Integration and coordination of pain management in primary care

Pain is one of the most common symptoms reported to primary care providers and has significant implications for health care costs. The primary aim of this article is to describe and illustrate how to integrate the treatment of chronic pain in the primary care setting. First, we address the integration and coordination of care between mental health and primary care. We then present a typical case and discuss the patient's treatment, outcome, and prognosis. The article concludes with a discussion of issues that frequently arise when integrating psychological treatment for pain in primary care settings.     

Low back pain patients in primary care: Subgroups based on the multidimensional pain inventory

Classification of patients into homogeneous subgroups is an important objective in primary care management of low back pain patients. The purpose of this studyis to (a) identify and describe cluster profiles based on self-reported multidimensional pain inventory Scale (MPI) scores among subacute and chronic nonspecific low back pain patients; (b) describe characteristics of the clusters in relation to disability, life satisfaction, functional self-efficacy, and exercise self-efficacy; and (c) compare grouping by clusters based on self-reported MPI scores with grouping by symptom duration. Eighty-eight individuals participated. These had a median lower back pain duration of 7 months (range 1 to 144 months). Three clusters were identified; these were labeled interpersonally distressed, adaptive copers, and dysfunctional. The clusters differed significantly in disability and functional self-efficacy scores, but not in life satisfaction and exercise self-efficacy scores. The results of this study in a primary care setting are discussed in relation to previous results in pain clinic settings.     

Patients' versus general practitioners' assessments of pain intensity in primary care patients with non-cancer pain.

Pain is a major cause for visiting a primary care physician. There are, however, few studies on the assessment of pain patients at the primary care level. The aim of this cross-sectional study was to investigate the concordance between general practitioners' (GPs') and patients' assessments of pain intensity and whether this assessment is influenced by the duration or intensity of pain. Seven hundred and thirty-eight patients aged 16 to 75 years, who were visiting a GP because of pain, participated. Both the patients and the GPs rated pain intensity using the horizontal 100 mm Visual Analogue Scale (VAS). Means and correlations were calculated using non-parametric tests. The VAS scales were arbitrarily divided into five grades (one unit = 20 mm) to investigate the concordance between GPs' and patients' assessments of pain intensity. Spearman 's correlation coefficient between GPs' and patients' assessments was 0.31 for non-chronic pain (of duration less than six months) and 0.20 for chronic pain. GPs evaluated graded pain intensity at least one unit lower than patients in 37% of the visits. In one-fifth of the visits (20.5%), the GP's rating was at least two units lower than the patient's rating. The more severe the pain as assessed by patients, the greater the non-concordance between patients' and GPs' assessments. There was considerable non-concordance between GPs' and patients' assessments of pain intensity. GPs tended to estimate their patients' pain intensity as clinically significantly lower than the patients themselves, particularly in chronic and severe pain.     

Screening older people with musculoskeletal pain for depressive symptoms in primary care

Background

Older patients presenting to GPs with musculoskeletal pain are at high risk of having concurrent depression.

Aim

To investigate the performance of ultra-short (1–4 items tools) screening questions used during the consultation, and through a patient questionnaire to detect depressive symptoms among older adults presenting with musculoskeletal pain to general practice.

Design of study

Cross-sectional survey, linked GP consultation data.

Setting

General practices in central Cheshire, UK.

Method

Consecutive patients aged ≥50 years presenting with non-inflammatory musculoskeletal pain were eligible to participate. GPs screened all patients in the consultation for the presence of depressive symptoms using two questions. All patients were sent a postal questionnaire within 1 week of consultation containing the Hospital Anxiety and Depression Scale and the written version of the depression screening questions.

Results

The total number of patients included in the study was 428. In total, 35.5% of consulters had comorbid depressive symptoms, with 13.5% experiencing moderate or severe symptoms. Just over half of participants (n = 218/242; 51.4%) screened positive on self-administered screening at home compared with only 78 (20.8%) on GP-administered screening in the consultation. There was little difference between GPadministered and self-administered screening in the probability of depressive symptoms among those who screened positive with regard to exhibiting signs of having depressive symptoms.

