What’s in the web for family physicians − a review on pain and its management strategies for family physicians

Sio-pan Chan 陳少斌，Wilbert WB Wong 王維斌，Alfred KY Tang 鄧權恩

Pain is the most basic instinct crucial for survival, and is one of the most common reasons why patients seek medical care. The International Association for the Study of Pain (IASP) defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain can be acute or chronic. Acute pain is short-lived and will disappear once the underlying cause has resolved. On the other hand, chronic pain can persist long after the initiating cause has fully recovered. In the definition of pain, the phrase “emotional experience associated with actual or potential tissue damage” highlights the significant role of cognitive perception in how individuals interpret painful stimuli, indicating that pain is affected by one’s perception.

Chronic pain is a complex condition that can be considered as a disease itself. It is defined as pain that lasts for an extended period of time, typically more than three to six months, and can result from various underlying causes such as injury. Chronic pain can significantly affect an individual’s quality of life, leading to disabilities, depression, anxiety, and reduced overall well-being. Recent researches have indicated that chronic pain is more likely due to a maladapted pain signal interpretation by the brain. Hence, the treatment for chronic pain requires a more holistic approach that goes beyond merely prescribing painkillers.

The pain pathway

Nociceptors are the primary receptors of pain. When sufficiently stimulated, the primary afferent nociceptor contacts second-order pain-transmission neurons in the spinal cord. The second-order cells relay the message through well-defined pathways to higher centers, including the brain stem reticular formation, thalamus, somatosensory cortex, and limbic system. Inflammatory mediators, such as prostaglandins and cytokines, also play a role in sensitising nociceptors and amplifying pain signals. Most studies on physiology of pain are based on skin nociceptors. Neuropathic pain and other pain without specific nociceptive stimuli are less well understood, notable examples being the phantom limbs syndrome and fibromyalgia.

Pain sensation can be moderated at various levels along the pain pathway, i.e. at the peripheral, spinal, and supraspinal levels. Peripheral modulation involves the inhibition of nociceptor activation or the release of endogenous pain modulators at the site of injury. Spinal modulation occurs through the activation of inhibitory interneurons or the release of neurotransmitters such as endorphins, serotonin, and norepinephrine that block pain signals from reaching the brain. Supraspinal modulation involves the descending pain modulation system that releases neurotransmitters. These neurotransmitters can inhibit pain signals at the spinal cord level and also influence the emotional and cognitive aspect of pain perception. This is probably the reason why antidepressants remain as mainstay of treatment in managing chronic pain regardless of whether depression is present.

When dealing with patients in pain, it is imperative to give an accurate assessment and treatment to patients. Improper or inadequate management of pain may result in medico-legal consequences. A handy approach is to document the patients’ degree of pain on a numeric scale of 1-10, appropriate painkillers to be given with reference to the painkiller ladder. On the other hand, the use of potent opioids should be avoided if a safer alternative is available.

For most family doctors, acute pain management is relatively simple. Acute Pain should subside within a reasonable time once the offending cause is treated. As for chronic pain management, it is crucial to identify any underlying treatable causes such as a prolapsed disc or multiple melanoma. Chronic pain syndrome remains as a diagnosis by exclusion. An X-ray of osteoarthritic spine is unlikely to be the true cause of chronic back pain. A more holistic approach is needed to look into the physical, social and psychological background of the patient.

Chronic pain management can be pharmacological or non-pharmacological or a combination of both. Pharmacological treatments include simple analgesics, NSAIDs, Cox II inhibitors, opioids, tricyclic antidepressants, SSRIs, SNRIs, Gabapentinoids, anticonvulsants, steroid injection etc. Non-pharmacological treatment includes different modes of physiotherapy such as heat or cold treatment, ultrasound, Extracorporeal Shockwave Therapy (ESWT), etc. Acupuncture is commonly selected as a pain treatment by patients prior to seeking medical advice from family physicians.

