Chronic pain: Is it the bane of your general practice?

Chronic pain is a significant public health problem in Australia.1 Recent figures and surveys suggest that chronic pain affects approximately 17% of males and 20% of Australian females.1,2 Prevalence rates are even higher within older age brackets of both sexes. A population-based survey by Walker et al (2004) emphasised the magnitude of lower back pain (LBP) problems.3 The lifetime prevalence of LBP was quoted at nearly 80%. Whilst most of this pain was low-intensity and low-disability pain, about 10% of respondents were significantly disabled by their LBP within the previous 6-month period.3

Common sites for pain include the back (45%), legs (42%), shoulder (29%), arm (22%) and neck (20%) but occasionally pain may affect multiple body sites.⁴ The majority of chronic pain develops secondary to injuries sustained during sport or work, highlighting the potential for preventative strategies.⁴ In particular, strategies need to be developed to prevent primary injury and avoid progression from acute to chronic pain. Unfortunately there are currently no clinical guidelines addressing these issues.

It has been demonstrated that chronic pain can substantially impact on the activities of daily living of patients. A survey by Blyth et al. (2001) revealed that chronic pain interfered with daily activities in 11% of males and 13.5% of females.² Furthermore, chronic pain may cause psychological distress, lead to poor self-rated health, impede quality of life, and increase the need for disability benefits and health care services.^1,2 In addition, chronic pain is associated with high levels of analgesic use and other non-pharmacological pain-related interventions.⁴ The risks of self-medication and polypharmacy of analgesic medications may cause serious health consequences.

Several studies have investigated the interaction of chronic pain sufferers with health services.^1,4 It is well demonstrated that pain is a frequent reason for general practice consultation in Australia.⁵ Studies have confirmed that chronic pain sufferers access and consume health services at excessive rates, even after consideration of confounding factors (such as age, gender, general health, co-morbidities psychological distress and access to care).^1,5 The extent of use is directly related to the level of pain related disability.¹ Patients with disabling chronic pain are twice as likely to have been hospitalised or to have attended the GP in the last 12 months and five times as likely to have visited an emergency department.¹ In addition, most patients will access a variety of multidisciplinary services including pharmacists, physiotherapist, chiropractor, orthopaedic surgeons and occasionally mental health services, thus emphasising the large burden of chronic pain on the entire Australian health system.⁴

Neuropathic pain has been identified as a common feature of chronic pain syndromes. Broadly defined, neuropathic pain refers to pain initiated or caused by lesions or dysfunction in the peripheral or central nervous systems.^6,7 Patients may describe burning, shooting, cold or tingling sensations in conjunction with pain.⁶ General practitioners are now armed with tools such as the DN4 Neuropathic Pain Diagnostic Questionnaire to identify and manage this problem.⁶ Neuropathic pain is particularly difficult to treat. It is now recommended that all chronic pain patients with neuropathic components should be offered a trial of treatment and enrolled in a multidisciplinary pain clinic to minimise the distress caused by this disorder.⁷ Pharmacological options include antidepressants, anticonvulsants and opioids.⁷ Australian treatment algorithms in primary care suggest pregabalin and gabapentin should be first line treatments for chronic pain with neuropathic components due to their proven efficacy and lack of serious adverse effects.⁸

The magnitude of chronic pain in general practice and the burden on the community cannot be under-estimated. Despite the prevalence of this condition, there are no national guidelines on the management of chronic pain, in contrast to well-developed guidelines for acute pain.⁴ There are various treatments for chronic pain with proven efficacy, so appropriate guidelines need to be developed to guide medical professionals to develop a coordinated approach to the management of pain-related disability.⁴ Future research into the management of chronic pain will also be welcomed.

Click here to view the DN4 patient questionnaire.

References:

Blyth FM, et al. Chronic pain and frequent use of health care. Pain 2004; 111 (1-2): 51-8.
Blyth FM, et al. Chronic pain in Australia: a prevalence study. Pain. 2001; 89(2-3): 127-34.
Walker BF, et al. Low back pain in Australian adults: prevalence and associated disability. J Manipulative Physiol Ther. 2004; 27(4): 238-44.
Blyth FM, et al. Chronic pain-related disability and use of analgesia and health services in a Sydney community. Med J Aust. 2003; 179 (2): 84-7.
Knox SA, Britt H. The contribution of demographic and morbidity factors to self-reported visit frequency of patients: a cross-sectional study of general practice patients in Australia. BMC Fam Pract. 2004; 20: 5:17.
Bouhassira D, et al. Positive management of persistent pain – a nNeuropathic pain diagnostic questionnaire (DN4). Pain 2005; 114(1-2): 29-36.
Helme R. Drug treatment of neuropathic pain. Australian Prescriber 2006; 29 (3): 72-75.
SPHERE. Positive management of persistent pain – neuropathic pain treatment algorithm and diagnostic questionnaire. Available at http:/www.spheregp.com.au/index.htm