The challenges of pain management in primary care
A new study reveals that European primary care physicians find dealing with chronic pain patients to be challenging, but at the same time rate it as a low priority area. Across Europe 84% of the 1308 primary care physicians who participated in the study found, that their initial training in chronic pain management was not comprehensive.
These are some of the findings in a just published pan European survey among primary care physicians from 13 European countries. I have been part of the study group. In short were approximately 100 primary care physicians from each of the 13 countries randomly taken from a more than 500,000 physicians database. The physicians answered an online survey.
The picture is an illustration form the paper. It shows how the physicians rated chronic pain according to challenge and priority compared with other chronic conditions like cancer and diabetes. It is noteworthy and scary that even though the primary care physicians find chronic pain challenging, and given the fact from other studies that every third person seeking primary care present a pain problem, the participating physicians still give chronic pain not just low priority but the lowest priority compared with cardiovascular diseases, diabetes, cancers, respiratory disorders, and mental illness. Sure all are important, very important, but still is chronic pain the primary reason to seek help in primary care, and it compromise the quality of life for those living with the pain.
The medical educations normally provides much knowledge about the other five conditions mentioned in the comparison, but not, as also confirmed by 84% of the participating physicians, about (chronic) pain. I am not in doubt there is a connection, and this highlights the crucial need for increasing, or perhaps even to start providing medical students with knowledge about pain and chronic pain. No matter which specialty the medical students select, they will have a responsibility for the management of persons with pain many times every day.
In the short video below you can see the papers first author Dr. Martin Johnson presents the abstract from the survey.
The survey also revealed some very interesting findings about pain assessment. I will come back to that in my next blog post here on the Picture of Pain blog.
The challenges of pain management in primary care: a pan-European survey
Johnson M, Collett B, Castro-Lopes JM.
J Pain Res. 2013 May 22;6:393-401. doi: 10.2147/JPR.S41883. Print 2013.
Kim Kristiansen, M.D. (2013). The Challenges of Pain Management in Primary Care Picture of Pain Blog
Depression together with pain, but not pain alone, may increase activity in the immune system and inflammation. These are the important findings of a new study just published in the journal “Pain Medicine”.
We know that depression may increase patients’ vulnerability to pain, and the co-existence of pain and depression has previously been a subject here on the Picture of Pain blog, and is the subject of our latest scientific publication.
The new study is a primary care study from Rochester, New York. By assessing the inflammatory marker IL-6 the researchers found how inflammatory activity were linked to depression, pain and chronic medical morbidity, and the findings are important.
Patients with elevated depressive symptoms had IL-6 associated with greater pain reports and with chronic medical morbidity. However in contrast those relationships were not found among patients without clinical significant depressive symptoms. This suggests that depressive symptom alone or in combination with chronic disease burden, may have increased vulnerability to pain and increased inflammation. Furthermore seemed depression severity and pain severity to be associated without relation to medical morbidity.
Recent evidence suggests that depression treatment may reduce systematic inflammation. It is also possible that by reducing inflammation, depression treatment might serve as a pathway to reducing pain associated with chronic medical morbidities.
We have in a recent published study found, that 58% of primary care patients meeting criteria for depression come with a pain problem. Not making a comprehensive assessment of pain and its impact including mood and depression, and designing treatment according to findings, bear the risk of missing the co-existence. Thereby the patient may not be provided with optimal treatment, and even not reduce accompanying inflammation and associated health concerns.
Poleshuck, E.L., Talbot, N.L., Moynihan, J.A., Chapman, B.P. & Heffner, K.L., 2013, Depressive Symptoms, Pain, Chronic Medical Morbidity, and Interleukin-6 among Primary Care Patients, Pain Medicine.
Kristiansen, K., Lyngholm-Kjaerby, P. & Moe, C., 2012, DoloTest in General Practice Study: Sensitivity and Specificity Screening for Depression, International Journal of Family Medicine, 2012, pp. 1-8.
Kim Kristiansen, M.D. (2013). Pain and Depression Linked to the Immune System Picture of Pain Blog
Patients with chronic pain after revision total knee arthroplasty demonstrate widespread pain sensitization, according to findings just published from a Danish study.
Sensitization is a process of changed pain responses in the nerve system leading to increased pain perception.
Comparing among other tests pain threshold and pressure pain tolerance, patients with chronic knee pain after revision total knee arthroplastsy shoved significant more pain sites, decreased pain threshold and pressure pain tolerance, and facilitated pain summation response, compared with patients without knee pain after revision.
This study highlights the importance of being careful when planning re operation for patients with sensitization, and thereby to be aware of this prior to deciding a possible re-operation.
TEDMED has selected 20 great challenges of health and medicine. These 20 include challenges like managing chronic diseases, whole patient care, the role of the patient, medical communication, impact of stress, and promoting active lifestyle. The identified challenges are all areas where improvements and solutions are much needed, but most of them are also a challenge to traditional approaches in healthcare.
