COLLECTED REPORTS ON THE
Rheumatic Diseases
2005
SERIES 4 (REVISED)
Published by the
Arthritis Research Campaign (arc)
Editors:
Ade O Adebajo FRCP(Glasgow)
D John Dickson MBChB FRCP(Glasgow) FRCP(London) MRCGP
These reports are produced under the direction of the
arc Education Sub-Committee.
They were first published individually between 2000 and 2003
and were subsequently reviewed for this volume.
CHRONIC PAIN: A PRIMARY
CARE CONDITION
INTRODUCTION
Blair H Smith
Department of General Practice and Primary Care
University of Aberdeen
Chronic pain presents a major challenge to primary care.
It is a symptom associated with many of the common
primary care conditions, but it may also be regarded
as a distinct entity. It stimulates a huge number of prescriptions, investigations and referrals, causes frustration
in its resistance to treatment, and leaves patients and
doctors with low expectations of successful outcomes.
It is often seen as the side-effect of a ‘more interesting’
condition (such as a connective tissue disease), or an
inevitable part of the ageing process. Its lack of outward
sign may even lead to assumptions about the veracity
or severity of reported symptoms or a search for other
gain (such as social security benefits). Yet research shows
that chronic pain is common and important, may be
preventable, and that general practitioners (GPs) and
their colleagues in primary care have an important role
in its management. Individuals with chronic pain use the
primary care services up to five times more frequently
than the rest of the population.
•Chronic pain is a distinct diagnosis,
encompassing all sites and causes of
long-term pain
•Chronic pain is common and important in primary care
•The effects of chronic pain are farreaching, and are at least as important
as its cause
•General practitioners (GPs) have a
crucial role in assessing and managing
people with chronic pain, treating its
effects to limit disability and maximise
patients’ potential
DEFINITIONS
•Assessment and management must be
multidimensional and rehabilitative, and
agreed, realistic treatment goals are
important
Pain of any kind is difficult to define, in view of its subjective nature. The most commonly accepted definition
is that of the International Association for the Study of
Pain (IASP) which acknowledges the multifactorial
nature and the importance of individual interpretation
and experience:
•Acknowledging the diagnosis of chronic
pain is a simple, yet important, step in
its management
Pain is an unpleasant sensory and emotional experience
associated with actual or potential tissue damage, or
described by the patient in terms of such damage.1
The IASP goes on to define chronic pain as:
Pain which has persisted beyond normal tissue healing
time.2
‘Normal tissue healing time’ is taken (arbitrarily) to be
3 months. This apparently simple definition introduces
the notion of the maladaptive nature of chronic pain.
The difference between acute and chronic pain is more
than one of semantics or of an arbitrary transition point;
chronic pain is not just acute pain that has lasted a long
First published September 2002; reviewed June 2005
125
affects all aspects of physical health, not only those
directly related to the underlying cause. It is associated
with significant disability, unemployment and loss of
other physical roles. These produce social and financial
problems, which include reduced earning capacity, family disharmony and isolation. The interaction between
chronic pain and depression has been well-demonstrated,
and it is likely that ‘bi-directional’ causal mechanisms
are at play. Other psychological consequences include
reduced self-esteem, anxiety and sleep disturbance. Recent research has suggested a higher mortality, particularly from cancer, among people with widespread
benign pain.7
time.3 From the GP’s viewpoint it is important that, while
treatment of acute pain tends to focus on its cause, with
a view to a cure, treatment of chronic pain must also
focus on its effects, with a view to limiting disability and
maximising potential.
Classification of chronic pain is difficult, and is often
based on the site or cause of pain. While there are clearly
important diagnostic and treatment distinctions between
many causes of chronic pain, there are also many similarities, and the severity of chronic pain may be more
important than the cause. This article addresses chronic
pain as a distinct diagnostic concept, which includes pain
arising from all sites and causes. This approach allows
important consideration of the experience and needs
common to all sufferers, encourages practical consideration of the effects of chronic pain, and proposes the
adoption of common management strategies. It also
circumvents difficulties with vague or impossible diagnoses, and with pain arising from multiple causes or
sites.
DIAGNOSIS AND ASSESSMENT
A diagnosis of chronic pain (despite the arbitrary component – see above) is often crucial. There is evidence to
suggest that patients who accept their pain’s chronicity,
rather than continue exclusively to seek relief or cure,
fare better with therapeutic intervention. Retrospectively, many patients report that the moment when their
doctor diagnosed chronic pain (or used an equivalent
term) was the moment when acceptance and a degree
of resolution began. It is, of course, important also to
diagnose and assess any other treatable condition, such
as rheumatoid arthritis or endometriosis; this diagnosis
and consequent treatment will be undertaken using the
usual channels of assessment, investigation and (where
appropriate) referral. It is equally important, however,
to consider chronic pain as a distinct diagnosis, to allow
for both otherwise undiagnosed conditions and the
fact that many ‘treatable’ conditions produce persistent
pain symptoms, which may ultimately become the most
significant and disabling aspect.