We have performed an internet research on updates on the concept of pain its management as follows:

Pain management: A fundamental human right

The article explored medical and ethical issues related to the concept of pain management as a human right. This concept has had gained momentum over the years. The problem of unrelieved pain was surveyed in three areas, namely acute pain, chronic non-cancer pain, and cancer pain. The adverse physical and psychological effects and social and economic costs of untreated pain were then outlined and discussed. In the article, the author had advocated framing pain management as an ethical issue, defining pain management as a fundamental human right, and issuing guidelines and standards of practice by professional bodies.

Analgesic use in primary care

The website is a practical guide on non-opioid medications commonly used in primary care for pain management. It is important for primary care physicians to stay updated on the mechanisms, benefits, and risks of these analgesics for effective management of both acute and chronic pain. They offer effective relief for a wide array of acute and chronic pain conditions without the associated risks of opioid-related adverse effects or the potential development of addiction. With an aging and increasingly fragile population, presence of multiple coexisting chronic conditions may create uncertainties for practitioners in the management of chronic pain. Management strategies can be formulated with the materials in the website.

Chronic pain: clinical updates and perspectives

The series of articles provides a comprehensive overview of chronic pain research, covering new research developments, clinical updates and treatments perspectives in chronic pain. Management of chronic pain conditions present a multifaceted challenge for family physicians, and knowledge on latest research and evidence-based practices in pain management is considered vital. A patient-centered approach which considers the physical, psychological, and social aspects of pain as well as collaborating with interdisciplinary teams including physical therapists, psychologists, and pain specialists would enhance the effectiveness of treatment plans. In addition, patient education on selfmanagement techniques, lifestyle adjustments, and pain coping strategies are also important. This empowers patients to participate actively in their own care and promotes long-term pain management.

Chronic pain management: non-pharmacological therapies for chronic pain

Several key psychological therapies that can be effective in chronic pain management were discussed in the article. Cognitive-behavioural therapy (CBT) helps patients develop coping strategies and modify pain-related thoughts and behaviours, while acceptance and commitment therapy (ACT) focuses on improving psychological flexibility and helping patients accept and adapt to chronic pain. Mindfulness-based interventions can also reduce pain intensity, improve physical functioning, and enhance overall well-being. Physical therapies, exercise therapy, including aerobic, strength, and flexibility training, can improve physical function, reduce pain, and enhance quality of life. Manual therapies, such as massage, spinal manipulation, and mobilisation, can provide short-term pain relief and improve physical function.

Complementary and alternative therapies may have a role in chronic pain management. Acupuncture has been shown to be effective in reducing chronic pain, particularly for conditions like low back pain, neck pain, and osteoarthritis.

Understanding fibromyalgia

Fibromyalgia is a chronic pain condition characterised by widespread musculoskeletal pain, fatigue, sleep disturbances, and cognitive difficulties. The exact causes of fibromyalgia are not fully understood, but it is believed to involve a combination of genetic and environmental factors that trigger how pain signal is processed in the brain and body. Fibromyalgia is often accompanied by other related conditions, including chronic fatigue syndrome, irritable bowel syndrome, migraine headaches, temporomandibular joint (TMJ) disorders, and depression or anxiety. Treatment for fibromyalgia typically involves a multifaceted approach, including medications, physical therapy, lifestyle modifications, and psychological therapies. The goals of treatment are on pain reduction, sleep improvement, and restoration of overall body functions and quality of life.

A review of the opioid epidemic

The article provides a comprehensive review of the opioid epidemic in the United States, which has led to a significant increase in the number of deaths due to opioid overdose in the past two decades. The introduction of highly potent synthetic opioids, such as fentanyl, has aggravated the problem further and had led to a surge in the number of overdose deaths.

To address the opioid epidemic, the authors suggest a multi-pronged approach. This includes improvements in prescription drug monitoring programs, enhancement of access to evidence-based medication-assisted treatment, and improvement of the distribution and availability of the overdose reversal drug naloxone. The authors had emphasised the importance of investing in comprehensive prevention, harm reduction, and longterm recovery support services. The article also stressed on the need to regulate the pharmaceutical industry and crack down on illegal opioid sales to curb the crisis. Ultimately, the authors emphasised that a collaborative, sustained effort across sectors is critical to combat this complex and evolving public health emergency effectively.