P is Pain in GP Giuliano Piccoliori SIMG – Società Italiana di Medicina Generale Accademia Altoatesina di Medicina generale

What are we speaking about Pain is one of the most common reasons for consultation in general practice. Estimates of prevalence of chronic pain vary a lot, ranging from 2 to 40% with a median value of 15%. This wide variation may reflect true differences between populations, but also the use of different definitions and classifications of chronic pain in epidemiological studies. Most of chronic pain patients are in their 60s or 70s, are women and consult their GP 5 times more often than the others. The most common locations of chronic pain in the community are limbs and joints and the back. Neck and head are other important origins of chronic pain. Diagnostic classification is often vague or impossible. Pain and particularly chronic and recurrent pain is one of the most common reasons for consultation in general practice. Estimates of prevalence vary a lot, ranging from 2 to 40% with a median value of 15%. For instance according to a study of the WHO carried out in 1998 including 5500 subjects in 15 centers all around the world, chronic pain in primary care has a prevalence of 20%. This wide variation may reflect true differences between populations, but also the use of different definitions and classifications of chronic pain in epidemiological studies, for example the duration: some studies define chronic pain as persistent for more than three months...others as persistent for more than six months. Further, different methods of investigation, detection and assessment are used. A fact, we know for sure, is that chronic pain is more frequent in women and in the elderly. Most of chronic pain patients are in their 60ies or 70ies and consult their GP 5 times more often than patients, who are not suffering from chronic pain. The most common locations of chronic non-malignant pain in the community are limbs and joints (around a half of all chronic pain cases) and the back (around a third). Neck and head are other important origins of chronic pain. Diagnostic classification is often vague or impossible, also because other multiple and diverse factors contribute to the clinical picture.

The role of the General Practitioner Chronic pain causes reactive behaviors and psychological suffering. This generates anxiety and depression, which interact to cause or maintain the chronic pain Chronic pain can disrupt the life It is a devastating pathology which is called pain-disease. Because of being a "disease of the person" it is an issue that should be mainly allocated into the field of GPs. According to the "PAIN in EUROPE SURVEY”, 70% of chronic-pain-patients were treated by their GP and only 2% directly consulted a pain specialist. It is well known that chronic pain causes reactive behaviours and psychological suffering, the latter mainly caused by social withdrawal, the reduction of activities and interests. This generates quite reliably chronic anxiety and depression, which on their hand, interact to cause or maintain the state of chronic pain in a vicious circle. Chronic pain really disrupts the life of those who suffer from it. It takes shape as a real devastating and destructive pathology which is called pain-disease. And exactly because of its special characteristic of being a "disease of the person" it is an issue that is or should be allocated into the field of GPs, who approach their patients in a holistic way. According to the "PAIN in EUROPE SURVEY”, a large survey conducted on chronic pain in 2004, in which 46000 people were interviewed, 70% of chronic- pain-patients were treated by their GP and only 2% directly consulted a pain specialist.

Italian Pain reSEarch – IPSE Indicators Tolerability Impact on the daily acitivities Referrals Examinations Therapy drugs other Outcomes QoL Prevalence Site Diagnosis Duration Frequency Intensity Irradiation Type Riassumendo si tratta di rilevare indicatori che ci consentano di descrivere il profilo epidemiologico e statistico del problema dolore nel nostro setting, il suo impatto sulla qualità di vita degli assistiti, la gestione sia diagnostica che terapeutica e gli esiti. Description Management

Italian Pain reSEarch/ IPSE – The CRF In 2006 SIMG, the Italian Society of General Practice, had carried out a study on patients with moderate to severe pain in general practice, called “IPSE – Italian Pain reSEarch”. Within this study an electronic case report form was developed for the purpose of evaluation and typification of pain through indicators such as duration, history, location, intensity, irradiation, type, frequency, tolerability, and impact on the quality of life. Requirements for this form were mainly fast and simple application. It was implemented in the Italian electronic health record (EHR) – software for GPs, Millewin, the official practice software used by one third of all Italian GPs. In this study 95 GPs from 14 Italian regions participated, who in total care for about 137000 “registered” citizens. You have to consider that in the Italian health care system, every citizen over 14 has to be registered with a GP in order to get access to NHS. In this way, the patient-population of Italian GPs for gender, age but also diagnoses, medications and treatments in great parts depicts the general Italian population. This is epidemiologically very interesting and quite unique in Europe. Coming back to the IPSE study: The GPs had to include all the patients, who consulted them because of a pain-related problem (acute and chronic) with a pain-intensity of more than 3 on the Numeric Rating Scale In one year 11% of the overall registered patients met the inclusion criteria for the study and were enrolled. The average age of these patients was 59 and 60% were women. Around 30% of those suffered from chronic pain. This corresponds to about 3% of all registered patients. The group of the diseases of the musculoskeletal system was by far the most frequent with 78%. Among the causes for chronic pain osteoarthritis was leading the list with 20%, followed by low back pain with 14%. As expected, depression, anxiety and insomnia were significantly more frequent in the patients affected from chronic pain compared to all registered patients.

