What is the GP pain management protocol?

Background

In primary care, pain is a common reason for encounters. The complexity of assessing and managing chronic pain syndromes is often tricky.

The mnemonic presented for assessment is the ‘4Ps’ (pain, other pathology/past medical history, performance/function, and psychological/psychiatric status). We can use the 4Ps (physical, psychological, and pharmacological) for management and review. The literature indicates that only 34% of primary care physicians are comfortable managing patients with chronic back pain.2,4 Many GPs believe they need more training in their medical school training (82%) or postgraduate general practice training (55%) to manage these patients.

Case Study

Joan, a 64-year-old former worker in the process industry, has chronic low back pain that began after an injury at work about 14 years ago. She tried several pain medications and antidepressants, as well as a rehabilitation program in an inpatient setting, but without success.

Joan’s lower back/sacral pain sometimes radiates to her left hip, buttock, and anterior thigh. She has occasional paraesthesia in the medial left lower leg and the dorsum of her foot. This pain is 4/10 on a VAS and worsens when walking or doing physical activity. Joan’s pain medication causes constipation. She is currently taking oxycodone/naloxone – 10 mg twice daily – and baclofen -5 mg three times per day.

She has nightmares and significant depressive symptoms, as well as substantial fear avoidance and poor activity pacing.

The physical examination revealed an abnormal posture, with the left pelvis elevated. There was a reduced range of motion in the lumbar region and tenderness around the sacroiliac and piriformis joints on the left. On the left, there were signs of sacroiliac dysfunction. The lower limbs were not abnormally affected by the neurological examination.

Joan returned to her GP, who asked what she could do about her lower back pain.

This is an unusual scenario for a general practitioner. Patients with chronic pain often have a long and complex past, including several physical ailments and psychosocial problems. Below is a possible scheme to help GPs analyze common pain scenarios logically and organize and plan future action. This article focuses on using the scheme as a framework and tool for assessing and managing chronic pain rather than addressing the specifics of any given pain condition. Low back pain is addressed elsewhere.

The author developed the ‘4Ps mnemonic’ for assessment and treatment after years of experience teaching GPs and trainees in pain medicine. Many find it useful, mainly when cases are complex.

Assessment

The 4Ps of assessment for chronic pain are:

Pain: the type of pain, its possible causes, and possible pathologies.

Comorbidities/other Pathologies/ Past Medical History – Knowledge of the patient’s medical history and comorbidities is essential. Treating comorbidities can improve the quality of life for patients and give them more emotional and physical reserves to manage pain. It may also affect the treatment options for chronic pain. Some medications, like tricyclic antidepressants, should be used cautiously in patients with cardiac comorbidities.

Performance/function: It is essential to determine the level of activity and function and whether the patient has been deconditioned. It would help if you also looked for any signs of fear avoidance, which could reduce patients’ physical and social functions.

Psychological/Psychiatric – assessment of the psychological/psychiatric status, particularly for depression, anxiety, and other psychological comorbidity, may be helpful.

Other issues may be necessary or relevant to a specific case.

Applying the 4Ps in a case

What is the cause of your left lower back pain? Is it sacroiliac joint pain, lower lumbar facet pain, or piriformis syndrome?

Comorbidities/other Pathologies/ Past Medical History – Chronic constipation

Performance/function-reduction in function due to fear avoidance, poor pacing, and reduced performance.

Psychological/psychiatric – significant depressive symptoms, occasional nightmares, and anxiety symptoms. These symptoms could be indicative of post-traumatic disorder.

Joan’s case was not remarked on for any other issues.

Management strategies

Chronic pain is persistent. Treatment should focus on managing the pain and gaining functional benefits rather than just treating it. It is not realistic to expect pain to be gone forever. Over-emphasis on pain reduction can lead to frustration for the doctor and the patient. A comprehensive pain management plan can be developed after a biopsychosocial holistic assessment.

You can use a different set of four Ps:

P physical reactivation, including exercise and stretching programs, can benefit chronic pain patients. In these situations, a physiotherapist, or an exercise physiologist who is adequately trained and can provide pain education, will significantly help.

