Identification and Management of Chronic Pain in Primary Care: a Review

Abstract

Chronic pain is a common, complex, and challenging condition, where understanding the biological, social, physical and psychological contexts is vital to successful outcomes in primary care. In managing chronic pain the focus is often on promoting rehabilitation and maximizing quality of life rather than achieving cure. Recent screening tools and brief intervention techniques can be effective in helping clinicians identify, stratify and manage both patients already living with chronic pain and those who are at risk of developing chronic pain from acute pain. Frequent assessment and re-assessment are key to ensuring treatment is appropriate and safe, as well as minimizing and addressing side effects. Primary care management should be holistic and evidence-based (where possible) and incorporates both pharmacological and non-pharmacological approaches, including psychology, self-management, physiotherapy, peripheral nervous system stimulation, complementary therapies and comprehensive pain-management programmes. These may either be based wholly in primary care or supported by appropriate specialist referral.

Full text

PSYCHIATRY IN PRIMARY CARE (BN GAYNES, SECTION EDITOR)
Identification and Management of Chronic Pain in Primary
Care: a Review
Sarah Mills
1
&Nicola Torrance
1
&Blair H. Smith
1
Published online: 28 January 2016
#The Author(s) 2016. This article is published with open access at Springerlink.com
Abstract Chronic pain is a common, complex, and challeng-
ing condition, where understanding the biological, social,
physical and psychological contexts is vital to successful out-
comes in primary care. In managing chronic pain the focus is
often on promoting rehabilitation and maximizing quality of
life rather than achieving cure. Recent screening tools and
brief intervention techniques can be effective in helping clini-
cians identify, stratifyand manage both patients already living
with chronic pain and those who are at risk of developing
chronic pain from acute pain. Frequent assessment and re-
assessment are key to ensuring treatment is appropriate and
safe, as well as minimizing and addressing side effects.
Primary care management should be holistic and evidence-
based (where possible) and incorporates both pharmacologi-
cal and non-pharmacological approaches, including psychol-
ogy, self-management, physiotherapy, peripheral nervous sys-
tem stimulation, complementary therapies and comprehensive
pain-management programmes. These may either be based
wholly in primary care or supported by appropriate specialist
referral.
Keywords Chronic pain .General practice .Primary care .
Multidisciplinary .Pharmacological
Introduction
Chronic pain is a common condition in primary care and one
that challenges both the distinction between mind and body
and the concept of cure being the goal of medical intervention.
Pain is a complex biopsychosocial phenomenon which
manifests, according to the International Association for the
Study of Pain (IASP) definition, as Ban unpleasant sensory
and emotional experience associated with actual or potential
tissue damage or described by the patient in terms of such
damage^[1]. IASP further defines chronic pain as Bpain which
has persisted beyond normal tissue healing time^. While the
shift from acute to chronic pain is, rather arbitrarily, placed at
12-week duration, the main differentiation in management is
that in acute pain, the focus is on addressing the cause of the
pain, while in chronic pain management, the focus is on ad-
dressing the effects of the pain and maximizing function and
quality of life. The current International Classification of
Diseases (ICD) does not code chronic pain as a distinct diag-
nosis. However, proposals for ICD-11 include a code for
Bchronic pain^and for its subgroups, defining chronic pain
as a distinct clinical entity as opposed to a result of other
clinical conditions [2].
Estimates of the population prevalence of chronic pain vary
widely, with between 8 and 45 % of the population reporting
chronic pain, and between 10 and 15 % of the population
presenting to their general practitioner (GP) [3]. The preva-
lence of chronic pain increases with age.
