Primary Care Physicians May Be Chronic Pain Patients’ First Resource

Primary Care Physicians May Be Chronic Pain Patients’ First Resource

The International Association for the Study of Pain (IASP) defines chronic pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage.” (1) Chronic pain, which is said to be pain that lasts for 12 weeks or longer, (2) can be a frustrating experience for patients and physicians alike, since, unlike acute pain, there is not always an identifiable underlying physical pathology that accounts for the continued pain, but a complex mix of psychological, behavioral and medical factors. (3)

Despite the complexity of chronic pain, these patients rarely start out their healing journey with a pain specialist, but are more likely to see their primary care physician (PCP) (3). In fact, a 2010 study in Southern Medical Journal found that primary care physicians treat approximately 52% of chronic pain patients.(4) However, PCPs are not all trained in pain management and may underserve a patient’s needs, according to a book called Relieving Pain in America, published by the National Academy of Sciences. The authors describe the results of a 2009 American Medical Association (AMA) Pain Medicine Summit, indicating that “[t]raining was seen as poor or ‘not leading to competency’ at both the undergraduate and residency levels in all suggested areas of pain treatment.” (5)

At least one pain medicine expert has specifically advocated for the training of primary care physicians in chronic pain management, writing in the journal Pain Medicine that “it is vitally important” (6) for PCPs to be aware that “chronic pain has not only a potential tissue-damage component but also a high likelihood that changes in the nervous system as well as affective and environmental factors are likely to be playing a significant role in the patient’s complaints and pain behaviors.” (6)

PCPs may want to adopt a three-pronged strategy with chronic pain patients, as recommended in a 2013 study in the British Journal of Anesthesia, and assess: (7)

  • The extent of the physical impairment as caused by the underlying disease or injury
  • The extent to which the illness and resulting pain or disability prevent the patient from enjoying their usual activities
  • Whether the patient’s behavior “seems appropriate” to the disease or injury causing the pain, or whether they are attention seeking, drug-seeking or other means of compensation through their behavior.

From there, physicians should be sure they are up to date with a comprehensive tool kit of options to help their chronic pain patients manage their pain:

  • Good screening tools such as pain diagnostic questionnaires (3)
  • Awareness of up-to-date relevant guidelines for pain management such as the National Institute for Health and Care Excellence (NICE) guidelines, and the IASP Neuropathic Pain Special Interest Group (NeuPSIG) (3)
  • Drug interventions—Awareness of a wide range of opioid and non-opioid analgesic medication management options (3)
  • Non-medication interventions, including massage, physical therapy and acupuncture (3)
  • Psychological interventions, such as cognitive behavioral therapy (3)
  • Non-surgical physical interventions such as physiotherapy and peripheral nervous system stimulation, etc. (3)

A pain medicine expert concludes, “It is time for changes in the education of physicians and the provision of care for chronic pain patients.” (6)

REFERENCES
1. International Association for the Study of Pain (IASP). IASP Terminology. https://www.iasp-pain.org/Education/Content.aspx?ItemNumber=1698
2. Human Performance Resource Center. What is the difference between acute and chronic pain? 30, April, 2018.
3. Mills, Sarah. Identification and Management of Chronic Pain in Primary Care: a Review. Curr Psychiatry Rep. 2016; 18: 22. Published online 2016 Jan 28. doi: 10.1007/s11920-015-0659-9
4. Breuer, B. Pain management by primary care physicians, pain physicians, chiropractors, and acupuncturists: a national survey. South Med J. 2010 Aug;103(8):738-47. doi: 10.1097/SMJ.0b013e3181e74ede.
5. IOM (Institute of Medicine). 2011. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press. https://www.uspainfoundation.org/wp-content/uploads/2016/01/IOM-Full-Report.pdf
6. Loeser, John D. The Education of Pain Physicians. Pain Med. First published: 08 January 2014. https://doi.org/10.1111/pme.12335
7. Dansie, E.J. Assessment of Patients with Chronic Pain. Br J Anaesth. 2013 Jul; 111(1): 19–25. doi: 10.1093/bja/aet124.