The Role of the GP

Dr Ray Doyle outlines the role of the GP in diagnosing chronic pain, including some very helpful definitions and advice.

The statistical information may have changed since this campaign. For more updated information from Irish studies, you can read the PRIME study.

The content from the slides used in the video are reproduced below.

Chronic Pain: What Is The Role of the GP?

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage.

Chronic pain is pain that persists beyond 3 months. It may be recurrent or persistent. It usually affects work, wellbeing and quality of life.

The quality of chronic pain

The quality of Chronic Pain can vary:

Neuropathic (neve) pain: typically has a burning/stinging/shooting, hard to describe quality
Nociceptive (tissue damage): acute sharp, dull or aching. It is a medical term used to describe the pain from physical damage or potential damage to the body.
Pain can have both nerve and non nerve qualities.

Dr Doyle also shares some statistics:

It is estimated that Chronic Pain affects 13% of the Irish population 25% of adults report episodes of back pain within the past month
1 in 40 report disabling neck or back pain
Each year 5% of GP patients consult their GP with low back pain (and that is only one form of Chronic Pain)
Up to 19% of those suffering chronic pain also suffer from depression

Chronic Pain affects a person’s wellbeing, family life, social relationships and ability to work. Few people off work with Chronic Pain for over a year ever get back to work.

Results from the PainSTORY survey of patients

Pain Study Tracking Ongoing Responses for a Year (PainSTORY) was a survey of pain treatments taken over one year. There were 294 Patients from 13 European countries involved.

- 6 out of 10 of people surveyed feel pain controls their life
- 95% suffer moderate to severe pain
- 64% feel they are on the most appropriate medications
- 64% report problems walking
- 60% problems sleeping
- 2 out of 3 admit to feeling anxious/depressed
- 28% admit to wanting to die because of pain severity

What is the role of the GP?

- Prevention
- Diagnosis
- Investigation
- Treatment
- Referral
- Support and continuity of care

Why is the role of the GP so crucial in Chronic Pain diagnosis?

- May know the person prior to the onset of pain
- May know their prior coping skills
- Knowledge of their past medical conditions
- Knowledge of working environment/how pain began
- Knowledge of family and support structures available to sufferer
- Can visit at home during acute pain crises
- Can also provide support to family, friends and carers in their role

. . .

Prevention

Acute pain management

- Treating episodes of acute pain quickly and effectively may prevent the development of chronic pain
- Referring early to other services if need be to achieve this

Identifying risk factors of chronic pain

- Low mood/depression
- Anxiety
- Social/financial/work pressures
- Fears around further injury
- Treating these early if indicated

Explaining chronic pain

- Explaining the mechanisms behind pain and the rate of recovery, and the likely course, providing reassurance
- Exploring and helping to change any misconceptions around pain and the meaning of any painful episode

Advice

- Remain active if at all possible
- Continue working if feasible
- Remain involved in social and other activities
- Avoid too much rest

Follow-up

- Ensure that any acute pain is settled
- Some people may not mention that the pain has not fully settled
- There could be early intervention in the acute stage, if GP believes there is progression to a more chronic phase

. . .

Diagnosis of chronic pain

There are two aspects to diagnosis of chronic pain:

1. Diagnosis of chronic pain itself.
2. Diagnosis of other medical conditions

Treatment may reduce the pain burden (rheumatoid arthritis/gout/ migraine)
Diagnosis of other conditions which may add to the pain burden (depression/anxiety)

. . .

Investigation of chronic pain

In many cases, a careful history and a physical examination will point to a cause.
Blood tests and X Ray/scans may help to confirm a treatable cause for the pain
The GP may be aware of lifestyle and occupational pursuits that may be contributing to the maintenance of the pain
May identify harmful side effects from medication (ie liver and kidney impairment on blood testing)

. . .

Treatment of chronic pain

Treatment should be multidisciplinary and involve GPs, Pain Specialists, Physical Therapists, Psychologists, Occupational Therapists, Surgeons and others.

Treatment needs to be structured and individualised (what suits one person may not suit another)

Patient expectation is important as pain relief may not be the only goal from a patient perspective.

Pain control should start early, be individualised, flexible and have agreed upon goals

There should be encouragement to maintain normal activities if possible, with adequate pain relief.

Pharmacological treatment:

1. Tailor treatment to the patient and the pain type
2. Start at low doses and go slowly up
3. Anti-inflammatory medication used where inflammation is felt to be important
4. Specific medication may be needed for nerve pain. (eg Anticonvulsant or antidepressant medication)
5. Medication for mood and anxiety
6. Agree goals of therapy with any type of treatment

Non-pharmacological treatment:

1. Physiotherapy
2. Other manual therapy: osteopathy, chiropractic, massage, aromatherapy
3. Occupational therapy
4. Psychological support/CBT
5. Acupuncture/dry needling
6. Meditation
7. Exercise

Not all treatments work for all patients. Trial and error is important. Treatments may have side effects. The GP is ideally placed to inform patients about these and what may best suit their patients.