Traditionally healthcare professionals are educated to identify a disease or other health problem, and then treat it if possible. The modern and informed patient are often presenting more complex chronic – and thereby not curable – conditions, which in it self is a challenge. Presented with patients with these symptoms and syndromes health professionals might find their authority and self-image challenged, since the symptoms and complaints presented by the patients do not fit into to the normal biomedical frame for understanding and treating medical conditions. Further more does these symptoms and complaints not always fit to well into the traditional understanding of scientific and evidence based disease management, which is a deep and integrated part of our pride for what healthcare professionals do and how we work.
As healthcare becomes more specialized multiple specialists will often be looking only at “their part” of the patient’s problems, and often it is the primary care physician who must try to connect the dots.
Taking a look across the 20 great TEDMED challenges makes it obvious that a changed approach to modern healthcare are shared by many of them. Changes in attitude are not necessarily the easiest part of anything, but since these 20 areas in healthcare are crucial, facilitating the needed changes across the challenges are an important part of bringing them forward. It is goodbye to the well known healthcare-centered care and hello to active patients, shared decision making, and an on-going process towards defined goals together.
Not communicating is not an option in healthcare – or anywhere else for that matter. We communicate and decide constantly each day, and it is not possible not to communicate with others we encounter and not possible not to decide. Not talking to or otherwise interact with others is a very powerful negative communication, and not choosing between options is in it self a choice and a decision with the consequences it will lead to. If you don’t ask questions is that because you have understood everything, is it because you can’t digest more information, or are you just struggling with the information you already have received? –Or is it because you just don’t care?
We also hear what the other part is not saying.
So why not chose to actively and engaged communicate and make decisions in healthcare whether you are the patient or the clinician.
Communication is not optional so see this interesting TEDMED discussion about medical communication
According to our new study published in International Journal of Family Medicine, where we looked at 715 persons coming to primary care, 66% of the men and 54% of the women (58% in total) who met the criteria for depression came to primary care due to a pain problem.
Research has demonstrated pain and depression has a strong negative impact on each other, and that simultaneous treating both can have enhanced effect on outcome, function and quality of life, and simultaneous treatment of pain and depression also reduces the risk of misuse of opioids.
Depression together with pain is associated with considerable functional impairment and decreased quality of life, increased health care utilization, and difficult clinician-patient relationships. Irish researches have found that 5% of chronic pain patients account for 26% of costs due to pain,. This was the patients who experienced the highest pain intensity and the patients with a combination of chronic pain and depression. At the same time we know, that these patients are those with the lowest quality of life, so finding and treating these patients have both human and economical importance.
Pain, sleep problems and depression share neurological pathways and are often coexisting. Take a look at the graph showing data from the same study. On the horizontal axis is score on sleep problems at DoloTest (0-100, 100 being worst possible). This line is divided into 5 segments along the sleep VAS line. The blue columns are showing the relative frequency of patients meeting criteria for depression within each segment; the line is showing the average pain intensity in each sleep-problem segment. Data from average primary care that demonstrates a close co-existence in accordance with our knowledge from neuropsychological research.
Presence of concomitant depression with chronic pain increases the risk of misuse of opioids, when defined as using opioids for stress or sleep and using more than prescribed. Increasing depression score leads to an increasing risk of misuse of opioids. Alicia Grattan and colleagues present this in a paper in the a recent issue of Annals of Family Medicine. Even though opioids might reduce pain it might also be able to reduce the burden of pain by its cognitive- and calming effects, but where opioids can be part of treating pain, depression and anxiety or sleep problems should not be treated by this, but instead by relevant pharmaceutical or non-pharmaceutical treatment. If these patients are asked if they “feel better”, they might answer “yes”, this might be due to reduction in pain experience but might also be du to its calming effects. Or by both.
So when more than half or the patients meeting the criteria for depression comes to primary care clinics with a pain problem, there is a great risk for missing the depression and treating pain alone with potential serious problems.
Assessing pain alone is like measuring the length but not the waist circumference when buying a new pair of trousers: you are most likely to have trouble keeping the more significant parts covered.
Kristiansen K, Correlation between Sleep, Pain and Depression in Primary Care Patients using DoloTest®. Poster at WONCA EUROPE; Warsaw, Sept. 9. 2011
Grattan A, Sullivan MD, Saunders KW, Campbell CI, Von Korff MR. Depression and prescription opioid misuse among chronic opioid therapy recipients with no history of substance abuse. Ann Fam Med 2012, Jul;10(4):304-11.
Raftery, Miriam N, Padhraig Ryan, Charles Normand, Andrew W Murphy, Davida de la Harpe, and Brian E McGuire. “The Economic Cost of Chronic Noncancer Pain in Ireland: Results From the PRIME Study, Part 2.” The journal of pain : official journal of the American Pain Society 13, no. 2 (2012): doi:10.1016/j.jpain.2011.10.004.