With pain affecting 100 million Americans [4], 25 million
of whom report chronic daily pain [5], at an estimated eco-
nomic cost of $560–635 billion/year [4,6], chronic pain is one
of the most important issues in both medicine and public
health. Because of the relative newness of pain medicine as
an independent subspecialty, the existence of multiple pain
professional organizations and the increasing demands on
This article is part of the Topical Collection on Psychiatry in Primary
Care
*Sarah Mills
s.e.e.mills@dundee.ac.uk
1
Division of Population Health Sciences, University of Dundee,
Mackenzie Building, Kirsty Semple Way, Dundee DD2
4BF, Scotland, UK
Curr Psychiatry Rep (2016) 18: 22
DOI 10.1007/s11920-015-0659-9
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

the service, pain management risks are being inconsistent and
uncoordinated [4]. It has been argued that Bthe system of pain
care delivery in the United States has not kept pace with so-
cietal needs or the public’s expectations for accessible, quality
pain care^[4]. Addressing chronic pain in a general practice
setting has the potential to be the solution to delivering high-
quality, readily accessible pain management which is avail-
able to the population in the volume required; however, inher-
ent to that solution are the challenges posed by identifying and
managing chronic pain within the constraints of general/
family practice.
Dubois et al. in their report on American pain management
education concluded that Bpain care in America [is]
fragmented, inconsistent, and incomplete, with uneven access
and disparate quality^in which Bundertreatment and dispar-
ities in care have been repeatedly demonstrated^[4]. In the
USA, only 52 % of patients with chronic pain are managed
in primary care, with the rest relying on specialist care pro-
viders [4]. Given that Bthe supply of pain specialists is
exceeded greatly by the demand^[4] and that primary care
represents a more cost-effective mechanism for healthcare de-
livery [7], increasing the volume of patients managed in pri-
mary care could be a crucial step to delivering the coordinated
and consistent care patients with chronic pain require. The
Institute ofMedicine, established that Baddressing the nation’s
enormous burden of pain will require a cultural transformation
in the way pain is understood, assessed and treated^[8].
Chronic pain has wide-reaching personal, social and psy-
chological impacts, as well as national economic conse-
quences. The report BPain in Europe^demonstrated that, most
people who experience chronic pain live with it for at least
7 years and that one in six chronic pain sufferers say that their
pain is sometimes so bad that they want to die [9]. Of partic-
ipants surveyed, 27 % said that they were less able or unable to
maintain relationships with friends and family and over 40 %
of chronic pain sufferers say their pain impacts on everyday
activities [9]. Breivik more recently demonstrated that, in pa-
tients with chronic pain, 21 % had been diagnosed with de-
pression because of their pain, 61 % were less able or unable
to work outside the home, 19 % had lost their job and 13 %
had changed jobs because oftheir pain [10]. It is estimated that
40–60 % of patients with chronic pain have inadequate man-
agement of their pain [9,10].
It is of great relevance to primary care that chronic pain is
also associated with significant increase in morbidity and mor-
tality [11,12], with 20–50 % of chronic pain sufferers having
co-morbid depression [9,13,14•]. In an important study on
multimorbidity, Barnett et al. established that chronic pain is
one of the commonest morbidities to co-occur with other
long-term conditions, but also that 88 % of patients with
chronic pain have other chronic illnesses [9,13,14•]. The
most common comorbidities were cardiovascular disease
and depression. This high prevalence of comorbidities in
patients with chronic pain can limit the applicability and utility
of clinical guidelines to multimorbid patients with chronic
pain [15] and restrict what treatment options can be used in
pain control. Further research on managing chronic pain in
multimorbid patients is essential to optimise improvements
in health status, functioning, and quality of life and possibly
also improve the management of their other major chronic
health conditions [16]. Recent research has demonstrated a
link between chronic pain and mortality. Torrance et al.
established that severe chronic pain was significantly associ-
ated with all-cause mortality and particularly death from car-
diovascular disease [11]. Such evidence suggests that in
assessing patients with chronic pain, physicians should view
chronic pain as a serious risk marker for premature mortality
[11,14•].