Conclusion

Older patients consulting their GP with musculoskeletal pain frequently have comorbid mental ill health. Ultrashort depression screening questions administered during the consultation miss a large number of those with depressive symptoms, including six out of eight patients with severe symptoms. An improvement in the performance of screening questions in this patient group or narrowing the definition of ‘high risk’ from all patients aged ≥50 years presenting with musculoskeletal pain could help to improve detection.     

Self-management practices among primary care patients with musculoskeletal pain and depression

The objective of this study was to assess the effect of clinical depression on pain self-management practices. We employed a cross-sectional analysis of baseline data from the Stepped Care for Affective disorders and Musculoskeletal Pain (SCAMP) study. Participants included 250 patients with pain and comorbid depression and 250 patients with pain only and were enrolled from urban university and VA primary care clinics. Musculoskeletal pain was defined as low back, hip or knee pain present >or=3 months and with at least a moderate, Brief Pain Inventory severity score >or=5. Depression was defined as a PHQ-9 score >or=10. We used multiple logistic and Poisson regression to assess the relationship between individual and combined effects of depression and pain severity on two core pain self-management skills: exercise duration and cognitive strategies. Depressed patients exercised less per week than did nondepressed patients but showed a trend towards more frequent use of cognitive strategies. On multivariable analysis, depression severity substantially decreased the use of exercise as a pain self-management strategy. In contrast, depression and pain severity interacted to increase the use of cognitive strategies. Depression and pain severity have differential effects on self-management practices. Understanding the differences between preferential strategies of pain patients with and without depression may be useful in tailoring pain self-management programs.     

Population survey comparing older adults with hip versus knee pain in primary care

BACKGROUND: Knee pain is nearly twice as prevalent as hip pain in elderly people, yet knee replacement is far less common than hip replacement. AIM: To investigate whether systematic differences in the primary care management of hip versus knee problems might explain the disparate rates of joint replacement. DESIGN OF STUDY: Cross-sectional, population-based postal survey. SETTING: Random sample of 5500 Oxfordshire residents aged 65 years and above. METHOD: Screening questions were used to identify symptomatic individuals: "During the past 12 months, have you had pain in or around either of your hips/knees on most days for 1 month or longer?". Standard (Lequesne) severity ratings were obtained for each hip and knee. Logistic regression was used to estimate odds ratios (ORs) for "knee cases" versus "hip cases" for selected healthcare services and attitudes toward replacement. RESULTS: Among 3341 responders, 212 hip cases and 612 knee cases were identified. Knee pain led to a GP consultation more often than hip pain (OR = 1.76, P = 0.04), but specialist referral was no more likely (OR = 0.85, P = 0.57). Similar percentages of hip and knee cases would agree to hip/knee replacement surgery if it was offered, but hip and knee cases differed in their views on the general success of joint replacement. CONCLUSIONS: Some variations in primary care management for hip versus knee pain were apparent. People with hip pain were mostly positive about replacement outcomes, whereas people with knee pain were more uncertain about replacement. Attitudes appeared to be influenced by knowing someone who had undergone such surgery.     

Prognostic factors for musculoskeletal pain in primary care: a systematic review.

BACKGROUND: Estimating the future course of musculoskeletal pain is an important consideration in the primary care consultation for patients and healthcare professionals. Studies of prognostic indicators tend to have been viewed in relation to each site separately, however, an alternative view is that some prognostic indicators may be common across different sites of musculoskeletal pain. AIM: To identify generic prognostic indicators for patients with musculoskeletal pain in primary care. DESIGN OF STUDY: Systematic review. SETTING: Observational cohort studies in primary care. METHOD: MEDLINE, EMBASE, PsychINFO and CINAHL electronic databases were searched from inception to April 2006. Inclusion criteria were that the study was a primary care-based cohort, published in English and contained information on prognostic indicators for musculoskeletal conditions. RESULTS: Forty-five studies were included. Eleven factors, assessed at baseline, were found to be associated with poor outcome at follow up for at least two different regional pain complaints: higher pain severity at baseline, longer pain duration, multiple-site pain, previous pain episodes, anxiety and/or depression, higher somatic perceptions and/or distress, adverse coping strategies, low social support, older age, higher baseline disability, and greater movement restriction. CONCLUSION: Despite substantial heterogeneity in the design and analysis of original studies, this review has identified potential generic prognostic indicators that may be useful when assessing any regional musculoskeletal pain complaint. However, Its unclear whether these indicators, used alone, or in combination, can correctly estimate the likely course of individual patients' problems. Further research is needed, particularly in peripheral joint pain and using assessment methods feasible for routine practice.     

