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The OPENMinds Primary Care group is a group of European primary care physicians (PCPs) with an interest in pain management, formed to improve the understanding and management of chronic pain in primary care.
A survey was conducted to assess the challenges of chronic nonmalignant pain (CNMP) management in primary care in Europe, focusing particularly on pain assessment, opioid therapy, and educational needs.
A questionnaire was developed for online use by PCPs in 13 European countries (Belgium, Denmark, France, Germany, Ireland, Italy, the Netherlands, Norway, Poland, Portugal, Spain, Sweden, and the UK).
A total of 1309 PCPs completed the questionnaire, approximately 100 from each country. Most PCPs (84%) perceived CNMP to be one of the most challenging conditions to treat, yet a low priority within healthcare systems. Only 48% of PCPs used pain assessment tools, and 81% considered chronic pain and its impact on quality of life to be underassessed in primary care. PCPs were less confident about prescribing strong opioids for CNMP than for use in cancer pain. Most PCPs (84%) considered their initial training on CNMP was not comprehensive, with 89% recognizing a need for more education on the topic.
These findings reveal that PCPs in Europe find CNMP a challenge to treat. Areas to address with training include underuse of pain assessment tools and lack of confidence in use of opioid therapy. Guidelines on CNMP management in primary care would be welcomed. The insights gained should provide the basis for future initiatives to support primary care management of chronic pain.
It is estimated that 70% of patients with chronic pain are managed in primary care.1 Chronic pain is a key reason for consulting primary care physicians (PCPs), accounting for 22% of presenting conditions,2 with over a third of adult appointments with a PCP involving a patient in chronic pain.3 Furthermore, patients with chronic pain consult their PCPs five times more frequently than patients without such pain.4 With such extensive and regular exposure to the needs of patients with chronic pain, it might be expected that PCPs would be highly confident and proficient in its management. However, at least 40% of patients with chronic pain treated in a routine practice setting do not achieve adequate pain relief.5 This suggests that chronic pain management presents a challenge to many physicians.6
Surveys of PCPs conducted in the USA report considerable frustration and dissatisfaction with the management of chronic pain.3,7 These and other surveys conducted in North America identified challenges, including a lack of confidence in chronic pain management, concerns about the use of opioid analgesia, and dissatisfaction with training.8,9 Similar challenges may face European PCPs.
With this in mind, the pan-European Opioids and Pain European Network of Minds (OPENMinds) Primary Care group (OMPC) was formed, to act synergistically with the already established OPENMinds group of leading European experts who specialize in the research and management of pain. The OMPC aims to explore initiatives that enhance pain management in primary care in Europe. The first initiative of the OMPC was a survey of PCPs to assess the challenges of chronic nonmalignant pain (CNMP) management in primary care in Europe, focusing particularly on pain assessment, opioid therapy, and educational needs. The findings should form an evidence base for future initiatives.
The OMPC group met in November 2010 and identified CNMP and opioid analgesia as particular problems encountered by PCPs. The OMPC Steering Committee developed a questionnaire on chronic pain (pain present for at least 3 months, several days per month, and present in the last month), as defined by the International Association for the Study of Pain (IASP).10 The questionnaire (see Supplementary material) was translated into European languages that were appropriate for the target countries. Back-translation was used to check for the validity of the terminology used.
The research was conducted online to reach a large number of respondents from different countries in a timely and efficient manner. An online panel of more than 500,000 physicians across Europe was used. From this panel, a sample of approximately 100 PCPs was taken from each of 13 European countries (Belgium, Denmark, France, Germany, Ireland, Italy, the Netherlands, Norway, Poland, Portugal, Spain, Sweden, and the UK). The samples were selected to be nationally representative in terms of sex, age, and regional distribution. All respondents were PCPs (3–45 years of experience) spending at least 20 hours each week in direct patient care. Respondents received compensation (within accepted guidelines) for their participation. Fieldwork was undertaken in July 2011.
Responses to each question were collated and analyzed for the total group and for subgroups defined by sex, years in practice, practice size, and country. Responses within subgroups were compared using one way analysis of variance (ANOVA), followed by the Bonferroni t-test for multiple comparisons or by the Student’s t-test when comparing only two groups; a P-value < 0.05 was considered statistically significant.
A total of 1309 PCPs completed the questionnaire (Table 1).
