Introduction
Pain is an uncomfortable sensation linked with actual or potential tissue injury. Chronic pain continues beyond the usual healing time of tissues. Acute, chronic pain conversion occurs after about three months. The primary focus of acute pain management is to treat its cause aiming at the cure. On the other hand, chronic pain management focuses on dealing with the effects of pain and enhancing the quality of life (QoL). About 90 percent of patients with chronic pain have underlying long-term conditions such as heart disease and depression. Therefore, chronic pain is associated with a significant increase in suffering and deaths, making it relevant to primary care.
The general practitioner (GP) in primary care provides complete medical care to patients. However, effective chronic pain management depends on a multidisciplinary approach aimed at minimizing pain and teaching patients to cope with chronic pain.
How Is Chronic Pain in Primary Care Identified?
While arriving at a pain diagnosis, it is useful to decipher the mechanism of pain. It can be nociceptive (pain due to tissue damage by physical or chemical agents), neuropathic (due to nerve damage), or a mixture of both. The diagnosis is vital as the clinician can decide on pharmacological and non-pharmacological interventions.
However, it is challenging to assess chronic pain in general practice due to physical, psychological, and social factors. Furthermore, there are many restrictions due to less time and limited resources. Initial assessment should evaluate the severity, impact, frequency, and type of pain. GPs must include screening tools and brief interventions along with identifying the causes.
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STarT [Subgroups for Targeted Treatment] Back Screening Tool (SBST): The STaRT back tool helps physicians in primary care to assess patients whose condition can progress from acute to chronic lower back pain (LBP). However, the tool is only applicable to back pain.
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LANSS Pain Scale: The Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) pain scale is a screening tool for pain analysis and classification. Its primary purpose is to assess if the cause of pain is predominantly neuropathic. The LANSS scale is the only tool to distinguish between neuropathic and nociceptive pain. However, one must note that it assists clinicians in assessing the severity of pain or its causes.
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Brief Pain Inventory: It is a self-reported questionnaire covering the impact of pain on the patient’s life and its management. It also assesses the symptoms and current treatment efficacy. The advantage is that it covers all types of chronic pain rather than assessing them separately.
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Hospital Anxiety and Depression Scale: It can screen patients with chronic pain for other associated medical conditions.
These tools have the potential to aid GPs in identifying patients at risk of chronic pain. Further, GPs can also target treatments to decrease the progression to severe chronic pain.
What Are the Novel Approaches to Managing Chronic Pain in Primary Care?
In chronic pain management in primary care, the aim is to exclude treatable and modifiable disease causes. Then, GPs must support the patient to live with the maximum QoL despite their chronic pain.
GPs must ensure to try any novel treatment so that effective treatments are not discarded due to inappropriate drug timing, poor drug compliance, or unrealistic patient expectations. New patients may consider novel medications for chronic pain ineffective if they do not cure pain. Hence, treatment should incorporate pharmacological and non-pharmacological approaches aimed at the overall management rather than the cause.
Pharmacological-
- Chronic Neuropathic Pain- Patients with predominantly chronic neuropathic pain should be given regular Paracetamol at baseline levels. Then, it must be followed by adjuvant analgesics such as tricyclic antidepressants (TCAs), Gabapentin, and Pregabalin. Topical Lidocaine (a local anesthetic) and Capsaicin (an ingredient found in chilies) can reduce neuropathic pain. However, they should be given in patients for localized pain, or the usual treatments are contraindicated. Tramadol (an opioid analgesic) can also be prescribed in primary care. Still, studies recommend that only specialists or secondary care physicians should prescribe opioids for neuropathic pain.
- Chronic Nociceptive Pain- For chronic nociceptive pain, GPs must try Paracetamol first. Then, Non-steroidal anti-inflammatory drugs (NSAIDs), such as Ibuprofen and Naproxen, should be augmented. But, NSAIDs should be used after noting the patient’s age and underlying medical conditions (asthma, kidney disease, and risk of GI ulcers). Recent research suggests that practitioners prescribe NSAIDs frequently, and patient safety regarding inappropriate dosing is mandatory. Topical NSAIDs (Diclofenac gel) can be effectively prescribed in numerous chronic pain cases. They have better safety and comparable efficacy than oral NSAIDs.
Complementary Therapies: Complementary medicine is an addition to pain control regimens in primary care. A recent survey showed that about 70 percent of patients with chronic pain used complementary therapies. It also revealed that patient satisfaction levels were higher in the group using complementary therapy. The complementary therapies are osteopathy (physical manipulation, massage, and relaxation), chiropractic (manual therapy including spinal manipulation), homeopathy, acupuncture, and herbal practices. Rarely, hypnosis and aromatherapy are used.
Role of Pharmacist: Pharmacists carry expertise in therapy and polypharmacy. New research shows that pharmacists can contribute additional benefits to primary care. Also, one can include them for the provision of information, discussing barriers to chronic pain management, monitoring pain disability, and managing pharmacotherapy. These points can optimize pharmacological treatment for chronic pain and minimize the adverse effects of drugs for patients.
Collaboration: Collaboration between patients and doctors is emphasized and can produce significant improvement in patient outcomes with chronic pain. It is because research aimed at clinicians and patients demonstrates improved management of chronic pain.
Mindfulness: Mindfulness is an approach with benefits to mental and physical processes contributing to behavioral issues and emotional distress in chronic pain patients. It is an emerging tool in research for chronic pain management. Mindfulness helps patients with chronic pain to focus their minds and body together in the moment. Daily mindfulness practice aids patients who have negative thoughts about pain. One must note that these thoughts can affect mood and increase pain duration. Patients can achieve body relaxation by focusing on the breath sensations. All of these can manage pain and reduce depression and anxiety.
Telecare: Telecare in chronic pain patients is growing, revealing its benefits in chronic pain management. It is especially true in the COVID-19 pandemic that called for sudden changes to expand and implement telehealth to enhance care for chronic pain patients. Telecare aptly responds to the challenge of remote care implementation in pain services.
Conclusion
Considering the number of chronic pain patients in primary care, practitioners must have appropriate evidence, training, and resources to manage chronic pain. Recent guidelines and trials show promising results for pharmacological and non-pharmacological interventions in the holistic care of chronic pain patients. However, limited studies focus on chronic pain management in primary care. Therefore, continuing education and research toward targeted primary care for chronic pain can ensure the effective management of patients.
