Chronic pain (CP) is one of the most frequent medical problems in Portuguese primary health care (PHC), with a prevalence of 33.6%1 and up to 37% of patients reporting uncontrolled pain. 2 These patients significantly show poorer functioning capabilities and quality of life than the general population. This is mainly associated with pain interference with physical functioning, sleep, mood, professional life, relationships and family life, and social life. 3 Improving the quality of life in patients suffering from CP is paramount, and a holistic approach must be implemented for each patient. 4 However, proper holistic pain evaluation and management may be time-consuming in a routine PHC consultation, which, in addition to the need for more training in this area, is one of the most frequent barriers to the adequate treatment of pain identified by family physicians (FP), including in our PHC unit. As several studies show, untreated CP results in an increased use of medical consultations, namely in PHC. Although there are several Pain Units in hospitals, most CP patients are followed by their FP. 5
Given the tremendous impact of this disease, we initiated a specific consultation targeting patients with CP in our PHC unit, with the primary purpose of providing pain relief. This consultation is available to all our patients with subacute pain at risk of chronification and patients with CP who are resistant to primary treatment. The referral criteria are patients presenting persistent or recurrent pain for at least three to six months, which persist beyond the healing of the injury that caused it, exist without apparent and justifiable injury, and are resistant to analgesic and/or simple adjuvant therapy. FPs with difficulty providing adequate pain control and/or optimizing therapy in patients who fulfill these criteria can refer their patients to this consultation.
For the moment, only the medical team is involved. However, given the importance of the nursing team in the evaluation and follow-up of this patient (including assessment of vital signs, questionnaire application, counseling, and ensuring correct therapeutic administration), a plan is being developed for their participation in this consultation.
Furthermore, since a multidisciplinary approach is often needed to treat these patients, a protocol with a Hospital Pain unit was implemented to establish referral circuits and training plans for PHC professionals. The referral criteria were established as the absence of functional improvement with regular therapy, neuropathic pain that is difficult to control, an essential psychosocial component that benefits from a psychological evaluation, and the need for multidisciplinary or interventional treatment. Additionally, the facilitated communication with this unit allowed the discussion of clinical cases without needing patient referral and for better coordination in referring patients who needed observation in a medical or psychology consultation.
In our PHC unit, one FP performs this consultation weekly. Each medical consultation is 30 minutes for each patient. A holistic evaluation includes a complete clinical history, pain, comorbidities assessment, and evaluation of the family and social context, integrating all these variables and determining how they can influence the patient’s pain. Follow-ups are scheduled according to the patient’s needs. Among other questionnaires, the Brief Pain Inventory (BPI) is applied to evaluate pain interference on functioning at the first appointment and is re-evaluated after six months of follow-up.
In the first six months, there were 31 patients with uncontrolled pain referred by their FP to this consultation. Most patients were female (77.4%), and the median age was 74 [65, 79] years old. Most patients presented with pain in the lumbar region, and osteoar-throsis was the most prevalent etiology. At the visual analog scale, at the first appointment, the median maximum pain reported in the previous week was 8 [6, 10], and the minimum was 2 [0, 3].
At the first consultation, the BPI showed that 64.5% of the patients reported severe interference with general activity. Also, 54.8% of the patients had interference with mood and walking ability, 45.1% had trouble sleeping, 25.8% had moderate to severe interference in normal work (including housework), and 16.1% regarding relations with other people. Additionally, 29% revealed severe interference with the enjoyment of life, with 1 patient reporting death thoughts.
Non-pharmacological strategies were strongly recommended, alongside pharmacological therapies (with opioid and non-opioid drugs), including massage, walking, water aerobics, socialization with friends and family, and physiotherapy. Most of the patients accepted these recommendations and implemented them in their daily lives. Massage and walking were the most acknowledged, followed by water aerobics.
Although our consultation is relatively recent, with most patients having less than six months of follow-up, those with longer follow-ups showed a median decrease of 3 [2.5, 3.5] points in both maximum and minimum pain levels. Our results showed that patients improved in all parameters evaluated in the BPI, mainly regarding sleep, mood, walking ability, and enjoyment of life.
Even though the literature thoroughly describes the impact of pain on patients’ quality of life, much is needed to enhance this problem. Evaluate potential gaps in medical training regarding CP is mandatory. Low knowledge or training may lead to difficulties in proper pain management, which mainly results in undertreated patients, increased risk of CP, and loss of quality of life.
Considering the high prevalence of CP, these patients cannot be managed only in the hospital setting. More pain consultations in PHC should be implemented with stronger training and logistic conditions, which may be a great strategy to approach patients with this health problem. Nevertheless, referral protocols with Hospital Pain Units should be encouraged to ensure a proper multidisciplinary approach when needed, as we implemented in our PHC unit. A nursing consultation is also crucial for treating these patients and should be implemented.
The long-term impact of this consultation on our patient’s pain levels and quality of life will be studied, and we hope to have stronger results over time. However, we can already find the impact that uncontrolled pain has on patient’s lives and the positive outcomes that a specific pain consultation on PHC can have. FP should prioritize patients with this health problem. Since family physicians share the patients’ environment and know their context so well, they are privileged to address pain in a holistic approach fundamental to the primary care setting.
Acknowledgements
The authors would like to thank the entire USF Ramada team for their support in creating the USF Ramada Pain Consultation.