Patients with CNMP were seen as challenging to manage by 88% of PCPs, though this view was less likely among the minority (n = 57) stating that they worked within a large multidisciplinary team (definition not given) compared with other practices (77% vs 87%–90%), and in those from Portugal (81% vs ≥91% of respondents in the UK, Sweden, and Ireland). On average, the PCPs surveyed perceived CNMP to be a low priority within the healthcare system, despite the challenges it poses (Figure 1). Regardless of sex, length of experience, and practice size, 79% of PCPs stated that the management of CNMP should be higher on the government health agenda; this view was particularly prevalent in Italy, France, Poland, Spain, and Portugal (88%–91%) compared with the Netherlands and Denmark (≤55%). Nearly three-quarters of respondents (74%) stated that chronic pain should be considered a disease in its own right (ranging from 56% of those in Denmark to 94% of those in Italy), though 57% considered that chronic pain is more a symptom than a condition (ranging from 42% in Germany and 43% in Italy to 70% in the Netherlands and 71% in Sweden).
Fewer than half (48%) of the PCPs used pain assessment tools (Table 2); this was significantly lower among those practicing for ≥31 years (31%) compared with physicians in practice for 6–20 years (52%–60%) (P < 0.05). Pain assessment tools were used by 70% of doctors stating that they worked in a large multidisciplinary team (not defined), compared with 43%–49% of practitioners in other practices (P < 0.05). Among respondents using assessment tools (n = 628), the most commonly used were visual analogue scales (mentioned by 64%) and numerical rating scales (51%). Although the majority (83%) of those using assessment tools recorded the results in the patients’ notes, this corresponded to just 40% of all PCPs surveyed.
Among those not using assessment tools, the main reason given was lack of knowledge (26%); this was a greater problem for those with many years of practice (40% of those in practice for ≥31 years vs 12% for ≤5 years). Other reasons given included the view that tools were not useful (18%), the lack of time (16%), the preference “to just talk with the patient” (13%), and the view that these were too impersonal (12%).
Overall, 81% of PCPs surveyed believed that chronic pain and its impact on quality of life is underassessed in primary care. Fewer than half (49%) of the PCPs reported having adequate time in their consultations with patients to discuss pain and its management, and only 64% felt they had adequate tools for the diagnosis and management of CNMP.
Of the patients with CNMP seen by the respondents, 40% were managed without use of opioids, 40% used weak opioids only (commonly used for the management of mild to moderate pain), 11% used strong opioids only (commonly used for the management of moderately severe to severe pain), and 9% used both strong and weak opioids. PCPs were generally confident about prescribing opioids for cancer pain but less confident about opioid use in CNMP (Figure 2). Confidence was particularly low in Norway, Sweden, and Poland, with 46%, 43%, and 37%, respectively, reporting a lack of confidence in the use of strong opioids for CNMP compared with ≤20% in the UK, the Netherlands, France, and Italy. Among the 304 PCPs who were very confident using strong opioids for CNMP, the most common reasons given were experience (mentioned by 34%) and available treatments (33% overall, with 70% in practitioners with ≤5 years of experience vs 22%–40% in those practicing for longer). Among the 92 PCPs who were not confident at all about using strong opioids in CNMP, the main reasons given were concerns about addiction or abuse (35%) and adverse events (22%).
The majority of PCPs (86%) reported that constipation was the side effect of strong opioids most commonly raised as an issue by patients (Figure 3); there was significantly lower reported concern about constipation in Portugal (56%) than in all other countries (P < 0.05).
Overall, 84% of PCPs reported that their initial training in CNMP management was not comprehensive. More respondents from the UK, Belgium, Poland, and the Netherlands were dissatisfied with their initial training (88%–91%) than those in France, Germany, and Ireland (72%–78%). During the preceding year, 75% of respondents had received formal training and education on CNMP management, with a lower proportion in Sweden (42%) than in all other countries and ≥92% in Italy, Spain, and Poland. This training was for an average of 10 hours and was significantly lower (≤5 hours) in UK, France, Sweden, Belgium, the Netherlands, and Ireland compared with ≥20 hours in Italy and Spain (P < 0.05). The main reason given by the 332 respondents who had not received such training during the last year was lack of time (mentioned by 70%). Most PCPs (89%) surveyed perceived a need for more education on CNMP management.
