Practical approach to a patient with chronic pain of uncertain etiology in primary care

Figures & data

Box 1 Common types of chronic pain with uncertain etiology

Low back pain

Chronic headache

Musculoskeletal/joint pain

Chronic pelvic pain

Temporomandibular disorder

Abdominal pain/irritable bowel syndrome

Fibromyalgia

Chronic widespread pain

Note: Data from Jackson et al¹⁹ and Treede et al.²⁰

Box 2 Associated and contributory behavioral and psychological factors in chronic pain

Belief that pain and activity are “harmful” Depression, anger, frustration Anxiety, fear, aversion (intention to avoid factors associated with pain) Catastrophization (tendency to exaggerate the severity of pain or associated outcomes) Reduced activity level, withdrawal from daily activities Sleep disturbance Dependence on medication and increased use of health care services Over-dependence on family and other carers Social withdrawal, social anxiety Extended rest, disability, problems at and absenteeism from work, poor performance/dissatisfaction at work Adverse impact on social relationships, social isolation Poor self-image, low self-esteem, role confusion High intake of alcohol or other harmful substances Compensation issues Financial difficulties Suicide risk Spiritual emptiness, lack of meaning, religious needs Perceived injustice (Why did this happen to me?; Nobody understands me)

Note: Data from references ⁷, ²⁵, and ^32–34.

Figure 1 Multiple mechanisms of chronic pain and potential effects of management strategies.

Table 1 Effect of pain modulators on general pain mechanisms

Mechanism	Pain modulator
	Anti-inflammatory; immunosuppressant	Gabapentanoid	Antidepressant
Peripheral sensitization	✓		Possibly
Ectopic activity		✓
Central sensitization		✓	✓
Central disinhibition		✓	✓

Note: Data from Vardeh et al.⁴

Figure 2 Bidirectional relationships between pain, mood and sleep.

Notes: Adapted with permission from Jain R, Webb DA. Chronic pain: addressing the triad of pain, sleep and depression/anxiety. SA J Diabetes. 2016;9(3):7–11. © Homestead Publishing (Pty) Ltd.³⁹

Box 3 General principles for biopsychosocial management of chronic pain of uncertain etiology

The management approach is primarily nonpharmacological with pharmacological modalities if necessary. Unnecessary medication should be avoided. Assess pain and its impact on functioning. Assess and manage risk factors for chronic pain, including mood and sleep. Discuss realistic expectations of treatment outcomes (ie, improvement in function). Validate the patient’s experience and empower them to take responsibility for self-management. Involve other health professionals from the onset (eg, biokineticist, physiotherapist, psychologist). Avoid unnecessary additional special investigations. Assess and rationalize current medication, including an assessment for analgesic-induced pain (eg, rebound, withdrawal). Opioids (including codeine-containing formulations) should be tapered and preferably discontinued. Pharmacological management should be carefully considered and may require rational polypharmacy. Encourage increased movement, healthy nutrition and socialization. Encourage early return to normal daily activities and work.

Note: Data from references ⁷, ¹³, ¹⁵, ³², ³³, ⁴⁶, and ^52–58.

Box 4 Helpful brief screening questions to identify risk factors for chronic pain, disability and delayed return to work

What do you think is the cause of your pain? How has your pain affected your life? What do you think will help you with your pain? What are you doing to cope with your pain? Do you feel depressed? Do you feel anxious? How well are you sleeping? Do you feel rested when you wake up in the morning? How has your family/co-workers/employer responded to your pain? Have you had time off work due to pain? When do you think you might return to work?

Notes: Data from Kendall et al³⁴ and Goertz et al.⁵⁹

Table 2 Examples of foods appropriate to an anti-inflammatory eating plan

Eat more of	Eat less of
Green leafy vegetables Other colorful vegetables, including beans, squash, broccoli, carrots, celery Nuts and seeds Fruit and berries (fresh fruit is encouraged) Whole grains Omega 3; fish Yogurt, fresh cheese (eg, ricotta, mozzarella, cottage cheese) Poultry, lean meat, eggs Extra virgin olive, canola oils	Red meats Omega 6 (vegetable oils) Saturated and trans fats Butter and stick margarine High-glycemic and refined carbohydrates (eg, grains and starches) Pastries, chips and sweets Processed meats Fried/fast foods Alcohol Caffeine Foods with added sugar/fructose syrup and/or salt

Notes: Data from references ⁵⁶, ⁵⁷, ⁶⁵, ⁶⁸.

Table 3 Relative indications for choosing a specific pain modulator

Amitriptyline	Pregabalin/gabapentin	Duloxetine
Comorbid insomnia Comorbid headache disorder	Comorbid anxiety Insomnia Neuropathic pain component	Comorbid depression Neuropathic pain component

Notes: Data from National Institute for Health and Care Excellence (NICE),¹³ Chetty et al,¹⁵ and Verdu et al.⁹⁰

Box 6 Concerns associated with long-term use of benzodiazepines

Over-sedation Drug interactions Cognitive difficulties Neurodegeneration Falls and associated trauma Reduced mobility and driving skills

Poor sleep quality Depression and emotional blunting Adverse effects (elderly; pregnancy) Drug abuse/dependence Socio-economic costs with long-term use

Notes: Data from Ashton.⁹⁴

Box 5 Sleep health recommendations

The bed is only for sleep and sex. Avoid daytime napping. Avoid caffeine from 14 00 hrs (eg, drinks; combination medicines, such as treatments for “flu”). Electronic devices should be avoided within 90 mins before bed time. Enjoy a warm bath or shower before bed. Eliminate ambient light in the bedroom. If you are unable to sleep, get up and go to another room Do something quiet, calm and relaxing in dim light. Do not fall asleep anywhere other than your bed. Do not watch the clock. Go back to bed when sleepy. Go to bed at the same time each evening and get out of bed at the same time each morning. Always use the alarm in the morning set for the same time. Ensure adequate sleep on weekends to compensate for the sleep debt accumulated during the working week.

Notes: Data from Webb et al.⁶³

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