Rethinking chronic pain in a primary care setting

Figures & data

Figure 1. (A) The three main types of pain pathophysiology give rise to chronic pain conditions. (B) These types of pain may present separately or in combination to contribute to the overall pain experience.

PHN = postherpetic neuralgia; pDPN = painful diabetic peripheral neuropathy.

Table 1. Consensus among guidelines for the treatment of chronic pain.

Guideline	Year	Topic	Biopsychosocial management	Multidisciplinary approach	Use of opioids	Assess pain mechanism
ASIPP: Guidelines for Responsible Opioid Prescribing in Chronic Non-Cancer Pain [72]	2012	Opioid use	✓	✓	2nd line	✓
VA-DOD: management of opioid therapy for chronic pain [73]	2010	Opioid use	✓	✓	2nd line	✓
Washington State Interagency Guideline on Opioid Dosing for Chronic Non-Cancer Pain [74]	2015	Opioid use	✓	✓	2nd line	✓
APS-AAPM: use of chronic opioid therapy in chronic noncancer pain [75]	2009	Opioid use	✓	✓	2nd line	✓
Utah clinical guidelines on prescribing opioids for treatment of pain [76]x	2010	Opioid use	✓	✓	2nd line	✓
ICSI Health Care Guideline: assessment and management of chronic pain (2013 update) [77]	2013	Chronic noncancer pain	✓	✓	2nd line	✓
ACR: recommendation for the use of nonpharmacologic and pharmacologic therapies in OA of the hand, hip, and knee [78]	2012	OA	✓	✓	2nd line	No mention
ACR: guidelines for the management of rheumatoid arthritis [79]	2002	RA	✓	✓	No mention	No mention
AAN/AANEM/AAMP&R: Evidence-based Guideline: treatment of painful diabetic neuropathy [18]	2011	pDPN	✓	No mention	Level B evidence	No mention
IASP/NeuPSIG: pharmacologic management of neuropathic pain [19]	2010	Neuropathic	✓	✓	2nd line	✓
EFNS guidelines on the pharmacological treatment of neuropathic pain (2010 revision) [20]	2010	Neuropathic	No mention	No mention	2nd or 3rd line	✓
Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome [22]	2012	FM	✓	✓	Discouraged	✓
EULAR: evidence based recommendations for the management of fibromyalgia syndrome [21]	2008	FM	✓	✓	Not recommended	✓

ASIPP: American Society of Interventional Pain Physicians; VA-DOD: Veteran’s Affairs-Department of Defense; APS-AAPM: America Pain Society-American Academy of Pain Medicine; ICSI: Institute for Clinical Systems Improvement; ACR: American College of Rheumatology; OA: osteoarthritis; AAN/AANEM/AAMP&R: American Academy of Neurology/American Association of Neuromuscular & Electrodiagnostic Medicine/American Academy of Physical Medicine and Rehabilitation; IASP/NeupSIG: International Association for the Study of Pain/Neuropathic Pain Special Interest Group; EFNS: European Federation of Neurological Societies; EULAR: European League Against Rheumatism.

Table 2. Patient pain descriptors/reported symptoms among the three types of pain.

Nociceptive pain	Neuropathic pain	Sensory hypersensitivity
Sore Throbbing Dull Tender Aching Cramping	Hot Burning Electric shocks Stabbing Painful cold Tingling Prickling Numbness Pins and needles Allodynia Hyperalgesia	Symptoms vary but may include: Widespread pain with neuropathic pain qualities including allodynia and hyperalgesia Fatigue Nonrestorative sleep Cognitive dysfunction Mood disturbance Hypersensitivity to sensory input such as bright lights, loud noises, and smells

Figure 2. Recommended medication classes for the three types of pain pathophysiology.

^aBased on strength of clinical evidence. NSAIDs = nonsteroidal anti-inflammatory drugs; AEDs = antiepileptic drugs; SNRIs = serotonin-norepinephrine reuptake inhibitors; TCAs = tricyclic antidepressants.

Figure 3. A 4-step approach to universal precautions for opioid prescribing in patients with chronic pain.

Universal precautions in opioid prescribing for chronic pain are recommended. Used with permission from www.rethinkopioids.com[72] Copyright ©2014 Pfizer Inc.

Table 3. Key elements regarding the assessment of the patient with chronic pain.

Assessment	Items to review	Tools available
Basic assessment of the patient	General health status; medical history; comorbid conditions; prior and current medication; family history	No specialized tools needed
Basic pain assessment	Severity; location; duration	No specialized tools needed
Assessment of pain pathophysiology	Description of pain; presence of hyperalgesia; allodynia; signs of hypersensitivity to noise, light, or smell	IDPain; PainDETECT; FS; and others
Assessment of psychosocial factors	Effects on function; mood; sleep; interactions with others	ACT-UP and others

FS: Fibromyalgia Survey; ACT-UP: how pain affects patient Activity, how patients Cope with their pain, how patients Think about their pain, how pain Upsets their mood, and how pain affects their interaction with People.

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