Best Practices in the Assessment and Management of Chronic Pain- At least 116 million adult Americans suffer from chronic pain, which remains the leading reason for patient visits to primary care. The socioeconomic burden is significant. Medical expenses and lost productivity associated with chronic pain conditions reach an estimated $635 billion in the United States each year.1 Effectively treating this patient population is particularly challenging because pain can be caused and maintained by numerous biologic factors—including genetic predisposition, tissue injury, aging, joint and disc degeneration, previous medical interventions, and such chronic diseases as osteoarthritis, diabetes, and cancer, to name a few. Further, the patient-specific pain experience is not solely dependent on painful sensory inputs; emotional status, psychological responses, and social circumstances markedly contribute to pain levels and impairments in physical, affective, cognitive, and occupational functioning. The heterogeneity of chronic pain—in etiologies, clinical presentations, and outcomes—confounds diagnosis and treatment. Mechanism-based pain classification, comprehensive patient histories, and targeted approaches to physical exams can help clinicians better identify the causes of chronic pain and select appropriate treatments. For example, whenever possible, clinicians should match the analgesic mechanisms of action of prescribed medications with the likely underlying pain etiology. Further, combinations of pharmacologic, nonpharmacologic, and interventional treatment approaches may be required for some individuals. Primary care clinicians are on the frontline of chronic pain management. Long-term relationships with patients facilitate comprehensive and longitudinal assessment of evolving symptoms, allowing for tailored therapeutic regimens that help patients reach functional goals.
Discuss the neurobiology of pain processing and how dysfunction in nociceptive pathways contributes to various chronic pain disorders. Comprehensively assess patients with chronic pain based on biopsychosocial factors that shape the severity, chronicity, and adverse functional consequences of the painful conditions. Evaluate the clinical profiles of available pharmacologic agents based in part on mechanisms of action, analgesic effectiveness, and treatment-related risks and side effects. Employ mechanism-based pharmacotherapy for patients with common chronic pain syndromes, such as low back pain, osteoarthritis, fibromyalgia, and painful neuropathic disorders. Combine pharmacologic and nonpharmacologic therapies for patients with chronic pain with the objectives of reducing pain, meeting predefined functional goals, and minimizing potential treatment-related harm.
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