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Managing chronic pain in general practice: a practical guide
Dr Cormac F Mullins – Consultant in Anaesthesia and Pain Medicine Cork University Hospital discusses the challenge of managing pain in general practice and demonstrates strategies in four case studies M any challenges exist to managing chronic pain in general practice including patient complexity, short consultation times, patient expectations of biomedical investigation and treatment, lack of proper service integration and transparency of referral pathways and fear of missed pathology and litigation. 1 Lengthy waiting lists exist for specialist chronic pain services in the Republic of Ireland and wait times greater than six months are associated with a clinical deterioration. 2,3 Sláintecare has emphasised the importance of community services that can appropriately care for certain patient presentations and more efficiently triage referrals. 4 Within chronic pain, this would entail a greater availability of community physiotherapy and integrated musculoskeletal services with access to specialist multidisciplinary input from orthopaedics, pain specialists or rheumatologists to allow for advanced clinical prioritisation of certain patients. 5 While chronic pain transitions to this more integrated model of care, the onus is on clinicians to provide evidence-based treatment with an emphasis on supportive self-management, patient education, tiered interventions, encouraging return to normal activities, work and exercise, and avoid over-reliance on imaging and interventional therapie. 6 Perhaps the most important strategy involves reframing chronic pain for the patient away from a focus on tissue damage and encouraging re-orientation towards usual and meaningful activities. 7 This change in mindset can allow people with chronic pain to be encouraged to break the cycle of fear-avoidance of activity and begin the rehabilitation process in earnest. 8 The purpose of this article is to provide an overview of commonly encountered clinical scenarios in chronic pain and suggested management advice for general practice Case 1 M.B. is a 48-year-old man bus driver who reports low back pain for four weeks duration. There are no red flag symptoms. He is requesting an MRI to get to the bottom of his problems. This is a relatively common presentation in general practice. Reassurance, education and supportive self-management should be employed as first line management with an emphasis on usual activities, exercise and avoiding bed rest. 9-11 Most episodes of back pain improve significantly within six weeks, and low levels of pain are reported at 12 months. 12 There should be a focus on functional goals and improvement (“If you had 50 per cent less pain, what would you do that you can’t do now?”), rather than on spinal abnormalities and investigations. Many patients can exhibit fear-avoidance signs whereby fear of further pain leads to avoidance of physical activity. In a chronic setting, this can lead to further disability and worsening pain. High quality evidence exists for exercise therapy in back pain, fibromyalgia and hip and knee osteoarthritis for reducing pain and improving function. 13 Red flags ( Table 1 ) should be excluded and a neurological and musculoskeletal examination should be conducted to investigate for radiculopathy, a specific biomechanical cause or maladaptive movements. The Keele start back tool is a short and very useful method for quantifying disability and negative beliefs ( https://startback.hfac.keele.ac.uk/training/resources/startback-online/ ). 14 These have been described as yellow flags symptoms, and are a risk factor for chronicity. If identified, these should be prioritised and addressed where possible. Patients can be helpfully stratified into low-, medium-, and high-risk for persistent disabling symptoms. 14 High risk patients should be identified early and considered for referral to physiotherapy and tertiary care if symptoms do not settle. Early imaging is discouraged as this can lead to over-reliance on biomedical modalities rather than focusing on function and relieving disability. Imaging has not been shown to improve patient outcomes and is associated with unnecessary radiation and medical intervention. 15 Guidelines consistently recommend against the use of routine imaging in low back pain except where a specific cause is suspected. 16 As with any chronic medical illness, lifestyle factors such as obesity, 17 smoking, 18 and low levels of physical activity 19 should be addressed. Early supervised physiotherapy is normally not required but it can be considered those with risk factors or for whom recovery is slow. 20 For those with radicular pain or radiculopathy, there is insufficient data to recommend that initial management should differ from the approach outlined here, 9,11 however, referral to specialist centres can be considered with failure to improve for consideration of interventional therapy to augment the recovery. Table 1: Red flag signs and symptoms in back pain Cancer Night pain, thoracic pain/non mechanical Weight loss History of cancer Age <20, >55 Fracture Recent trauma Deformity Osteoporosis Infection Unwell Ex-iVDU Steroids HIV Cauda Equina Bowel bladder dysfunction Loss of perianal sensation Sexual dysfunction MB is wondering what medications he can take in the short-term to help. Pharmacological treatment can be used for those with persistent symptoms. 9 Paracetamol is no longer recommended as first-line in the management of low back pain due to the lack of evidence of its efficacy and possibility of harm. 21 Non-steroidal anti-inflammatory drugs or COX-2 inhibitors should be considered as first-line therapy. Ideally a short course of the lowest effective dose should be used with consideration of the potential side-effects. 11 Most guidelines recommend that weak opioids can be used for short periods, however there is a lack of clear evidence of a benefit and patients should be counselled about side effects. 