Primary care is Bfirst-contact, accessible, continued, com-
prehensive and coordinated care^[17]. In most countries, of
the 20 % of the general population who experience chronic
pain, the overwhelming majority are managed in primary care
by their family doctor (general practitioner, GP), while only
0.5–2%[9] are ever referred to secondary care for pain man-
agement. Consultations on pain account for 22 % of all pri-
mary care consultations [12], and pain is one of the main
reasons for patients seeking contact with healthcare [18].
Patients with chronic pain visit their GP twice as often as
patients without chronic pain [19]. They also have a consid-
erably higher level of use of emergency and unscheduled care
than patients without chronic pain [20,21] risking a care plan
dictated by short-term decision making rather than compre-
hensive oversight of their pain as a whole [22].
GPs see undifferentiated illness in patients whom they as-
sess, diagnose and manage in the space of a 10-minute ap-
pointment. The successful management of chronic pain in
primary care relies on a multidisciplinary and holistic ap-
proach aimed at both minimizing pain as much as possible
and teaching patients how to live well with chronic pain.
Addressing chronic pain in primary care avoids the risk of
Bprofessionals from disparate backgrounds…[offering] treat-
ments based on their specialty skill sets instead of providing
the comprehensive multidisciplinary pain care that many pa-
tients need^[4]. For any advances in identification and man-
agement of chronic pain to be useful in a primary care setting,
they must be useable within the time and resource constraints
and restrictions that are inherent to general practice.
Identification of Chronic Pain in Primary Care
In managing patients with chronic pain in primary care, the
aim is generally to rule out treatable and modifiable causes
and then support the patient to live as well as possible, with the
maximum quality of life in spite of their chronic pain. This
support takes the form of drug, non-drug and self-
management interventions.
22 Page 2 of 9 Curr Psychiatry Rep (2016) 18: 22
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The assessment and management of chronic pain in general
practice is challenging because of its complex multimodal
nature (including physical, psychological and social factors)
and restrictions imposed by available time and resources [23].
Initial assessment should be holistic and includes an evalua-
tion of the severity, impact and type of pain the patient is
experiencing [24•]. GPs must therefore move beyond a search
for identifiable and treatable pathology, though this is also
important.
Screening Tools and Brief Interventions
While there is no substitute for robust clinical assessment,
screening tools can be a useful way to identify patients at risk
of severe chronic pain or complications of chronic pain and to
inform their management (Table 1). Some screening tools for
specific kinds of chronic pain have been shown to be effective
in primary care. The STaRT Back Tool was developed in UK
primary care and is designed to help physicians in the assess-
ment of patients at risk of progressing from acute to chronic
low back pain (LBP) [25]. The tool consists of nine questions
addressing known risk factors. It stratifies patients into low,
medium and high risk and recommends appropriate treatment
for each patient based on their risk level [25]. The STaRT
Back Tool is available free-of-charge at http://www.keele.ac.
uk/sbst/. Traeger et al. have also been developing and
validating a screening tool which can help identify which
individuals are at risk of progressing from acute pain to
chronic pain among those presenting with acute LBP [26].
Tools such as the Leeds Assessment of Neuropathic
Symptoms and Signs (LANSS), the Neuropathic Pain
Diagnostic Questionnaire (DN4) the Neuropathic Pain
Questionnaire (NPQ), ID Pain and PainDETECT are useful
in determining whether pain is likely to be neuropathic, an
important factor in determining subsequent management
[27]. Other tools such as the Hospital Anxiety and
Table 1 Tools for assessing, classifying and predicting pain [25][27,73–75]
Tool Specifics Advantages Disadvantages
STaRT Back Free-of-charge. Consists of nine
questions addressing known risk
factors for progression from acute
to chronic pain.
Clinically relevant and useful.
Stratifies patients into low,
medium and high risk. The tool
recommends appropriate
treatment.
Only applicable to back pain, not
generalizable
Leeds assessment of neuropathic
symptoms and signs (LANSS)
Incorporates sensory description and
bedside examination of sensory
dysfunction. Contains 5 questions
on symptoms and 2 clinical
examination points.