EPIDEMIOLOGY OF CHRONIC PAIN
Chronic pain is commoner than many might think. A
World Health Organization (WHO) study across fifteen
countries estimated a prevalence of 22% among primary
care attenders,4 and a literature review of communitybased studies found a prevalence of 15%.5 More recent
work in the UK estimated the population prevalence as
high as 46%.6 Although these high figures undoubtedly
include many in whom the condition is relatively mild,
a reasonable consensus is that the prevalence of severe
disabling chronic pain is between 5% and 10%. There
is consistent evidence that older individuals and those
in lower socio-economic groups are more likely to be
affected, and an inconsistent suggestion that women
are at greater risk. The presence of other psychosocial
characteristics, such as depression or deficient social
support, has also been shown to be associated with
chronic pain, and may provide clues to treatment or prevention. A relative lack of longitudinal research renders
it difficult to distinguish between cause and effect with
many of these associations. Newer evidence is emerging
to support the intuitive impression that recovery from
chronic pain is rare: once an individual has developed
chronic pain, he or she is likely to keep it. This fact requires us to be realistic in our management objectives,
and emphasises the importance of prevention.
The severity of chronic pain is again difficult to assess,
given its subjective nature. Nonetheless, several useful
tools have been devised, and some may be useful in the
context of primary care. The Chronic Pain Grade,8 for
example, provides four hierarchical grades of severity
based on pain intensity and pain-related disability, from
Grade I (low intensity–low disability) to Grade IV (high
disability–severely limiting). This simple, seven-item
questionnaire is responsive to change over time, and
could be used to judge the relative need for treatment
as well as its success. Perhaps 16% of sufferers have the
most severe grade of chronic pain.6
A full assessment of chronic pain must be multidimensional (physical, psychological, social), and may, at its
worst, require admission to a specialist centre in view of
the breadth and depth of potential impact.9 Local hospital
pain management clinics will also provide multidimensional assessment with a view to management. However,
THE IMPACT OF CHRONIC PAIN
Although the experience of chronic pain is subjective, it
has a wide-ranging impact that must be appreciated by
primary care professionals. Chronic pain detrimentally
126
the high prevalence of chronic pain means that the majority of sufferers must be assessed in primary care. With
his/her knowledge of and access to patients’ medical
and social histories, the GP is uniquely placed to assess
chronic pain patients appropriately. This is part of the
specialist discipline of general practice.10 This assessment
will often be informal, will be conducted over several
visits, and will deploy years of accumulated knowledge
of the patient and his/her background. The main message
is, not that this assessment be undertaken (because it
probably will be anyway), but that it is crucial for the
management of the patient with chronic pain.
TABLE1.TheWorldHealthOrganization(WHO)
AnalgesicLadder.12This simple, three-stepped app-
roach to analgesic prescription was originally devised
for cancer pain, but is applicable to most chronic
pain. Move a step up the ladder if pain control is not
achieved on the current step. Adjuvant therapy may
include tricyclic antidepressants or anticonvulsants.
Step 1
Non-opioid
+/– adjuvant therapy
Step 2
Weak opioid + non-opioid
+/– adjuvant therapy
Step 3
Strong opioid + non-opioid
+/– adjuvant therapy
MANAGEMENT
The management of chronic pain has to balance both
treatment and rehabilitation. An evaluation of the therapies available in primary care is beyond the scope of this
article. It is a familiar concept to GPs that cure need not be
the objective of medicine. Perhaps the key is for patients
and professionals to agree realistic goals of treatment,
and, equally importantly, to agree that which cannot be
cured. For example, the goal may be to return to work
(see Figure 1), acknowledging that certain activities will
be limited because of pain.
apy includes corticosteroids and radiotherapy in cancer
pain. The role of ‘unconventional’ analgesics, such as
tricyclic antidepressants and anticonvulsants, is now
well-established in neuropathic pain, and these should
be considered at an early stage. Drug treatment for
specific conditions, such as osteoarthritis and rheumatoid arthritis, has been well-researched and presented
elsewhere. Drug treatment for chronic pain is often
monitored imperfectly, and it is essential to ensure continued safety as well as effectiveness of treatment, remembering particularly that many patients purchase
analgesics over the counter in addition to receiving
prescriptions.
