Chronic Pain in Primary Care: Practice Update

Experiencing pain is as close to a universal human encounter as exists, with the exception of birth and death. Acute pain is often reflexive and serves to prevent immediate injury; somatic pain can be a sign of pathology that needs to be addressed before it progresses, doing irreparable harm, or leads to death. In most cases of acute pain, but in far from all, the etiology is identifiable.

Chronic pain conditions are often a mystery. Unlike acute pain, chronic pain is rarely protective and often has the opposite effect, impairing overall health by limiting a person’s ability to lead an active, engaged life.

Pain is one of the most common reasons for patients to seek care from primary care physicians. For acute pain-from a sore throat, a recent injury, or a disease that can be diagnosed, there is usually a clear treatment path to follow. For chronic pain that may have been present for months, even years, however, the way forward is often much less clear.

A study that examined the impact of disease around the world¹ found that of the most common chronic conditions, seven are primary pain conditions where pain is the chief problem, such as tension-type and migraine headaches, low back and neck pain, and other musculoskeletal conditions. The study also found that chronic low back pain is responsible, by far, for the greatest number of years spent living with a disability. There are many widespread diseases, too, such as diabetes and HIV/AIDS that can cause chronic pain that is difficult to manage.

In the United States, an estimated 126 million have experienced pain during the previous three months with 25 million suffering chronic pain and over 23 million reporting a lot of pain.²

Why do so many people suffer from pain for which health care providers often can offer only limited relief?

There are so many reasons (next)>>

No objective measure

There is no objective, quantitative measure for pain. We practice in a an era of medicine where we have the ability to observe in remarkable detail the internal functions of the body without inflicting damage; to test physiologic function at the level of nano elements; to discuss genetic makeup as it relates to predisposition to specific diseases; and yet, we still have to rely on the patient’s self-report to know if they are experiencing pain or to discern the presence of pain through observation of physical behavior in those of limited cognitive ability. 

Stubborn orthodoxy

Another significant problem is that in our efforts to manage chronic pain, we are still often influenced by beliefs that have been disproven but are still widely held as fact-among our colleagues and our patients as well.  

It is axiomatic in medicine that pain must have an identifiable etiology that can be detected through sufficient inquiry and evaluation. In cases of acute pain, that course of investigation is often rewarded. Too often today, however, patients with persistent pain undergo expensive evaluations that reveal no abnormality at all. On the other side of that coin, and also common, imaging may reveal abnormalities that are determined to be causative and judged to be remediable but for which interventions to correct them provide little if any benefit, and may even exacerbate the pain. For example, it is still commonly believed that bulging vertebral disks cause low back pain, although numerous studies have found little correlation between a this finding and the presence or severity of pain. Moreover, following fusion surgery, less than half of patients realize an optimal outcome, ie, only sporadic pain, slight restriction of function, and only occasional use of analgesics.³

There is little satisfaction for a health care provider in explaining to a patient who has chronic pain that the cause is still a medical mystery-and very little consolation for a patient in hearing the sad truth. In the vast majority of patients with back pain, tension-type headaches, and migraine headaches, definitive evidence of cause remains elusive.

Needed: Better Rx, curricula  

There is also at best limited research in support of the efficacy of many commonly used treatments for chronic pain. Opioid analgesics are widely prescribed for many forms of chronic pain although there are no studies that demonstrate a clear benefit. In fact, rather than helping to improve patient functioning, use of opioids may lead to greater suffering related to misuse, overuse, and, when used chronically, the exacerbation of pain.

Another sad reality too seldom discussed is that despite the ubiquity of human pain, many physicians receive only limited education on effective methods of management in medical school or postgraduate training. This problem has been recognized for at least the past 30 years yet only modest changes to curricula have been made.  

This special report will provide overviews of our current state of knowledge regarding the most common chronic pain conditions that primary care physicians are likely to encounter, with a special focus on appropriate work-ups and therapeutic modalities, modalities that should be avoided, and when referral to physicians in other specialties is indicated.  

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Topics to be covered:

 â–º Low back pain and headaches

 â–º Opioid analgesics: Myths and facts

 â–º Neuropathic pain 

 â–º Pain and depression

Continue to the Chronic Pain Special Report Pre-test

PRE-TEST

The articles in this Special Report will update you on--or reinforce your knowledge of--the most current thinking on the etiology and treatment of chronic pain. But first, take our short pre-test and see what you already do know about the symptoms, assessment, and management of the conditions you see most often in primary care practice. You’ll see these questions again after the final installment of the report.

Question 1:

Answer and Question #2 on Next Page »

The correct answer is F. B and D

Question 2.

Answer and Question #3 on Next Page »

The correct answer is C. A bulging intervertebral disk

Question 3.

Answer and Question #4 on Next Page »

The correct answer is B. Duloxetine

Question 4.

Answer and Question #5 on Next Page »

The correct answer is C. Tension-type headache

Question 5.

Answer and Question #6 on Next Page »

The correct answer is D. Ibuprofen

Question 6.

Answer and Question #7 on Next Page »

The correct answer is C. More frequently in men

Question 7.

Answer and Question #8 on Next Page »

The correct answer is A. Myth

Question 8.

Answer and Question #9 on Next Page »

The correct answer is B. 18%

Question 9.

Answer and Question #10 on Next Page »

The correct answer is C. Tramadol

Question 10.

Answer on Next Page »

The correct answer is A. (venlafaxine) and B. (duloxetine)

Click here to go to Part I. Low Back and Headache Pain and Headache Pain: Practice Update>>