20 The use of gabapentinoids is being questioned after a randomised controlled trial failed to show any benefit for radicular pain. 22 Muscle relaxants can be considered for a short duration although clear evidence is lacking. 11 The British Pain Society website has patient information leaflets for commonly prescribed medications for pain including NSAIDS, gabapentin, pregabalin, amitriptyline and duloxetine that can be printed and handed to patients. 23 MB is wondering what kind of exercise should he do? There is no evidence to recommend one form of exercise over another. Patients can be asked what kind of activity they enjoy doing and prescribed this as a treatment. There may be specific considerations such as inability to weight bear (“do you ever swim instead?”) or pain when standing up (“are you able to cycle?”). Other options include walking, stretching, strength training, aerobics, aqua-aerobics, hydrotherapy, yoga, chair yoga, pilates and tai-chi. Active engagement in movement is preferable to passive treatments such as massage, acupuncture or spinal manipulation but short courses can be considered for patients who do not respond to other approaches. 9,24 Pacing is a crucial skill to emphasise for those who have chronic pain so that patients can learn to balance their effort expended on physical activity with rest in order to attaining greater function and participation in meaningful activities. 25 Patients should be advised that “pain does not necessarily equal damage and you can push yourself a little but not too much”. Setting realistic activity goals, monitoring progress and being patient is important. Many patient resources exist online for this such as on the Retrain Pain, the Pain Toolkit and IASP website. 26 M.B. is managing much better a few months later but has returned due to a flare up in his symptoms. He wants to discuss his management options again. Two-thirds of patients still report some pain at three months and 12 months. 27 Support, reassurance and encouragement is often required; not necessarily more testing, more medication, more referrals, or more procedures. Referral to a specialist can be made if there is suspicion of specific pathologies, radiculopathy, or if there is no clinical improvement. Interventional pain specialists provide assistance in treating pain conditions, which is optimally delivered within a broader context of optimisation of non-pharmacological approaches including patient education, exercise and supported self-management. Possible interventional approaches include epidural injection, neural blockade, neural ablation and implantable devices. 28 Evidence-based interventional pain procedures are safe with a recent study reporting a minor adverse event rate of 1.4 per cent for lumbar interventional pain procedures. 29 Case 2: AB is a 22-year-old female with pain in many body areas. The pain started in the low back but progressed to involve both arms and legs. AB struggles to do most activities and is struggling to stay in university due to the impact of the pain. She has had numerous investigations including X-rays and MRIs which have not found any cause. She is requesting more medication to help. Recently a third mechanistic descriptor, “nociplastic pain”, has been added to the International Association for the Study of Pain taxonomy. 30 This refers to pain that arises from altered nociception, despite there being no clear evidence of actual or threatened tissue damage causing the activation of nociceptors or evidence for disease or lesion of the somatosensory system causing the pain. It has also been referred to as chronic primary pain. 31 This pain is often non-mechanical, unpredictable, more widespread, and associated with impaired immune factors and other psychosocial factors. Assessment should focus on pain-related disability and other psychosocial factors that may be contributing to the presentation. 30 Supported self-management, avoiding further biomedical investigations and interventions should be stressed. While severe symptoms may require specialist referral, the majority of patients can be successfully managed within primary care. 32 Some medications can be helpful (e.g., pregabalin, duloxetine and amitriptyline) and it is reasonable to provide trials of these but frequently these can cause additional side effects without improving the clinical picture. 33 Establishing the goals of therapy in an empathetic manner is important. Education around chronic primary pain can allow for re-orientation towards treatment goals. Exercise is important in these conditions to reduce further disability. Psychological interventions are normally offered to those with persistent pain who have not responded to other treatments, or those with psychosocial barriers to recovery. These include: mindfulness meditation delivered in person or through a smart phone application; cognitive interventions such cognitive-behavioural therapy, acceptance commitment therapy or compassion-focused therapy; and relaxation therapies. For those with substantial disability, pain management programmes with co-ordinated delivery of psychological interventions and supervised physiotherapy provide better outcomes than standard treatment, however unfortunately access to such services is limited in the Republic of Ireland. 34,35 Pain-management programmes are built around the principles of acceptance-commitment therapy; key pillars of this include establishing goals and values, committed action towards these goals, developing mindfulness skills, acceptance and cognitive defusion. 36 Cognitive behavioural therapy can be useful where unhelpful health-related beliefs exist. Useful books for introducing patients to these concepts include The Happiness Trap by Russ Harris, and Feeling Good Therapy by David D. Burns. Many useful patient resources exist online such as Retrain Pain and the Pain Toolkit. 