Provides immediate information,
increasing its utility in the
clinical setting. Simple scoring
system. Clinically validated.
The scoring simplicity may affect its
discriminating ability. Not designed
as a pain measurement tool. Does
not take Bnumbness^into account
as a symptom.
Neuropathic Pain Diagnostic
Questionnaire/Douleur
Neuropathique en 4 questions
(DN4)
A clinically administered
questionnaire consisting of 4 main
questions (two addressing
symptoms and two addressing
sensory signs) with a total of 10
sub-points. Of those 10 sub-points,
7 items are based on symptoms
and 3 on clinical examination.
Covers sensory descriptors and
clinical signs. Covers 10 aspects
of pain. Easiest tool to score,
making it clinically very useful.
More detailed than LANSS but may
take longer to administer.
Originally produced in French, the
English version has not been
validated, and its scoring system is
based on the original French
questionnaire.
PainDETECT Based on patient’s self-reported
symptoms in a questionnaire
covering 9 items.
No clinical examination required,
making it easier to administer,
less invasive, and possible to be
delivered by non-clinicians.
Makes it possible to determine
the percentage of neuropathic
pain in ‘total pain’.[76]
Originally developed in German; the
English version has not been
validated. Does not take into
account clinical examination
findings, potentially missing
important clinical information.
Neuropathic Pain Questionnaire
(NPQ)
Contains 12 items; 10 related to
sensations and 2 related to patient
affect
No clinical examination required. Does not take into account clinical
examination findings.
ID Pain Covers 5 items of sensory description.
Contains one clinical question
clarifying if pain is related to joints.
No clinical examination required. Does not include clinical information.
Brief Pain Inventory A 9 question self-reported
questionnaire covering pain, its
management and its impact on the
patient’s life
Takes into account the efficacy of
current treatment and impact on
the patient’slifeaswellasthe
physical symptoms. Useful
measurementtooltoassesspain
over time during treatment.
Covers all pain rather than assessing
neuropathic or nociceptive pain
separately.
Curr Psychiatry Rep (2016) 18: 22 Page 3 of 9 22
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Depression Scale can be useful in screening patients with
chronic pain for other associated psychosocial comorbidities
in the context of a holistic assessment [28].
Current research aims to develop effective screening tools
and brief intervention techniques that can be used by GPs in
consultations. There is ongoing research to determine whether
the addition of patient-focused pain biology education to clin-
ical guideline-based care reduces LBP intensity at 3 months
and prevents their progression to chronic LBP [29]. New re-
search suggests that a model of brief intervention, in which
clinicians give involved feedback on behaviour and how to
reduce pain-generating behaviour, is successful in reducing
chronic pain from medication overuse headaches [30]. These
developments have the potential not only to aid GPs in iden-
tifying patients at risk of chronic pain but also in successfully
targeting early interventions aimed at reducing progression to
severe chronic pain.
Management of Chronic Pain in Primary Care
Assessment and re-assessment are essential in all stages of
managing chronic pain, and it is important to ensure that any
new treatment is given a full and proper trial, so that poten-
tially effective treatments are often not discarded because of
an incomplete trial of treatment, inappropriate timing or dose
of drugs, poor medication compliance and/or mismatched pa-
tient expectations [31]. Particularly, when treatments have
been tried at the onset of chronic pain, patients may consider
them not to have worked because they did not cure the pain;
however, with the continuation of chronic pain and the
shifting of treatment aims from cure to management, patients
may find previously discounted treatments of benefit.
Management should incorporate both pharmacological and
non-pharmacological approaches.
It is useful for GPs and patients to discuss and agree on
treatment goals before initiating treatment in order to have
objective standards against which to assess treatment success
or failure. An overall reduction of painintensity by 30–50 % is
formally considered to be a successful outcome, as is an over-
all improvement in quality of life [32]. It should be made clear
to patients that achieving complete freedom from pain is an
unusual outcome.
