1. View pain as a chronic disease.
Chronic pain is now seen by many as a chronic disease in its own right. An acceptance of this premise helps both patient and practitioner take a more long-term view of management, as we do with chronic lung or heart disease. This changes the aim of treatment to helping the patient regain control rather than seeking out nonexistent cures.
2. Avoid prescribing more painkillers initially.
It is important for the patient and practitioner to take time to consider the most appropriate course of action (which is rarely to arrange further investigations). Also, possibly the most unhelpful thing to do on first contact is to prescribe yet another painkiller.
3. Split your assessment into two appointments.
Splitting the assessment into two appointments stops you being overwhelmed by what may be a complex situation. The first appointment can seek to answer the question: ‘How did the patient get to this point?’ Ask when the pain started, how it has progressed and how it is now. Also ask about previous investigations and management, including helpful – or otherwise – medications and interventions. The second appointment can then ask: ‘Where is the patient going?’ A realistic plan can help to avoid frustration for both the patient and GP.
4. Explain pacing techniques to patients.
It is useful for you to be able to explain some concepts and managements techniques to patients – for example pacing, where patients gradually increase their level of activity.1 Discussing pacing is a particularly good rapport-building tool, as most patients can relate this to their own experiences. I’ve found this discussion can be done in a couple of minutes of the precious 10-minute consultation and is time well spent. These and other concepts can be found on www.paincommunitycentre.org.
5. Ask specifically about neuropathic pain.
It’s worth asking specifically about neuropathic pain symptoms, such as constant burning pain, intermittent shooting pain that is like an electric shock, dysaesthesia, paraesthesia, hyperalgesia and allodynia. Neuropathic pain will often coexist with chronic pain and responds poorly, in many cases, to standard analgesics. I would suggest familiarising yourself with a few medications that may be helpful for these patients. NICE offers some useful guidance on neuropathic pain management.2
6. Use the STEPS to manage medications.
A useful approach to medicines management in chronic pain is to follow these STEPS:
Safety – is it safe for the patient to continue on this medication in the long term?
Tolerability – can the patient tolerate this medication and its side-effects?
Effect – is the medication effective?
Price – are patients taking the best priced treatment? Expensive medications are fine, as long as they work.
Simplicity – is the analgesic regime as simple as possible? Would a long-acting preparation be preferable to frequent doses of short-acting analgesics?
Also consider non-drug treatments such as warmth, ice, transcutaneous electrical nerve stimulationand acupuncture, which are helpful for some patients, and relaxation techniques, which are useful for most.
7. Use strong opiates with care.
The patient needs to be clear about what you’re trying to achieve by prescribing strong opiates. Used correctly, strong opiates can be very effective in chronic pain management for some patients, but they should be used by practitioners who are confident in doing so. Opiates used in this context are distinct from palliative care, where the emphasis is primarily on symptom alleviation using a combination of short- and long-acting preparations. In contrast, chronic pain management is more about function, in my opinion, and short-acting strong opiates have a very limited – if any – contribution to make. In particular, short-acting strong opiates can quickly lead to a patient and practitioner feeling out of control on ever-escalating doses. The British Pain Society has produced useful guidance on this issue.3
8. Encourage self-management.
Successful pain management depends more on the patient than the GP. Pain management is the patient’s responsibility and the skilled practitioner is able to help the patient find their ability to respond to their chronic pain and its consequences. This may involve simply directing patients to self-management resources such as the pain toolkit, which can be downloaded from pulsetoday.co.uk/tools-and-resources, or self-help groups such as the Expert Patient Program.
9. Remove the focus from the pain.
Patients with chronic pain can have their life dominated by it. In a patient who is managing their pain well, the focus starts to shift away from pain as they begin doing more and getting their ‘life back’. Sometimes the pain may actually stay the same and it’s the other aspects of life that improve, including sleep, exercise tolerance, mood and general wellbeing – which are also very worthy end points. Some time spent addressing poor sleep and depression, although not necessarily directly affecting the pain, can make living with chronic pain more manageable.
10. Aim for continuity.
Take an active interest in your patients’ onward management – enjoy the benefits of a patient-practitioner partnership centred in self-management. Do your best to avoid other practitioners getting involved as this can lead to the patient receiving inconsistent advice, unhelpful medication changes or referrals for often fruitless further investigations.
Dr Tim Williams is a GP principle and community pain specialist in Sheffield.
Dr Williams has received payment for pain-related presentations from the pharmaceutical companies including Pfizer, Grunenthal and Napp. He also deliberated as part of an expert panel, funded by Astellas Pharma, that recommended Qutenza as an appropriate topical treatment for some patients with neuropathic pain. For the last twelve months Dr Williams has led a Health Trainer Community Pain Management Pilot in Sheffield.