26 Case 3: NS is a 38-year-old male who was involved in a road traffic accident two years ago. He suffered extensive injuries to his left leg and underwent multiple surgeries but has been discharged from the orthopaedic department following extensive rehabilitation. Unfortunately, he reports ongoing continuous pain in the leg which he reports as “burning” and is associated with electric shocks, numbness and pins and needles. It keeps him up at night and he is wondering what his options are. Neuropathic pain is defined as “pain caused by a lesion or disease in the somatosensory nervous system”. 37 The NeuPSIG guidelines have three levels of certainty for a diagnosis: “possible”, “probable” and “definite”, based on history, examination and investigations respectively. 38 Pain must be in a “neuroanatomically plausible” distribution based on the location of the lesion. Screening tools for neuropathic pain can be used for neuropathic pain including the Douleur Neuropathique en 4 questions (DN4) questionnaire 39 and the painDetect. 40 Examination may reveal signs of allodynia (pain due to a stimulus that does not normally provoke pain) or hyperalgesia (an increased sensitivity to a painful stimulus). There are four first-line medications for neuropathic pain: amitriptyline, gabapentin, pregabalin and duloxetine. 41 These can be employed as monotherapy or as combination therapy. Guidelines recommend trialling these for at least three months at a therapeutic dose, but frequently establishing whether a treatment benefit exists can made much before this. Therapeutic benefit must be balanced against possible side effects which can include drowsiness, weight gain and difficulty concentrating. Topical treatments are useful in discrete areas of peripheral neuropathic pain. This can include topical lignocaine patches or high-strength eight per cent capsaicin patches which can be administered as a day case procedure lasting approximately one hour in the pain clinic. Where medications have failed to provide a meaningful benefit, other treatment options exist. Spinal cord stimulation is a well-established medical device with level one evidence for the management of chronic refractory neuropathic pain. 42 The most common indications for this are failed back surgery syndrome, complex regional pain syndrome, peripheral neuropathy and diabetic neuropathy. It typically involves permanently inserting cylindrical leads into the epidural space which are sutured in place and tunnelled to a remote site and connected to an implantable pulse generator. In recent years, novel technologies including high-frequency, burst, closed-loop and dorsal root ganglion stimulation have provided promising advances and a greater likelihood of relief compared to conventional stimulation. 42 In carefully selected patients, this can lead to substantial improvements in pain, function and quality of life. Case 4: NO’C is a 42-year-old female with a history of worsening headaches which are unilateral and pulsatile in nature. Her headaches are severe and have a lot of migrainous features including nausea, photo/phonophobia and are functionally disabling. There is no aura but they do typically respond to sumatriptan. She is now struggling with headache symptoms most days and that there is rarely a day where she doesn’t take a painkiller for her headache. She has never taken a prophylactic agent or does not keep a headache diary. Chronic migraine patients have headache on at least 15 days a month for greater than three months with eight of those days meeting diagnostic criteria for migraine. 43 Each year, 2.5 per cent of episodic migraine patients progress to chronic migraine. 44 While episodic migraine is a polyphasic disorder with four phases of prodrome, aura, headache and postdrome, chronic migraine rarely follows this pattern, with fluctuation of migraineous symptoms and often a continuous headache present. 42 Medication overuse headache can further complicate the clinical picture. Headache diaries are essential to diagnose migraine and to monitor its response to treatment. They are also helpful in untangling migraine from other headache disorders such as medication overuse headache. The first step in patient assessment here is to exclude secondary headache disorders. The SNOOP mnemonic for red flag symptoms in headache has been expanded to SNNOOP10 ( Table 2 ). 45 Neuroimaging is not indicated in migraine unless there is a suspicion that a secondary cause for the headache is present. MRI may be considered in this case in light of the progressive nature of her symptoms (change of pattern) however, the yield from MRI in cases of headache even with red flag symptoms is very low at approximately 1-2 per cent. 46 The next step involves establishing timing and pattern of the headache considering the diagnostic criteria for migraine. Headache duration between 4-72 hours is required for a migraine diagnosis for an untreated headache but this can complicate the clinical picture if analgesia has been taken. Consideration should be given as to whether this is a chronic headache disorder (>15 days) or an episodic headache disorder (<15 days). If a chronic headache disorder has been identified, consider the features of the headache to determine if it is either a chronic migraine (unilateral, pulsatile, moderate-to-severe intensity, aggravated by physical activity and nausea/vomiting or photo/phonophobia); hemicrania continua (strictly unilateral, daily and continuous, associated autonomic symptoms, indomethacin-sensitive); new daily persistent headache (new onset unremitting headache in those with no prior history of headache disorder, bilateral location, tightening/pressing quality); or chronic tension-type headache (typically evolving from episodic tension type headache, bilateral location, pressing or tightening quality, mild-moderate intensity, not aggravated by physical activity). Excessive acute medication use can lead to medication-overuse headache. 