opens pores in the cell membrane (electroporation). It affects cardiac cells only, sparing nerve, oesophagus and pericardium.
• Practical gains: under 30 minutes in the left atrium, about 60 minutes or less overall. He now offers it to robust patients in their early 80s, and it suits heart-failure patients, who are sicker but gain the most.

Stopping anticoagulation after ablation

• New in the last 6–12 months: after a successful ablation with sustained sinus rhythm, patients with a CHA₂DS₂-VASc of 2 or less (sometimes 3 if other factors are favourable) may come off anticoagulation.
• How long in sinus first? In the trials, investigators waited 12 months. Trials were from North America and South Korea (one trial name sounded like “OCEAN”; not verified).
• Patients find a large reduction in AF burden reassuring when weighing the decision (the figures quoted were garbled).

Wearables and device-detected AF

• The data has outstripped the evidence. From pacemaker studies, low-burden AF detected incidentally on a device carries a stroke risk that is raised but much lower than CHA₂DS₂-VASc predicts. CHA₂DS₂-VASc was built on patients who present with symptoms and AF on an ECG.
• AF burden matters. A threshold isn’t established; he floated something like ~5.5 hours per month (no one really knows). Above that, patients look more like the historical cohort.
• Devices: Apple Watch is a bit better than Fitbit, and Samsung has recently updated its software. KardiaMobile (single-lead, finger plate, about $200 as stated) and a 6-lead version (about $300) are options for people without a smartwatch, and a credit-card-shaped one is coming.
• Why it matters: what the EP needs is symptom–rhythm correlation — is the “heart racing” actually an arrhythmia?

AF Q&A: who benefits from ablation, congenital heart block

• Heart failure: ablation has a mortality benefit — ejection fraction improves and there are fewer hospitalisations.
• Everyone else: mostly for symptoms — fatigue, “washed out”, lower exercise capacity, drugs not working or not tolerated (“I hate the beta blocker”).
• Young and asymptomatic (e.g. 50 years old): there are no trials, but he wouldn’t want to leave them in AF for 30 years, given lifetime risks of atrial dilatation, stroke and heart failure.
• Older (75–80+): be guided by symptoms. About 10% of people over 75 have AF (as stated). Patients who have “rolled along” unaware may need nothing more.
• Teenager with congenital complete heart block: still refer. Children are often not paced early because they outgrow pacing leads. The speaker linked congenital block to maternal factors (garbled; heard as “maternal workers”).

GP clinic checklist

1. Pain consult: run the 4 Ps — type, past history, function, psychology.
2. Thin-strip leg pain = radicular. Glove-and-stocking = peripheral neuropathy (check diabetes, vitamins). Post-stroke or spinal cord injury = refer early.
3. Before amitriptyline or a gabapentinoid: check liver, heart, age, cognition and falls risk.
4. Plan across physical, psychological, pharmacological and procedural pillars — not procedures alone.
5. Every opioid review: document the 6 As (Activity, Analgesia, Adverse effects, Aberrant behaviour, Affect, Appropriate documentation).
6. Early run-out → ask what else was tried; consider 7-day staged supply and a clear warning; check prescription monitoring.
7. Complex chronic pain with mood, sleep or trauma issues and private cover → consider the two-week inpatient pain program (~5–6-week wait; phone if urgent).
8. New AF: start a NOAC if indicated; FBC, kidney/liver bloods, TFTs, echo; weight loss, OSA treatment, less alcohol.
9. Post-ablation anticoagulation decisions: EP-led, after ~12 months of durable sinus rhythm in trials.
10. Wearable alerts: get a symptom–rhythm correlation. Low-burden device AF ≠ clinical AF for stroke risk.

Transcript caveats

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