Relevant Guidelines
A number of recent comprehensive guidelines focus on the
management of chronic pain and are relevant to primary care.
These include the 2013 Scottish Intercollegiate Guidelines
Network (SIGN) guideline BManagement of chronic pain^
(24), the 2–13 National Institute for Health and Care
Excellence (NICE) guidelines BNeuropathic pain—pharma-
cological management^[33,34], the 2009 American
BClinical Guidelines for the Use of Chronic Opioid Therapy
in Chronic Noncancer Pain^[35], the 2007 Canadian Pain
Society (CPS) guidelines for chronic neuropathic pain [36],
the 2015 IASP Neuropathic Pain Special Interest Group
(NeuPSIG) recommendations on BPharmacotherapy for neu-
ropathic pain in adults^[37•], the 2014 NICE clinical guide-
line BOsteoarthritis: care and management in adults^[38]and
the 2013 British Pain Society (BPS) BGuidance on the
Management of Pain in Older People^[39]and 2010
BOpioids for persistent pain^[40]. The SIGN Guideline is a
particularly robust tool for primary care physicians; a summa-
ry of its recommendations is in Table 2[41].
Drug Interventions
In their large-scale study of chronic pain, Breivik found
that almost half of all people with chronic pain were taking
non-prescription analgesics, including non-steroidal anti-
inflammatory drugs (NSAIDs) (55 %), paracetamol
(acetaminophen) (43 %) and weak opioids (13 %). Two
thirds were taking prescription medicines, including
NSAIDs (44 %), weak opioids (23 %), paracetamol
(acetaminophen) (18 %), COX-2 inhibitors (1–36 %) and
strong opioids (5 %) [10].
Given its good tolerability and efficacy, paracetamol has
long represented a good baseline drug for management of
chronic pain [42]. However, recent studies call this into ques-
tion, and we need a degree of circumspection about even this
basic treatment [16,43]. Additional analgesics should be
targeted to the type of pain. While pain type is broadly either
nociceptive or neuropathic, many pains are mixed, requiring
multi-modal pharmacology [43].
Pain that is predominantly neuropathic should be treated
with baseline regular paracetamol, followed by progression
through tricyclic antidepressants, then gabapentin and then
pregabalin [34]. Topical preparations, including lidocaine
and capsaicin, can be effective in managing neuropathic pain
and should be considered in patients where pain is very local-
ized and/or first-line treatments are contraindicated or have
been insufficient. While tramadol can be initiated in primary
care, it is recommended that morphine only be initiated for
neuropathic pain by secondary care physicians [44]. Patients
requiring strong opiates for neuropathic pain should be con-
sidered for referral to secondary care pain management
services.
For pain that is predominantly nociceptive, paracetamol
should be trialed in the first instance and then augmented as
appropriate with NSAIDs, such as ibuprofen and naproxen,
where no contra-indications exist. NSAIDs should only be
used after taking into account age and comorbidities (includ-
ing asthma, chronic kidney disease and risk of GI bleeding).
Current research suggests that inappropriate NSAID prescrib-
ing is common and needs to be addressed urgently to improve
patient safety [45]. Topical NSAIDs, such as ibuprofen gel,
22 Page 4 of 9 Curr Psychiatry Rep (2016) 18: 22
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can be used effectively in many causes of chronic pain and
have better safety than oral NSAIDs and comparable efficacy;
however, current evidence does not support their use in back
pain [46].
Use of opioids can be considered in patients with chronic
pain; however, extreme caution is needed. It is important to
note that prescribing above 120-mg morphine equivalent dose
per day requires specialist supervision [35]. When evaluating
potential use of opioids, it is important to bear in mind that
there is no evidence for their effectiveness in long-term use
and that there are risks of potentially serious adverse effects
including drowsiness, constipation, endocrine, respiratory de-
pression and even death. Compounding both these factors is
the risk of clinical dependence and addiction, meaning that
once patients have been started on opioids, it can be challeng-
ing to discontinue their use [35].
