Title: GPart - Dr Niamh Blythe - General Practitioner (GP) Perspectives Relating to Caring for People Living with Chronic Primary Pain
Funder: Public Health Agency, NI

Abstract: Background. One in 10 adults are diagnosed with chronic pain per annum, with 20% suffering from pain globally. (1) Historically, pain has been viewed as a symptom of disease, rather than defined as a disease state itself, which has contributed to a lack of prominence in the field of public health. Approximately 70% of chronic pain is managed in primary care (2), comprising 22% of presenting complaints. (3)Chronic pain conditions impose a significant clinical, social and economic burden and present a major pervasive public health issue. The Global Burden of Disease Study 2016 confirmed that pain and pain-related conditions are the principal cause of disability and disease burden globally.(4) More patients suffer from persistent or chronic pain than diabetes, heart disease and cancer collectively. (5) Chronic pain is often associated with the development of a problematic series of physical and psychological changes, adding greatly to patient burden. These include immobility, immunosuppression, sleep disturbance, medication dependence, social isolation and mental health issues. (6) It represents the most common reason for early retirement or work incapacity. Chronic pain can occur in the absence of apparent tissue damage, and is defined as primary or secondary. (7) Chronic primary pain (CPP) is the presence of pain in one or more anatomical areas, persisting or recurring for three months or longer, associated with significant functional disability or emotional distress, that cannot be better accounted for by an alternative diagnosis. (8) Prior to the diagnosis of CPP, it must be determined whether the pain can be attributed to a specific and recognisable cause, which would lead to a diagnosis of chronic secondary pain. These are grouped into six categories, namely, cancer-related pain, post-surgical or post-traumatic pain, neuropathic pain, secondary headache or orofacial pain, secondary visceral pain and secondary musculoskeletal pain. (7) These pain diagnoses have been included in the International Classification of Diseases, 11th Revision (ICD-11), released by the World Health Organisation (WHO) in June 2018, recently coming into effect in January 2022. (9) For the first time, a systematic coding system for chronic pain has been incorporated, providing an opportunity for standardised coding throughout healthcare systems. (10) The term “CPP” remains a novel concept, with studies predating this classification change referencing different nomenclature. (11) For this reason, other terminology including chronic non-cancer pain (CNCP) and the relevant available evidence will also be referenced throughout the protocol. Over the past two decades, there has been a significant increase in prescribing of opioids for CNCP, with growing controversy due to insufficient evidence to show improvement in either pain or function. (7, 12) Strong opioids are prescribed more frequently in Northern Ireland (NI) than elsewhere in the United Kingdom(UK). Opioid-related deaths in NI are more likely to involve prescription opioid drugs than in other UK countries. (13) Dissemination of recent UK guidance in response to these issues represents the first time CPP has been recognised by the National Institute for Health and Care Excellence (NICE) as a condition in its own right. (14) However, this guidance has polarised opinion from both patients and clinicians. (15-18) The British Pain Society commented “the blanket and inexpert withdrawal of medication in such a vulnerable group of patients could easily lead to despair and unintended harm.” (17) Concerns were also raised regarding the potential for decommissioning of specialist pain services, as well as GP capacity for the prescribing reviews required. (18) No guideline can encompass the unique features of individual patients and their clinical circumstances, nor can it replace clinical judgement. (19) A 2015 systematic review regarding clinician adherence to prescribing guidelines for CNCP across USA, Australia, Canada and France found a disconnect with guideline recommendations due to lack of clinician awareness and difficulties translating guidelines into clinical practice. (20) In Scotland, the Scottish Intercollegiate Guidelines Network (SIGN) guidelines for Management of Chronic Pain are recommended. (21) These are not consistent with NICE with reference to the recommendation that opioids may be considered in the short to medium term in carefully selected patients with CNCP, for patients where other treatments have been insufficient, and where benefit outweighs risk. (16) In the US, the Center for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain (2016) has been updated in 2022, providing an expansion to recommendations regarding the use of opioids, including within primary care. Despite not the intention of the 2016 guidance, new laws and policies were designed and implemented on a wide scale throughout the US, appearing to reflect the guideline recommendations. However, many of these have been inconsistent with the fundamental principles of the guideline, which were intended to be flexible and supportive of patient centred care. Such misapplication has contributed to patient harm with the undertreatment of pain, withdrawal symptoms, psychological distress and suicidal behaviours. (22) Given that the concept of CPP remains relatively new, a detailed exploration into GP perspectives regarding management of patients with CPP in the community is timely. Evaluation of the awareness and acceptability of published guidance may help inform public health strategies and development of local resources to more effectively manage patients living with CPP. Research Aims and Objectives. The primary aims of this study is to explore GP perspectives in relation to caring for people living with CPP. Secondary Objectives: To explore the challenges encountered regarding the management of patients with CPP. To assess the level of GP awareness of published guidance for CPP. To understand how guidance for CPP is used in primary care. To gauge the extent of the acceptability of this guidance within the GP community


Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING
Health categories: GENERIC HEALTH RELEVANCE