Chronic Pain and Its Management in Primary Care

from Southern Medical Journal

Hani Raoul Khouzam, MD, MPH, Department of Psychiatry, VA Medical Center, Manchester, NH

Abstract and Introduction

Abstract

Background. Chronic pain is commonly encountered in primary care, but it can be difficult to manage.
Methods. The purpose of this article was to review the definition of chronic pain, general guidelines of management, pharmacologic and nonpharmacologic treatment, the role of pain clinics, and rehabilitation goals.
Conclusions. Effective management of chronic pain is usually achieved by an interdisciplinary team, with involvement of both patients and their families, and integrates pharmacologic and nonpharmacologic treatment with needed surgical interventions, psychotherapy, and rehabilitation.

Introduction

Chronic pain (ie, pain lasting more than 3 to 6 months) is one of the most common conditions for which people seek medical attention.^[1] Although chronic pain is less common than acute pain, it may affect at least one of every three Americans at some point in their lives.^[1] It is estimated that every year 40 million American adults will have debilitating headaches, 90 million will complain of joint pain, and about 100 million will report episodes of back pain.^[2] By the turn of the 20th century, the medical treatment of chronic pain in combination with the loss of productivity and financial compensation reached an estimated yearly cost of $100 billion.^[3]

Despite its prevalence, chronic pain remains one of the most poorly understood and untreated conditions in primary care.^[4] This article focuses on the management of chronic nonmalignant pain.

Definition of Pain

The International Association for the Study of Pain defines pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in term of such damage."^[5] This definition highlights the complexity and multidimensional aspect of pain and suggests that pain is not just a reflection of the amount of physical injury but is a process that may be influenced by age, sex, culture, and environment, as well as unique individual makeup.^[6]

General Guidelines in Management

First, managing chronic pain requires an interdisciplinary team and involvement of both patients and their families.^[3] Such a team can be part of primary care setting or a specialty care clinic.^[4] The interdisciplinary team approach is multimodal and includes pharmacologic management, physical rehabilitation, psychologic intervention, behavior modification, and familial and spiritual support.

Second, any patient who has chronic pain needs comprehensive initial assessment, including detailed history, physical examination, diagnostic evaluation, and psychiatric assessment to identify the presence of comorbid psychiatric disorders. When these disorders are treated and the psychosocial stressors that trigger pain exacerbations are addressed, chronic pain levels can substantially decrease.^[8] Patients need to be supported and encouraged to maintain and improve their mobility and daily functioning. They need to be fully engaged in an active, productive life with normal interpersonal and social interactions.^[7]

Third, because the perception of pain is an individualized subjective experience, the most reliable indication of its existence is the patient's report rather than visible clinical signs, radiographic findings, abnormal vital signs, or behavioral disturbances.^[4] The absence of known physical, medical, or surgical causes of pain does not negate the presence of chronic pain.^[3,4]

Fourth, narcotics can alleviate pain when integrated within a rehabilitative model of treatment. The fears of drug dependence and addiction should not deter their usage in patients who respond to their effects and do not show signs of abuse.^[6] Surgical procedures should be used only when there is clear evidence of a reversible problem.