Patients should have their analgesia reviewed at each as-
sessment, in order to titrate medications to their maximum
effective or tolerated dose, assess the level of analgesia pro-
duced, and withdraw any medications that have not produced
the desired therapeutic effect. As patients’analgesia require-
ments will change over time, regular on-going medication
reviews are required to ensure that the medication continues
to be appropriate, that the analgesia is achieving the best clin-
ical outcome possible and that patients are not experiencing
side effects.
Non-Drug or Complex Interventions
Breivik’s evaluation of patients with chronic pain demonstrat-
ed that one third of chronic pain sufferers were not currently
using any treatment and that two thirds were using non-
medication treatments, including massage (30 %), physical
therapy (21 %) and acupuncture (13 %) [10].
Psychological Approaches
Cognitive-behavioural therapy (CBT) has been used in prima-
ry care both on its own and as part of a comprehensive pain
management programme (PMP). A recent randomized control
trial (RCT) has demonstrated that training healthcare profes-
sionals on a 2-day course allowed them to deliver a CBT-
based intervention in primary care settings to patients with
low back pain [47]. Participants who received CBT had im-
proved measures of disability, reduced pain intensity, reduced
depression and better quality of life 1 year after intervention
Table 2 Summary of some of the recommendations for chronic pain management made in the SIGN guideline.[77] Reproduced from BManaging
chronic pain in the non- specialist setting: A new SIGN guideline^
Area addressed by key
question
Summary of key recommendations Level of
evidence**
Assessment and planning
of care
In order to best direct treatment options, a comprehensive biopsychosocial assessment, including
identification of pain type (e.g. neuropathic) should be carried out in any patient with chronic pain.
GPP
Supported self-management Self-management can be used from an early stage in a pain condition, with patients being directed to
self-help resources at any stage in the patient journey.
GPP
Pharmacological therapies There should be at least annual assessment of patients on pharmacotherapy for chronic pain. GPP
Tricyclic antidepressants should not be used for the management of pain in patients with chronic low back
pain.
A
Amitriptyline (25 to 125 mg/day) should be considered for the treatment of patients with fibromyalgia and
neuropathic pain (excluding HIV-related neuropathic pain).
A
Strong opioids should be considered for chronic low back pain or osteoarthritis and only continued ifthere is
ongoing pain relief.
B
Specialist advice or referral should be considered if there are concerns about rapid opioid dose elevation or if
>180 mg/day morphine equivalent dose is needed
D
Psychologically based
interventions
Consideration should be given for referral to a pain management programme for patients with chronic pain C
There should be an awareness of the impact of healthcare workers behaviour, as well as the treatment
environment, in reinforcing unhelpful responses.
GPP
Physical therapies Any form of exercise or exercise is recommended in for patients with chronic pain. B
In addition to exercise therapy, advice to stay active should be given to patients with chronic low back pain.
This will improve disability in the long term. Advice alone is insufficient.
A
Complementary therapies Acupuncture should be considered for short term relief of pain in patients with chronic low back pain or
osteoarthritis.
A
a
This is not a comprehensive list. In total, 55 graded Recommendations are included in the Guideline
b
The grade of recommendation relates to the strength of the supporting evidence on which the evidence is based. It does not reflect the clinical
importance of the recommendation. Grade A is strongest; Grade D weakest; Good practice points (GPP) represent recommended best practice based
on the clinical experience of the guideline development group
Reproduced by permission of the British Journal of General Practice. Smith BH, Hardman JD, Stein A, et al. Managing chronic pain inthe non-specialist
setting: a new SIGN guideline. Br J Gen Pract 2014; DOI: 10.3399/bjgp14X680737
Curr Psychiatry Rep (2016) 18: 22 Page 5 of 9 22
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than those receiving standard care [48]. More recent evidence
suggests that acceptance and commitment therapy (ACT) can
be as effective as CBT in patients with chronic pain [49]. A
recent Cochrane review of 35 trials examining psychological
approaches to chronic pain management found that behaviour
therapy produced small short-lived benefits, but that patients
who had CBT showed improvements in pain, as well as in
disability, mood and catastrophic thinking [50].
