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Pain control

1 Pain is common It is estimated that 7.8 million people live with chronic pain in the UK. After mental health, it is the second most common reason to be in receipt of incapacity benefit, which costs the UK economy £126bn a year.

2 Comorbidities are very common in patients with pain These often cause more distress than the pain itself and the pain seldom improves until the secondary problems are addressed. About 49 per cent of patients in pain have depression and 65 per cent have difficulty sleeping. Identifying and treating the associated psychological problems is pivotal to the management of chronic pain in primary care.

3 Consider pain assessment to establish severity GPs are used to assessing blood pressure, pulse, temperature and respiration rate, and pain can be added to this list as the fifth vital sign. Pain is likely to cause the most distress if not assessed.

4 Frequent requests for analgesics are rarely abuse If a patient is frequently asking for more relieving analgesics this may mean the pain is not controlled and needs addressing further. Remember that 100 analgesics taken at a maximum eight tablets per day will only last 12.5 days – repeat prescriptions may need to take this into account.

5 Provide information to empower the patient Patient information leaflets are very useful and inform patients about where to obtain further information. Patients can then be proactive in their approach, which is often more important than the prescription.

6 Suggest 'active rest' Recommendations for active rest should include a programme of structured physical exercises to increase mobility, reduce muscle spasm and importantly to improve posture (both standing and sitting posture). Reinforce the message that aches after or during exercise do not usually mean they are causing further damage. Advise on the use of analgesics for the exercises.

7 Keep drug regimens simple Patients often end up on numerous mild to moderate analgesics, which can be confusing and dangerous. It also leads to poor pain control. Review analgesic prescriptions regularly and check patients know how and when to take them.

8 Refer for multidisciplinary assessment if necessary Pain clinics have an important role, although the availability of resources and waiting lists vary regionally. Where surgery is unlikely to cure the pain or physiotherapy has proved ineffective, patients may benefit from a full multidisciplinary assessment.

9 Chronic pain often has no cure Realistic goal setting is an integral part of primary care and can be used effectively to help the patient follow the correct pathway to managing their pain by setting achievable targets.

10 Use appropriate therapy All pain is not the same and therefore treatment needs to be tailored

to the patient. Consider adjuvant therapy

for neuropathic pains, for example tricyclic antidepressants or anticonvulsants. Severe pain may require opioid therapy, such as fentanyl

or buprenorphine patches, which are highly beneficial (see for a copy of the latest guidelines for using strong opioids). Non-drug therapy may be appropriate for many conditions – the list of treatments is huge.

Martin Johnson is a GP in Barnsley and chair of the RCGP pain committee

Competing interests Dr Johnson regularly chairs meetings and provides consultancy advice for a variety of pharmaceutical companies that include pain management in their portfolio

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