Over the last 20 years or so, high quality epidemiological studies have repeatedly shown that chronic pain is common and important in primary care. Up to half of the population currently has pain that has been present for at least 3 months.1 Studies using even the most exclusive case definitions have found that severe chronic pain is as common as ischaemic heart disease, diabetes or asthma (www.isdscotland.org). For example, high intensity, severely disabling chronic pain was found to affect more than 5% of adults.2 Chronic widespread pain is part of a clinically important spectrum at the far end of which is fibromyalgia, and can be defined specifically as ‘pain that is present both in two contralateral quadrants of the body and in the axial skeleton, present for at least 3 months’;3 the population prevalence of this is also at least 5%.4,5 These and other studies have consistently found that chronic pain is associated with poor physical, psychological and social health, and presents an enormous burden to the individual, society and the health services. Over a quarter of people with chronic pain, and half of those with severe chronic pain, have sought treatment and professional advice recently and frequently,2 most commonly in primary care.6,7
The causes of chronic pain are diverse, but often remain unknown. However, many common risk factors have been identified for chronic pain of any cause, body site or diagnosis. Similarly, the impact and management needs appear to be largely dependent on the severity or extent of pain, rather than on the diagnosis or body site. Despite this, a fruitless, prolonged and expensive search for a cause and cure often stands in the way of management of chronic pain and limitation of its impact. In other cases, the focus may be on treating specific diagnosed conditions (such as diabetes), at the expense of associated or underlying pain (such as diabetic neuropathy). The presence of chronic pain and the suffering it causes can therefore be overlooked by GPs and the rest of the health services.
Two papers in the Journal this month, however, will remind us, and shed some light on our approaches to management. Rohrbeck et al8 identified a group of individuals who presented to primary care with multiple regional pain syndromes, and found that their poor health and presence of other somatic symptoms were similar to those found among patients with chronic widespread pain and fibromyalgia in other settings. They conclude that we should be more aware of the possibility of fibromyalgia and adopt general approaches to pain management, rather than treating each pain symptom separately. Their findings lead them to consider the possible benefits of applying a global chronic pain diagnosis (such as fibromyalgia) more readily than we currently do, with some research suggesting that this may allow patients and physicians to move from a cure-seeking to a rehabilitative model of management.5,9 Labels and perceptions are also important in the patient-initiated study reported from the South of England.10 Opiates are among the most ancient armaments in our pharmacopoeia, yet we have been reluctant to use them in the fight against chronic non-cancer pain. Blake et al 10 found that reasons for this reluctance may be based on false premises, including a fear of addiction and the desperation that a morphine prescription is perceived to imply. Just as importantly, however, they found that overcoming these perceptions and initiating opioid treatment can lead to dramatic improvements in the lives of people with severe, long-term non-cancer pain, when balanced carefully with adverse drug effects and appropriate warnings. This is important and topical.11
Both of these papers highlight the need for GPs to consider things that may not be immediately apparent in patients who present with a significant pain syndrome: first, that this is likely to be part of a wider, long-term serious condition with important associated health implications; and secondly that successful treatment may require drugs and communication skills that we as a profession (and therefore probably also our patients) more usually associate with treatment of terminal illness. The difference is that, while both cancer and chronic pain are often lifelong conditions, the length of life with the latter is generally longer, and the stamina required to face symptoms, use health services and address adverse reactions therefore greater, if less intense.
We must address the management of chronic pain in primary care with the same rigour as for other important chronic conditions. As Rohrbeck et al, point out, and as was recently highlighted in a report commissioned by the Scottish Executive,12 an important first step is to recognise its existence and importance, so that we can apply evidence-based approaches to treatment and prevention. There is good evidence for the effectiveness of many drugs in chronic pain conditions (www.clinicalevidence.com/ceweb/conditions/msd/msd.jsp). The prescription of these according to the World Health Organisation pain ladder (www.who.int/cancer/palliative/painladder/en) is well-established in cancer pain, and may be transferable to non-cancer pain. Medication is therefore important, butinsufficient byitself to manage chronic pain. Most patients obtain incomplete relief from painkillers alone, and seek other forms of treatment.7 It seems intuitive that our understanding and application of the contributing clinical, psychological and social factors should allow the development of other effective treatments. In general, however, randomised controlled trials of non-drug interventions in primary care based on these factors have found, at best, marginal benefit, or none at all. This could be because the interventions need better targeting, because they are based on relatively unimportant risk factors, or because they are in fact ineffective.13 It could also be that GPs are missing opportunities to apply effective interventions by missing, for example, important psychological factors.14
There are several areas of research here to exercise the inquiring mind with a view to developing and improving management strategies for chronic pain in primary care. Much of this is current in various locations internationally, and includes secondary subgroup analysis of existing studies to determine whether interventions of apparently limited effectiveness were more effective in specific patient subgroups; the search for new risk factors for development or persistence of pain (including biological, as well as clinical and psychosocial factors); and the continued attempt to develop and apply new interventions, or to formally test existing interventions in randomised controlled trials.15 These include cognitive behavioural therapies, physical therapies, and complementary and alternative therapies, as well as pharmacological treatments.
Several innovative models of applying traditional primary care management to chronic pain are also being introduced, with the aim of optimising the skills and opportunities that exist in this setting. These include nurse- and pharmacist-led clinics, primary care-based pain management programmes, educational initiatives for patients and professionals, and proposals in the UK for the development of GPs with a Special Interest (GPwSI) in chronic pain. Chronic pain does not exist in a vacuum, and the complexity of comorbidities and multi-dimensional treatment needs suggest that these approaches will have much to offer. Some early evaluative work suggests that these might well be effective approaches,16,17 but rigorous trials are lacking, and this area is still in its infancy. Self-management strategies are also important,18 and it is mutually beneficial to involve the patient in management decisions, as Blake et al found.10
We cannot afford to ignore chronic pain, whether we are patients, clinicians, researchers or health service managers. With primary care at the forefront, there are many possible approaches to its management on the horizon. These will depend upon the arrival of evidence and resources. Meanwhile, however, we are reminded by the papers in this Journal that there is much we can do at a fundamental level to improve the lives of our patients with chronic pain.
- © British Journal of General Practice, 2007.