Self-Management
Self-management has been defined as activities which
Benhance function, improve mood and decrease pain^by
targeting and challenging the Bemotional, cognitive and be-
havioural responses to pain^[51]. There is evidence that sup-
ported self-management, for example self-management
programmes and electronic delivery including online re-
sources, is effective to complement other therapies [24•]. For
example, MoodJuice has been developed as a freely available
Chronic Pain Toolkit and Self Help Guide (http://www.
moodjuice.scot.nhs.uk/)) which can be accessed by patients
and which can form a useful framework for self-
management in chronic pain. The Pain Toolkit (http://
www.paintoolkit.org) is another well-established resource.
Boyers et al. determined that self-management is effective
and potentially cost-effective in improving pain among an
older adult population, though noted that further research
was required [52].
Physiotherapy
For musculoskeletal pain, current research confirms the
beneficial effect of physiotherapy on both pain intensity
and on physical function [53]. A recent systematic review
and meta-analysis in physiotherapy for chronic pain dem-
onstrated evidence for the effectiveness of adding motiva-
tional interventions to traditional physiotherapy in terms of
increasing physical activity and patient adherence to phys-
iotherapy exercises [54].
Peripheral Nervous System Stimulation
Trans-cutaneous electronic nerve simulation (TENS) is a pain
relief treatment which is based on the gate-control theory of
pain and which delivers recurrent stimulation to neurons via
electrodes placed on the skin. TENS has been shown to have a
positive analgesia outcome (24) and is a patient-centered ap-
proach in that patients are able to control the frequency, inten-
sity and duration of treatment. One recent study showed that
TENS proved beneficial in 70 % of patients over the course of
2 months and that TENS-responsive patients decreased pain
intensity scores by a mean of 9.8 on a 0–100 mm scale [55].
External noninvasive peripheral nerve stimulation (EN-PNS)
is a novel form of peripheral nerve stimulation that is currently
under development and uses an external nerve-mapping probe
that is placed on the skin and connected to a power source
[56]. Initial clinical trial results indicate the potential for huge
benefit, though the sample size was small [56].
Complementary Therapies
Complementary and alternative medicine (CAM) is a com-
monly used addition to pain control regimens. One recent
survey demonstrated that over 70 % of patients with chronic
pain had used complementary therapies and that levels of
patient satisfaction were higher in the group using CAM
[57]. The complementary therapies most commonly used for
chronic pain are osteopathy, chiropractic, homeopathy, acu-
puncture and herbalism (and rarely hypnosis and aromathera-
py) [58,59]. Most patients using alternative medicine do so in
conjunction with conventional healthcare [58]. There is good
evidence in favour of the use of acupuncture leading to its use
being recommended for patients with osteoarthritis or chronic
low back pain, but limited or absent evidence for the effec-
tiveness of other CAM treatments [24•]. The 2010 NICE
guidelines for LBP advocate the use of spinal manipulation
[60]. However, a more recent systematic review of 26 RCTs
found that, while there is high-quality evidence demonstrating
that spinal manipulation has a small and significant benefit on
pain levels and functional status, there are insufficient data to
determine whether this benefit is clinically relevant or to
gauge its effects on outcomes such as return-to-work,
quality-of-life and financial implications of care [61].
Comprehensive Pain Management Programs
PMPs are effective in both primary and secondary care [23].
One study demonstrated that individuals engaged in PMPs in
primary care required less medication and had lower
healthcare utilization over the following 3 years [62]. In their
new guidelines, the BPS advocates the use of PMPs, based on
cognitive behavioral principles, as the treatment of choice for
people with persistent pain with biopsychosocial dysfunction
[63]. However, in practice, access to PMPs is geographically
restricted, limiting their utility in primary care pain
management.