Drug treatment is important, though should not be the
only treatment modality employed. The WHO Analgesic
Ladder (Table 1) is a useful guide, part of whose function is to remind us that there is rarely benefit in trying
alternative therapies on the same rung. Adjuvant ther100%
Other treatment approaches available in primary care
include physical and occupational therapy, psychological treatments such as counselling, and treatment of comorbidity such as depression. These may involve referral
to other members of the primary care team. We must
also address the impact of chronic pain by considering
the effect on employment, providing support with aids
and benefits, and considering the need for home care
management.
Employed
Unable to work
80%
60%
Some treatments (such as disease-modifying antirheumatic drugs) need to be initiated in secondary
care, and other specialist treatments (such as nerve
blocks or surgical interventions) can only be provided by
specialists. Judicious referral to colleagues in secondary
and tertiary care is therefore an important part of the
strategy. Referral to pain management programmes,
where these are available, is also an option. Ultimately,
though, the ongoing care of the patient with chronic
pain is likely to return to the GP, and these referrals will
represent temporary episodes. The GP’s responsibility
is to optimise their long-lasting benefit through the encouragement of realistic expectation and the provision
of continuing medical support. A rehabilitation model
of management should therefore complement specific
treatments (Table 2).
40%
20%
0%
No chronic Grade I
pain
Grade II
Grade III Grade IV
FIGURE1.Chronicpainseverity*andreported
inability to work due to sickness or disability
(peopleofemploymentage).11 Chronic pain reduces the ability to work, and this makes the chronic
pain itself more severe. This graph shows how the percentage of people unable to work for health reasons
is greater in people with severe chronic pain, reaching
60% at the most severe.
*Chronic Pain Grade (see text)
127
agement of chronic pain, and this is an important, even
a specialist role. Many approaches to management are
possible, and a multidimensional approach, in discussion
with the patient, is the most helpful. New methods of
delivery of care are under research, but perhaps the
most important step in management is a mutual acknowledgement of the diagnosis of chronic pain.
TABLE2.Componentsofarehabilitativeapproachtochronicpainmanagement.13 In chronic
pain, rehabilitation is often the aim of management,
rather than cure. This approach must involve many
aspects and disciplines, each with a different objective, but with the overall aim of maximising future
quality of life.
•
•
Assessment
Education
•
•
Improving physical condition
Recovery or maintenance of activities
•
•
Relaxation and sleep management
Medication reduction
•
•
Improving mood and confidence
Improving social functioning
•
•
Improving socio-economic circumstances
Managing relapse
ACKNOWLEDGEMENTS
The author is supported by an NHS R&D Primary Care Career Scientist Award, funded by the Scottish Executive Health Department.
FURTHER READING
Crombie IK, Croft PR, Linton SJ, LeResche L, Von Korff M (ed). Epidemiology of pain. Seattle: IASP Press; 1999.
Clinical Evidence (Musculoskeletal Disorders). www.clinicalevidence.
com/ceweb/conditions/msd/msd.jsp.
REFERENCES
The role of patient organisations, such as Arthritis
Care (www.arthritiscare.org.uk), Pain Association
Scotland (www.painassociation.com), Pain Concern
(www.painconcern.org.uk) and The Pain Relief Foundation (www.painrelieffoundation.org.uk), is also increasing. These can provide individual and group support, with increasing use of internet-based material.
1. Anon. Pain terms: a list with definitions and notes on usage. Recommended by the IASP Subcommittee on Taxonomy. Pain 1979;6(3):24952.
2. Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms. Prepared by the International
Association for the Study of Pain Subcommittee on Taxonomy. Pain
1986; Suppl 3:S1-226.
3. Jayson MIV. Why does acute back pain become chronic? Chronic
back pain is not the same as acute back pain lasting longer. BMJ
1997;314(7095):1639-40.
NEW RESEARCH AND POTENTIAL
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JAMA 1998;280(13):1142]. JAMA 1998;280(2):147-51.
The role of complementary medicine is not yet fully
evaluated. There is no doubt that many (and an increasing number of) patients attend therapists such as
homeopaths, acupuncturists and other healers, many
with apparent benefit despite the lack of objective scientific evidence to support this, and osteopathy is now
almost a part of mainstream medicine. Further research
in this field is required.
5. Verhaak PF, Kerssens JJ, Dekker J, Sorbi MJ, Bensing JM. Prevalence of
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mortality: prospective population based study. BMJ 2001;323(7314):6625.
New or alternative methods of assessing and delivering
care for patients with chronic pain are being explored in
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may be set in individual practices, groups of practices
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SUMMARY
12. World Health Organization. Cancer pain relief and palliative care:
report of a WHO Expert Committee. WHO Technical Report Series
804. Geneva: WHO; 1990.
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In summary, chronic pain is a frequent and important
problem in primary care, with far-reaching implications.
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