Psychological 7- psychological strategies to manage pain may be helpful. These include fear avoidance, anxiety, and stress management. Many techniques are available, such as cognitive behavior therapy8,9, acceptance-based treatments10,11, and mindfulness12,13. This article needs to provide a detailed description. Readers are encouraged to consult the pieces in the Reference section. 8- 12 A appropriately trained psychologist with experience managing chronic pain patients will significantly assist. A psychiatric evaluation for diagnosis and treatment may be necessary for patients with significant mental health issues.

Pharmacological/medications: It is essential to consider whether an appropriate remedy has been used and whether further medication optimization is required. Different types of drugs could be considered depending on the potential mechanism of pain. Some medications treat neuropathic and inflammation-related pain, such as gabapentinoids, tricyclic antidepressants, and gabapentinoids.

Procedure/intervention – are there any procedures that may be helpful for this patient (eg. Local anesthetics and corticosteroids can be injected into the joints, around the nerves (nerve block), or in the joints.

In addition, the treating doctor must provide pain education. The doctor treating you and other healthcare providers must communicate well to manage chronic pain. Following are the pain-management strategies that were used in Joan’s situation:

Physical: Referral to a chronic-pain physiotherapist to perform exercises that stabilize the spine and hips.

Psychological– A referral to a chronic Pain psychologist to learn stress management techniques and to address issues like fear avoidance or poor activity pacing.

Pharmacological/medication – no medication change due to the possible diagnosis of sacroiliac joint dysfunction. A procedural intervention (below) may be beneficial. After the intervention, medication use can be reviewed.

Procedure/intervention – referral to a radiologist for a CT-guided left sacroiliac joints corticosteroid and local anesthetic injection.

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It is helpful to keep in mind the “6As” recommended by Gourlay and colleagues

Activities: Observing if the patient’s activity level and functional status improved after introducing appropriate management strategies is critical.

Analgesia: To assess the change in pain level, you can use a visual-analog scale, a numerical rating scale, or a questionnaire such as the Brief Pain Inventory (BPI).

Adverse reaction: Has the treatment caused any adverse reactions?

Aberrance behavior: This is especially important when using opioids and non-opioid drugs such as benzodiazepines for short-term treatment of acute musculoskeletal discomfort. Monitoring is necessary to determine if there have been any unapproved dose escalations or reported missing scripts.

Affect: Observing if mood changes occur in chronic pain patients is critical. Decisions have to be made as to whether further psychological or psychopharmacological intervention is required.

Adequate documentation would be required in a high-quality, standard clinical practice. It is essential in high-risk areas, such as polypharmacy and opioid use.

Case continued

Joan’s low back pain improved significantly after receiving injections into her sacroiliac joint of corticosteroid and local anesthetic. This improvement lasted for several weeks. The pain returned. She went to her GP for help about five months after receiving the injections, despite not attending the recommended physiotherapist or psychologist sessions.

On examination, there was significant myofascial tightness in the left gluteal region and the left sacroiliac area. The nature of the pain and the psychosocial obstacles to recovery were explained and educated. A local anesthetic injection was given into the left gluteal region to temporarily relieve muscle tension and pain. The chronic pain physiotherapist prescribed short-term usage of a sacroiliac belt and appropriate exercises. She was encouraged to visit a psychologist to help manage her anxiety, mood, and stress.

After two months, the VAS score of her pain had dropped from 10/10 down to 2 or 3. She could go on holiday to another state without any problems. She feels much more positive and understands her multidisciplinary, comprehensive pain management.

The conclusion of the article is:

Conclusion: Although the scheme presented is not detailed in treating each chronic pain state, it provides a valuable framework to analyze and assess patients with chronic pain. The assessment is broader and includes biopsychosocial factors in a structured manner. Multidisciplinary management offers the best outcome without relying solely on one modality of treatment. This easily memorizable scheme for chronic management and pain assessment allows GPs to quickly analyze chronic pain and its effects on their patients. They can also consider other management strategies they haven’t explored before. This framework will enable GPs to focus on treating chronic pain patients without getting overwhelmed by all the issues that are often present. The framework also identifies alternative treatment options that may require referrals, such as for surgical procedures or injections.