Italian Pain reSEarch – IPSE Results 95 GPs from 14 Italian regions (137,000 patients) 11 % of all registered patients consulted their GP for a pain-related problem Average age 59 DS: 17 Women 62 % 3% presented a chronic pain (for more than 3 months) In base ai criteri di inclusione/esclusione prestabiliti sono stati arruolati dagli 84 medici 5277 pazienti, pari al 4,4% degli assistibili in carico. Su proiezione annua pari al 10,9%. Il 62% erano donne, l‘età media era di 59 anni. IL 52% aveva più di 60 anni. Se ci limitiamo alla popolazione over 60 vediamo che ben l‘8% delle donne ed il 6% degli uomini nel periodo di osservazione si sono presentatii con un dolore moderato-severo, su base annua il 23,5% delle donne ed il 17% degli uomini.

Italian Pain reSEarch – IPSE Results The group of the musculoskeletal system was the most frequent with 78%. Among the causes for chronic pain osteoarthritis was leading the list with 20%, followed by low back pain with 14%. Depression, anxiety and insomnia were significantly more frequent in the patients affected from chronic pain In circa il 27% die casi il dolore persiste per più di 3 mesi e nel 19% die pazienti da almeno 6 mesi. Nel 25% dei casi il dolore non è presente da più di 6 giorni. Il 27% dei pazienti arruolati corrisponde al 1,2% del totale degli assistiti in carico per il periodo considerato o al 3% su base annua.

Low Back Pain in General Practice in Alto Adige Results 25 GPs participated Registered patients 43.012 6% of all registered patients consulted their GP because of a LBP Women: 60% Average age: 55 Around 25% of them with chronic LBP Moreover in Alto Adige we have carried out a study on low back pain, in which 25 GPs took part with a total of 43000 registered citizens. In one year around 6% of the registered patients went to see their GP for an acute or chronic LBP. 60% of them were women and had an average age of 55. On average, in one GP´s practice there were 3 accesses and 2 patients for, respectively with LBP every week. About 1/4 of these patients suffered from chronic LBP. 24.11.2017 Giuliano Piccoliori

Critical points in the chronic pain care in general practice GPs are not used to explore the various components of the pain; The adjuvant analgesics are fewly and not correctly prescribed; Strong and weak opioids are prescribed in an insufficient amount From the results analysis of both studies I talked about, the IPSE and the Alto Adige study on the low back pain 3 main critical points have emerged: 1. The greatest part of the GPs are not used to explore the various components of the pain; 2. The adjuvant analgesics are fewly and not correctly prescribed; 3. In the treatment of chronic pain in general practice, strong and weak opioids, with are a precious drug in this context, are prescribed in an insufficient amount (even if, in the last years there has been a steep increase of the use of opioids in our setting)

Diagnostic > therapeutic path Simple assessment tools Thanks to the IPSE study, SIMG was involved in the development of a handbook on chronic pain for Italian general practice, that was published in 2013 by the Italian Ministry of Health and was distributed to all the 50.000 Italian GPs. By the way it contains an algorithm, a diagnostic therapeutic path to classify the pain on the basis of the so called pain generator and a guide to prescribe a specific therapy for the classified pain . The decisional algorithm was developed in collaboration with experienced pain specialists, and adapted for the operational setting of general practice. Educational courses for its use took place all over Italy. Diagnostic > therapeutic path

Networks of pain therapy Italian Law 38/2010 The networks of pain therapy, that were provided by an Italian law (38/2010), were only realized in some regions and provinces of the country. They consist of specialist care centers as central hubs and outpatients´ pain surgeries as peripheral spokes, as well as of GPs. It is possible to educate GPs to manage the chronic- pain-patient, to provide efficient treatment and A MORE EFFICIENT COLLABORATION WITH THE PAIN SPECIALIST. However, the way towards good and better care for chronic pain in the setting of general practice is still long. The networks of pain therapy, that were provided by an Italian law (38/2010), were only realized in some regions and provinces of the country. Those networks consist of specialist care centers as central hubs and outpatients´ pain surgeries as peripheral spokes, as well as of GPs. But our experience shows that it is possible to educate GPs to manage the chronic- pain-patient better, to provide efficient treatment and a more efficient collaboration with the pain specialist.

Conclusions The goal should be: to educate and train GPs in evaluation and assessment of chronic care patients to enable them to provide a good treatment for individual patients and to recognize when a referral to a specialist is needed. The big challenge of chronic pain can only be faced together, uniting competences, expertise and knowledge of GPs and pain specialists. I think that all Europe has an interest to educate and train GPs in this topic in order to enable them to self perform a correct evaluation and assessment of chronic pain patients , to professionally provide a good treatment for individual patients and to recognize when a referral to a specialist is needed. The big challenge of chronic pain can only be faced together, uniting competences, expertise and knowledge of GPs and pain specialists in a health care environment that provides a good infrastructural frame for this to happen naturally.

«…only for the gods life eternally flows without pain» Thank you for the attention