Emerging Research in Chronic Pain
Pharmacist Roles in Prescribing
Pharmacists have expertise in therapeutics and polypharmacy,
and new research demonstrates that pharmacist prescribing in
primary care has the potential to confer additional benefit over
medication review alone [64]. It has been suggested that
expanding pharmacists’roles to include the provision of
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information, discussing barriers to pain treatment, monitoring
pain disability and appropriately managing pharmacotherapy
optimizes the effectiveness of pharmacological interventions
for chronic pain and minimize adverse effects experienced by
patients [65].
Collaborative Intervention
Collaborative interventions, where the therapeutic relation-
ship between patients and doctors is emphasized, have
been shown to produce modest but statistically significant
improvement in outcomes in patients with chronic pain
[66]. Research exploring interventions targeted at both cli-
nicians and patients demonstrated improved management
in patients with chronic pain [67].
Mindfulness in Chronic Pain
Mindfulness, an approach aimed at developing beneficial re-
actions to both mental and physical processes that contribute
to dysfunctional behaviour and emotional distress, has fea-
tured as a tool in emerging research in chronic pain manage-
ment. McCubbin et al. demonstrated that mindfulness was
associated with improvements in patient-centered outcomes
for over a year after initial intervention and with a reduced
utilization of healthcare services for up to 18 months [68]. In
their study of Mindfulness Based Functional Therapy
(MBFT) in primary care, Schutze et al. showed good patient
adherence and satisfaction, reduced pain catastrophising and
improved physical functioning among people with chronic
LBP [69]. In spite of a number of recent studies in this area,
however, in their meta-analysis, Bawa et al. demonstrated on-
ly limited evidence in support of mindfulness-based interven-
tions for patients with chronic pain and called for more and
better studies in this area [70,71].
Tele ca re
The use of telecare in patients with chronic pain is growing
an evidence base suggesting it is beneficial in chronic pain
management. Kroenke et al. demonstrated that telecare
doubled the number of patients who achieved a reduction
in their pain of over 30 %. This pain reduction was
sustained at 12 months [72].
Decision Support Tool for Clinicians
The BPS has produced patient care pathways for chronic pain,
in collaboration with BMap of Medicine^, intended for use in
primary care. These decision maps are tools which are avail-
able online to any healthcare professional, as well as members
of the public, via http://bps.mapofmedicine.com/evidence/
bps/index.html. They are designed to present evidence-based
medicine in clinical flowcharts to help clinicians apply the best
evidence to the patient in front of them. They have developed
five evidence-based pain pathways covering chronic pelvic
pain, chronic widespread pain including fibromyalgia, neuro-
pathic pain, low back and radicular pain and initial assessment
and early management of pain. Such interactive flowcharts
have the potential to improve the management of chronic pain.
Conclusion
Given the frequency of chronic pain as a presentation in pri-
mary care, and that the vast majority of patients with chronic
pain are managed in primary care, GPs should have adequate
evidence, training and resources to assess and manage chronic
pain. Recent high-quality guidelines are available, and some
trials show encouraging results for the application of pharma-
cological and non-pharmacological interventions in the holis-
tic management of patients with chronic pain. However, there
continues to be a relative lack of high-quality primary-care-
focused research in chronic pain. Further education, research
and resourcing targeted at primary care management of chron-
ic pain is required to ensure that the care being delivered is as
efficient, effective and evidence-based as possible.
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no competing
interests.
Human and Animal Rights and Informed Consent This article does
not contain any studies with human or animal subjects performed by any
of the authors.
Open Access This article is distributed under the terms of the Creative
Commons Attribution 4.0 International License (http://
creativecommons.org/licenses/by/4.0/), which permits unrestricted use,
distribution, and reproduction in any medium, provided you give appro-
priate credit to the original author(s) and the source, provide a link to the
Creative Commons license, and indicate if changes were made.
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