Quick Tips for GPs

Tim Williams, GP and Community Persistent Pain Specialist, has spent the last decade treating patients with persistent pain. Here he outlines his Quick Tips for managing patients with persistent pain in primary care. You can also download the complete version of his Top Ten Tips on this page.

1. ‘Control not Cure’, so take your time

Persistent pain is now seen by many as a chronic disease in its own right. An acceptance of this helps both patient and practitioner take a more long-term view of management. It is important, for patient and practitioner, that time is taken to consider the next, most appropriate course of action.

2. Know how the patient got to this point

Split the assessment into two appointments. This avoids being over-whelmed by what can be a complex situation and helps to find out the pain story so far – when it started, how it’s progressed and finishing with how it is now as well as previous investigations and management.

3. Know where the patient is going

The second appointment can then answer ‘Where are they going?’ Without a realistic plan, both patient and practitioner can feel frustrated by a lack of progress. Time spent on S.M.A.R.T. goals at an early stage will get everyone going in the right (and same) direction.

4. Know some persistent pain concepts (and be able to explain them to patients!)

Perhaps the most useful are the pain cycle and pacing. Discussing pacing is a particularly good rapport-building tool as most patients can recognise un-paced behaviour in themselves.

5. Is there a neuropathic element to the pain?

It’s worth asking specifically about neuropathic pain symptoms, as they will often co-exist in persistent pain and respond poorly, in many cases, to standard analgesics.

6. Keep pain relief simple and effective

Follow these S.T.E.P.S. to answer the following questions:

  • Is it Safe for the patient to continue on this medication long term?
  • Can they Tolerate this medication with its side effects?
  • Is the medication Effective? Some patients can’t tell one way or another!
  • Are they are on the best Priced treatment? Expensive treatment is acceptable ifit works, in my book!
  • Is the taking of analgesics as Simple as possible? Would a long-acting preparation be preferable to frequent doses of short-acting analgesics?

7. Use strong opiates with care

Prescribing without a plan is pointless - prescribing strong opiates without a plan can be disastrous. Prescribing is just part of an overall strategy to help the patient realise their realistic goals. All need to know what you’re trying to achieve by prescribing strong opiates. Used correctly, strong opiates can be very effective in persistent pain management for selected patients, but should be used by practitioners confident in their use.

8. Self-management is the key

Successful pain management depends more on the patient than the practitioner. Pain management is the patient’s responsibility. The practitioner is able to help the patient find their ability to respond to their persistent pain condition and its consequences.

9. It’s not all about the pain

Well-managed pain is evident as the patient starts shifting their focus away from pain, doing more and getting their ‘life back’. Sometimes the pain may actually stay the same and it’s the other aspects of life that improve including sleep, exercise tolerance, mood and general well-being, which are also very worthy end points.

10. Continuity helps maintain control for everyone

Do your best to avoid other practitioners getting involved which can lead to giving the patient inconsistent advice, unhelpful medication changes or referrals, for often fruitless further investigations.