Predictors of hip joint replacement in new attenders in primary care with hip pain.

BACKGROUND: Studies investigating the factors associated with need for total hip replacement should ideally be based on prospective investigation of new attenders in primary care. AIM: To determine the incidence of listing for total hip replacement, and its predictors, among attenders in primary care with a new episode of hip pain. DESIGN OF STUDY: Prospective multicentre cohort study. SETTING: One hundred and ninety-five patients (mean age = 63 years, 68% female) with new episode of hip pain, attending primary care between November 1994 and October 1997. At the first visit, patients were evaluated for indices of pain and disability, range of hip movement, and radiographic changes of osteoarthritis. METHOD: General practitioner participants were recruited from the membership of the Primary Care Rheumatology Society to recruit all consecutive attenders with a new episode of hip pain. Annual follow-up was carried out to determine which patients were being 'put on a waiting list' for total hip replacement. RESULTS: Seven per cent of patients were put on a waiting list for total hip replacement within 12 months and 23% of patients within four years. At presentation, pain duration, pain severity, (including the need to use a stick) and restriction of internal rotation were the major clinical predictors of being put on a waiting list. Radiographic predictors of osteoarthritis performed similarly to the clinical measures. A simple scoring system based on both radiographic severity and two of the clinical measures was derived that identified groups at high likelihood of being put on a waiting list (sensitivity = 76%) with a low false-positive rate (specificity = 95%). CONCLUSION: New primary care attenders with pain are frequently accepted for total hip replacement soon after their first attendance--a decision that can be predicted by simple clinical measures.     

CAM therapies among primary care patients using opioid therapy for chronic pain

Background  

Complementary and alternative medicine (CAM) is an increasingly common therapy used to treat chronic pain syndromes. However; there is limited information on the utilization and efficacy of CAM therapy in primary care patients receiving long-term opioid therapy.     

Evaluation of a patient-centred approach in generalized musculoskeletal chronic pain/fibromyalgia patients in primary care

The aim of this paper is to assess whether patient-centred consultations are more effective than the usual style of consultations used by general practitioners with patients suffering from benign chronic musculoskeletal pain and fibromyalgia. It also seeks to evaluate the differential characteristics of these two clinical groups of symptoms. The study was designed as a cluster randomised and simple blind trial. Twenty general practitioners took part and 110 patients were recruited. Compared with patients who received the usual treatment from their family physician, those who received a patient-centred approach showed greater improvement after 1 year in terms of psychological distress (anxiety) and number of tender points, as well as showing positive trends in some important outcomes such as pain intensity. Significantly better results were observed in those patients suffering chronic pain than in those with fibromyalgia, particularly as regards associated symptoms, self-rated pain and physical mobility as measured by the Nottingham health profile.     

When race matters: disagreement in pain perception between patients and their physicians in primary care

Patients and physicians often disagree in their assessment of pain intensity. This study explores the impact of patient factors on underestimation of pain intensity in chronic noncancer pain. We surveyed patients and their physicians in 12 primary care centers. To measure pain intensity, patients completed an 11-point numeric rating scale for which pain scores range from 0 (no pain) to 10 (unbearable pain). Physicians rated patients' pain on the same scale. We defined disagreement of pain intensity as underestimation or overestimation by 22 points. Of 601 patients approached, 463 (77%) completed the survey. The majority of participants were black (39%) or white (47%), 67% were female, and the mean age was 53 years. Physicians underestimated pain intensity relative to their patients 39% of the time. Forty-six percent agreed with their patients' pain perception, and 15% of physicians overestimated their patients' pain levels by > or =2 points. In both the bivariate and multivariable models, black race was a significant variable associated with underestimation of pain by physicians (p < 0.05; OR = 1.92; 95% CI: 1.31-2.81). This study finds that physicians are twice as likely to underestimate pain in blacks patients compared to all other ethnicities combined. A qualitative study exploring why physicians rate blacks patients' pain low is warranted.