Chronic pain
Chronic pain consultations can be a nightmare for patients and doctors alike. The lack of effective treatment options and difficulties with drug addictiveness and side effects are key sources of dissatisfaction. It is surprising, then, that there is relatively little empirical research on the impact of patient–doctor communication on chronic pain consultation satisfaction. A Californian primary care study analysed video recordings of 86 consultations with patients taking long-term opioids for chronic musculoskeletal pain.1 The research team coded all pain-related communication during the visits, and supplemented this with pre- and post-consultation questionnaires. Patient requests for opioid dose increases were positively associated with worse ratings of patient experience and greater physician-reported consultation difficulty. Greater pain severity and more patient questions were each significantly associated with greater physician-reported visit difficulty, but not with patient experience. The authors conclude that primary care training should prioritise responses to patient requests for more opioids, although I’m not sure any amount of training can make these scenarios any easier.
Asthma
Multimorbidity is a fundamental challenge of modern medicine and an area that is now rightly receiving much attention from researchers and support from funding organisations. One of the goals of this research is to describe the prevalence of comorbidities, disease burden, and mortality across different populations. A recent cohort study of asthma patients from 36 primary care centres in Sweden showed that the most prevalent comorbidities were respiratory tract infections, rhinitis, hypertension, anxiety, and depression.2 The comorbidities associated with highest risk of exacerbation, meanwhile, were COPD, rhinitis, and nasal polyps. As this area of research grows, it becomes increasingly apparent that identifying and treating comorbidities is an important part of managing long-term conditions.
Sleep apnoea
When I think of obstructive sleep apnoea (OSA), the caricature that comes to my mind is of an obese lorry driver with a very large neck who presents with daytime sleepiness. The reality, though, is that it can also occur in children and cause significant problems with physical, social, and academic development. In a recent US study, researchers examined OSA screening practices in primary care.3 OSA was suspected in only 20% of snoring children, with large variations between different clinics and individual clinicians. The oldest children were the ones most likely to elicit concern for OSA, though the literature does not support a higher prevalence in this age group. Additionally, children from non-English-speaking families were half as likely to elicit concern for an OSA diagnosis. Although this may be explained by different cultural attitudes to snoring, it could also be a manifestation of the lower quality of care received by non-English-speaking patients across the US health system.
Methadone prescribing
What is the best way to recover from opiate addiction? By stopping cold turkey and struggling through the withdrawal symptoms or by taking a maintenance drug like methadone? I think there are benefits and harms of each, and they probably each have a role for different patients depending on their individual circumstances. For patients who do receive methadone maintenance therapy (MMT), there is increasing recognition that primary care is an ideal setting to manage it. A recent Canadian study explored the factors that primary care physicians consider important when contemplating whether to include methadone prescription into their practice.4
Physician-related factors included access to methadone expertise and help from allied health professionals. Patient-related factors included perceptions of methadone users as a ‘difficult’ patient group, and practice-related factors included unfair remuneration and safety risks. Although many GPs recognised the potential benefits of providing MMT for individuals and their families, policymakers who want them to take on MMT prescribing need to think carefully about how to facilitate and incentivise this in a suitable way.
- © British Journal of General Practice 2018