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Chronic Pain in Primary Care: Practice Update : Page 2 of 13

Chronic Pain in Primary Care: Practice Update : Page 2 of 13


No objective measure

There is no objective, quantitative measure for pain. We practice in a an era of medicine where we have the ability to observe in remarkable detail the internal functions of the body without inflicting damage; to test physiologic function at the level of nano elements; to discuss genetic makeup as it relates to predisposition to specific diseases; and yet, we still have to rely on the patient’s self-report to know if they are experiencing pain or to discern the presence of pain through observation of physical behavior in those of limited cognitive ability. 

Stubborn orthodoxy

Another significant problem is that in our efforts to manage chronic pain, we are still often influenced by beliefs that have been disproven but are still widely held as fact—among our colleagues and our patients as well.  

It is axiomatic in medicine that pain must have an identifiable etiology that can be detected through sufficient inquiry and evaluation. In cases of acute pain, that course of investigation is often rewarded. Too often today, however, patients with persistent pain undergo expensive evaluations that reveal no abnormality at all. On the other side of that coin, and also common, imaging may reveal abnormalities that are determined to be causative and judged to be remediable but for which interventions to correct them provide little if any benefit, and may even exacerbate the pain. For example, it is still commonly believed that bulging vertebral disks cause low back pain, although numerous studies have found little correlation between a this finding and the presence or severity of pain. Moreover, following fusion surgery, less than half of patients realize an optimal outcome, ie, only sporadic pain, slight restriction of function, and only occasional use of analgesics.3

There is little satisfaction for a health care provider in explaining to a patient who has chronic pain that the cause is still a medical mystery—and very little consolation for a patient in hearing the sad truth. In the vast majority of patients with back pain, tension-type headaches, and migraine headaches, definitive evidence of cause remains elusive.

Needed: Better Rx, curricula  

There is also at best limited research in support of the efficacy of many commonly used treatments for chronic pain. Opioid analgesics are widely prescribed for many forms of chronic pain although there are no studies that demonstrate a clear benefit. In fact, rather than helping to improve patient functioning, use of opioids may lead to greater suffering related to misuse, overuse, and, when used chronically, the exacerbation of pain.

Another sad reality too seldom discussed is that despite the ubiquity of human pain, many physicians receive only limited education on effective methods of management in medical school or postgraduate training. This problem has been recognized for at least the past 30 years yet only modest changes to curricula have been made.  

This special report will provide overviews of our current state of knowledge regarding the most common chronic pain conditions that primary care physicians are likely to encounter, with a special focus on appropriate work-ups and therapeutic modalities, modalities that should be avoided, and when referral to physicians in other specialties is indicated.  


Topics to be covered:

 ► Low back pain and headaches

 ► Opioid analgesics: Myths and facts

 ► Neuropathic pain 

 ► Pain and depression





Continue to the Chronic Pain Special Report Pre-test

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