A practical guide to recognize, assess, treat and evaluate (RATE) primary care patients with chronic pain

ABSTRACT

The management of patients with chronic pain is one of the most important issues In medicine and public health. Chronic pain conditions cause substantial suffering for patients, their significant others and society over years and even decades and increases healthcare utilization resources including the cost of medical care, loss of productivity and provision of disability services. Primary care providers are at the frontline in the identification and management of patients with chronic pain, as the majority of patients enter the healthcare system through primary care and are managed by primary care providers. Due to the complexity of chronic pain and the range of issues involved, the accurate diagnosis of the causes of pain and the formulation of effective treatment plans presents significant challenges in the primary care setting. In this review, we use the classification of pain types based on pathophysiology as the template to guide the assessment, treatment, and monitoring of patients with chronic pain conditions. We outline key methods that can be used to efficiently and accurately diagnose the putative pathophysiological mechanisms underlying chronic pain conditions and describe how this information should be used to tailor the treatment plan to meet the patient’s needs. We discuss methods to evaluate patients and the impact of treatment plans over a series of consultations, with a particular focus on strategies to improve the patient’s ability to self-manage their pain and related symptoms and perform daily functions despite persistent pain. Finally, we introduce the mnemonic RATE (Recognize, Assess, Treat, and Evaluate) as a general strategy that healthcare providers can use to aid their management of patients presenting with chronic pain.

KEYWORDS:

• Chronic pain
• primary care
• multimodal therapy
• bio-psychosocial
• nociceptive
• neuropathic
• nociplastic
• functional outcomes
• practical treatment

Declaration of funding

Development of this manuscript was funded by Pfizer and Eli Lilly and Company.

Disclosure of any financial/other conflicts of interest

Kevin B. Gebke has no disclosures to report. Bill McCarberg has acted as an advisor for Eli Lilly and Company, Scilex and Averitas and holds stock in Johnson and Johnson. Erik Shaw received personal compensation from SPR Therapeutics for consultancy, Tera Sera, Boston Scientific, and BDSI for speaking and Pfizer and Eli Lilly and Company for serving on an advisory board. Dennis C. Turk has received research grants and contracts from the US Food and Drug Administration and US National Institutes of Health and has received compensation for consulting on clinical trial and patient preferences from AccelRx, Eli Lilly and Company, Flexion, Novartis/GlaxoSmithKline, and Pfizer. Wendy L. Wright has acted as a consultant for GlaxoSmithKline and served on a speakers’ bureau for AbbVie, Biohaven, Pfizer, Merck and Sanofi. David Semel is an employee and stockholder of Pfizer. The authors have no other relevant conflicts of interest to disclose. Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Acknowledgments

Medical writing support was provided by Steven Moore, PhD, of Engage Scientific Solutions and was funded by Pfizer and Eli Lilly & Company.

Biographical note

Kevin B. Gebke is the Chair of the Department of Family Medicine, Indiana University School of Medicine and President, IU Health Community Medicine.

Bill McCarberg is Founder of the Chronic Pain Management Program for Kaiser Permanente (retired) in San Diego, California. He is past president of the American Academy of Pain Medicine and president of the Western Pain Society. He is also Adjunct Assistant Clinical Professor at the University of California at San Diego School Medicine.

Erik Shaw is an interventional pain management specialist and Medical Director of the Shepherd Spine and Pain Institute in Atlanta, Georgia.

Dennis C Turk is the John and Emma Bonica Chair of Anesthesiology and Pain Research at the University of Washington Medical School in Seattle, Washington.

Wendy L Wright is an adult and family Nurse Practitioner and the owner of two, nurse practitioner owned and operated clinics within New Hampshire.

David Semel is the US tanezumab Senior Medical Director for Pfizer, he has worked in the pain therapeutic area for 22 years.