47 Typical culprits include paracetamol or NSAIDS (>15 days per month) or triptans or opioids (>8 days per month). Offending agents should be stopped abruptly rather than gradually and consideration given to commencing prophylactic treatment for the underlying headache disorder. 48 The patient will need to be warned that headache symptoms may get worse before they get better. Transitional treatments, such as greater occipital nerve blocks, can be useful while waiting for uptitration of preventative medication while withdrawing the offending agents. Preventative treatments for chronic migraine should be individualised based on patient co-morbidity and tolerability and more than one agent may be required in certain cases. The greatest evidence base exists for metoprolol, amitriptyline, the calcium antagonist flunarizine, anticonvulsants valproic acid and topiramate. 49 Those who fail three or more preventative medications can be offered botulinum toxin type A for two cycles 12 weeks apart based on the PREEMPT study. 50 This involves administering 155U botulinum toxin type A over a total of 31 fixed-site injection points. The PREEMPT multi-centre RCT demonstrated a significant improvement in the frequency of headache days compared to placebo with a 50 per cent improvement in approximately 50 per cent of patients. Alternatively, chronic migraine or high frequency episodic migraine patients may be candidates for anti-CGRP antibody treatment which has a similar responder rate to botulinum toxin A injections. 51 Table 2: SNNOOP10 list of secondary headache signs and symptoms Case 5: A 39-year-old gentleman with a history of chronic pancreatitis has presented numerous times to the emergency department over the past three months with flare ups of pain. He was prescribed opioids by on his most recent discharge from hospital and says he was told that his GP would continue to prescribe them. He is currently taking oxycontin 20mg BD and oxynorm 10mg up to four times a day. Consultations surrounding opioids and opioid reduction in chronic non-cancer pain can be challenging. When patients present to hospital with severe acute pain, there is a need to balance two competing interests; the need to manage acute pain effectively to prevent its progression to a chronic pain state and the need to minimise the risk of persistent opioid use after this acute phase. 52 Risk factors for progression to chronic pain states include the severity of the acute pain which, if severe, warrants treatment with opioids. However, if caution is not exercised following hospital discharge a patient can inadvertently end up on prolonged opioid therapy. The Opioid Risk Tool is a very quick and helpful tool for use in stratifying those at risk of opioid use disorder based on a family or personal history of prior substance abuse, age 16-45 years, history of preadolescent sexual abuse and psychological comorbidity including ADD, OCD, bipolar, schizophrenia or depression ( https://www.mdcalc.com/calc/1757/opioid-risk-tool-ort-narcotic-abuse ). 53 Those at moderate to high risk require more monitoring (earlier review, limited prescriptions) or referral to a pain specialist. The CDC recently revised its guidelines for opioid prescribing in 2022. 54 Like the 2016 guidelines, opioids are recommended only where necessary, at the lowest effective dose and for no longer than the expected duration of severe pain. For those receiving opioids for 1-3 months (subacute pain), the 2022 guideline advises that a reassessment should occur in order to avoid unintentional initiation of long-term opioid therapy. Like when commencing opioids, this should re-establish the goals of opioid therapy in terms of pain intensity and function, assess for the presence of side effects and therapy should only be continued where the clinical benefits outweigh the risks of therapy. Considering a recent systematic review which demonstrated that nonopioid are as effective as opioids in the treatment of many acute pain states, nonopioids should be optimised. 55 For those who have been receiving opioids for a longer timeframe (e.g., ≥1 year), the new guidelines advise that tapers of 10 per cent per month or slower is likely to be better tolerated. 54 Treatment changes should be conducted in a patient-centred manner with patient education on the risks and benefits of continued therapy with a shared decision-making framework. Motivational interviewing techniques are optimal in this regard and ultimately it will be more successful if the patient wants to reduce their opioids. Therapy should not be tapered stopped abruptly or reduced rapidly and inflexible application of recommended dosage or duration thresholds should be avoided to minimise patient harm. Patient support to facilitate opioid reduction is crucial from both care-givers and from within their social circle. Conclusion Chronic pain is a varied and challenging entity to treat in both a primary and tertiary setting. There is an onus on us as clinicians to provide care that is evidence-based and in line with international guidelines. In spite of this, there is an over-reliance in chronic pain on a biomedical interpretation of illness without appropriate regard to the relevant biopsychosocial contributors. Imaging rates are high with advice about education and staying active is only provided in a few consultations, 56 and the most common treatment provided is medication. 57 Many of the approaches outlined above involve a patient-centred approach where patient education and empowerment is crucial. This is the first step on better management of chronic pain. Continuous effort is required to challenge societal expectations regarding management of chronic pain in order to achieve greater alignment of care with clinical guidelines. Author Dr. Cormac F. Mullins Consultant in Anaesthesia and Pain Medicine Cork University Hospital and South Infirmary Victoria University Hospital, Cork References
Publish Date : 2023-11-01 17:09:52
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