Kim Kristiansen, M.D. (2013). Depressed Patients Seek Primary Care Due to Pain Picture of Pain Blog
Patient centered interview and establishing a positive patient-provider relationship has in a recent functional magnetic resonance imaging (fMRI) study proven able to reduce pain related responses from the pain important area of the brain called anterior insula. Patients were randomized to either patient-centered-interview or (standard?) clinician-centered-interview. In the clinician-centered style the clinician “knows all” and decides what is best for the patient, where the patient-centered style involves the patient, respect the patient’s values and activates the patient in their own condition. By using fMRI the researchers were able to detect reduced pain-related activation in the pain-important anterior insula region, when experiencing a painful stimuli while viewing a photograph of the interviewing doctor versus looking at a control image of an unknown doctor.
Is this placebo? Might be at least to some degree, but it demonstrates a communication style respecting the patient’s autonomy can be a treatment of the patients pain in itself.
It will be interesting to see future and especially more long time studies in this field. However the knowledge from this study is ready to be used right away. Risk free.
Ref: Sarinopoulos, I., Hesson, A.M., Gordon, C., Lee, S.A., Wang, L., Dwamena, F. & Smith, R.C., 2013, Patient-centered interviewing is associated with decreased responses to painful stimuli: An initial fMRI study, Patient education and counseling, 90(2), pp. 220-5
Kim Kristiansen, M.D. (2013). Healthcare professionals AS pain treatment Picture of Pain Blog
Pain and depression are often co existing and it is very important to be aware of both. We have recently published a study about easy screening for this co-existence in th International Journal of Family Medicine. The study is now on PubMed. You can read the abstract here and find link to both the paper, MedLine and my previous blog post about the study
DoloTest in General Practice Study: Sensitivity and Specificity Screening for Depression
Background. Coexistence of pain and depression has significant impact on the patient’s quality of life and treatment outcome. DoloTest is a pain and HRQoL assessment tool developed to provide shared understanding between the clinician and the patient of the condition by a visual profile. Aim. To find the sensitivity and specificity of DoloTest as a screening tool for depression for patients in primary care. Methods. All patients coming to a primary care clinic were asked to fill in a DoloTest and a Major Depression Inventory. Results. 715 (68.5%) of 1044 patients entered the study. 34.4% came due to pain. 16.1% met depression criteria, and 26.8% of patients coming due to pain met criteria for depression. 65.6% of the men and 54.2% of the women meeting the criteria for depression came due to pain. Depressed patients had statistically significant higher scores on all DoloTest domains. Selecting the cutoff value for the domain “low spirits” to be “65″ (0-100) for depression gave a sensitivity of 78% (70-85%) and a specificity of 95% (93-96%) for meeting depression criteria. Conclusion. DoloTest can with a high sensitivity and specificity identify persons meeting criteria for depression and is an easy-to-use screening tool to identify patients with the coexistence of pain and depression.
MERRY CHRISTMAS AND HAPPY NEW YEAR
Thanks to all Picture of Pain readers for your interest and support in 2012. We are are excited about the new year where we will launch a new tool, end some exciting projects and start new projects we are planing now.
Thanks also to all users of DoloTest – indeed a growing number. Thank you for kind feed back (and please send more )
Kim Kristiansen and the DoloTest-Team
I was asked by a reader of the Picture of Pain blog if I would share with my favourite top reads regarding ‘the relationship of Chronic Pain and positive mental health and / or ‘living with chronic pain through greater mental health’. In fact I think it would be great to make a list of best reads in this field, so here I will share some of my best reads, please share your best reads here too
Pain Chronicles, Melanie Thernstrom.
Melanie Thernstrom is a pain patient herself. Her mission is to share information about pain, information she would have liked to have had from the day her pain started. Findings from research regarding pain together with chapters about the history of pain, the attitude toward pain and persons with pain through history, and religious believes about pain. Through the book all this information is mixed with her personal story about pain, love, life and quality of life.
It seems to be a very difficult task to make all these pieces fit together to create a – well a picture of pain – but MT manages to make the puzzle fit together to create a journey trough humans lives with pain. The book presents a well-written mixture of knowledge, thoughts and feelings.
Overcoming Chronic Pain. Frances Cole
Dr. Frances Cole is a GP and cognitive behavioural therapist from Bradford in England. Together with three colleagues she has written this book. It is a very good book to patients with information about pain, treatments, and what the patient can do them selves to live better life with pain.
The Language of Pain. David Brio.
This is a special book. The author combines his knowledge as a physician with his own experience of illness and pain, and put it into a cultural context and references. A great insight into living with pain.
Stumbling on Happiness. Daniel Gilbert.
Well this book is not exactly about pain. I would rather say, that it is also about pain and whatever has influence on our quality of life and happiness. It is a wonderful book, well written and with a lot of humour. As the author states in the foreword is this book not a self-help book, but if you ever should have bought such a book and still felt miserable after you have read it, you can turn to this book and understand why. A must read.
I hope you will add your best reads in this field too
Kim Kristiansen (2012). Best Reads About Chronic Pain and Positive Mental Health Creating a list of best reads about chronic pain and mental health