Guidelines for pain management appear to be used more commonly for cancer pain than for CNMP (Figure 4). There are no universal guidelines for the management of CNMP, though 72% of respondents reported that these were required. This view was significantly more prevalent in women (76% vs 70% in men) (P < 0.05), recently qualified doctors (79%–83% of PCPs with ≤10 years experience vs 63%–67% of PCPs with ≥26 years experience), and those working with other PCPs and in multidisciplinary teams (73%–84% vs 62% of single practitioners). There were also considerable differences between countries, ranging from 96% and 91% in Spain and Poland, respectively, to 57% in France and Italy.
This large survey showed that PCPs in Europe, like their counterparts in North America, find the primary care management of CNMP a considerable challenge.3,5,7,9 Fewer than half of the PCPs across Europe used pain assessment tools, and the majority of respondents recognized that chronic pain and its impact on quality of life are under-assessed in primary care. There was some lack of confidence in prescribing strong opioids for CNMP. Overall, 89% of PCPs perceived a need for more education on chronic pain, and there was considerable demand for clinical guidelines focused on the management of CNMP.
The study has a number of limitations. Because of the online-survey format, respondents were self-selected, though representative of the PCP population within each country. Respondents were drawn from 13 countries, each with its own healthcare system, so there was considerable heterogeneity in terms of the size of primary care practices and the number of patients seen by each physician, although this approach ensured the results reflected the broad European situation. It should be noted that the overall findings of this survey were consistent with those of other approaches (eg, postal surveys, discussion groups) used in other surveys of PCPs.8,9,11 As with other surveys, time and size constraints of the study meant that related topics (eg, attitudes towards nonpharmacological management of pain) could not be considered.
The survey found a lack of clear guidelines for the assessment and management of CNMP (or lack of awareness of such guidelines). Although CNMP was seen by the majority of PCPs as a condition in its own right, guidelines on pain management may be fragmented – there are multiple guidelines for specific conditions (eg, headache, musculoskeletal conditions) that have chronic pain as a symptom. The numerous gaps in evidence may contribute to the lack of appropriate guidelines, and there is a need for further research in the management of CNMP.12 A recent review of the evidence available to guide the management of chronic pain in primary care, and other surveys of PCPs, also identified a lack of CNMP guidelines for the primary care setting.11,13 There appears to be an important potential role for professional organizations in developing and disseminating European guidelines for the management of CNMP in primary care.
Despite the recognized importance of formal evaluation to guide treatment and assess response,14 the survey found that over half the PCPs did not use tools to assess CNMP, primarily due to lack of knowledge, particularly amongst PCPs who have been in practice for many years. This situation could be addressed by improved education. There may also be a need for improved assessment tools, consistent with findings from PCPs in the USA.15 In another survey, PCPs reported a mean of 2.3 minutes spent on discussions about pain during their consultations with elderly patients and concluded that time constraints adversely affected pain management,16 suggesting that assessment tools should be quick and easy to use.
While short-term studies have established the clinical effectiveness of opioids for CNMP, evidence on long-term use remains limited.12 The survey found that 40% of the patients seen by the PCPs did not use any opioids for the management of CNMP, while one in five (20%) were managed using strong opioids (presumably for moderately severe to severe pain). Although almost two-thirds of respondents (64%) were fairly or very confident in the use of strong opioids for CNMP, more than a quarter of respondents (27%) showed some lack of confidence. Similar findings have been reported in other studies,3,5,15 including one US study that found 71% of PCPs felt moderately or strongly confident of their ability to treat chronic pain.7
The pan-European survey reported here and others have found PCPs are concerned about the potential for opioid addiction or misuse.17,18 A study of PCPs in the USA found that although most respondents believed it lawful and appropriate to use opioids for cancer pain, fewer than half held this view for CNMP;9 that study and others found widespread concerns that PCPs using such treatment could become the subject of investigation.8,19,20 Such US experiences and concerns may influence European PCPs.
The survey suggested some concern among PCPs about the potential for side effects from opioids. In a survey of PCPs in Canada, 42% reported that patients using opioids for CNMP had experienced at least one adverse event during the preceding year.8 According to the present study, constipation is the side effect of strong opioids most commonly raised as an issue by patients, consistent with other studies showing the high frequency of opioid-related bowel dysfunction in patients receiving treatment for chronic pain.21–23 The OMPC may be able to address the need for education to improve patient selection for opioid treatment and subsequent monitoring, and to disseminate information about minimizing opioid-related bowel dysfunction.
The survey found dissatisfaction with education on CNMP management, consistent with the findings of other studies. Despite pain being a common reason for primary care consultation,18,24 education about pain represents less than 1% of university-based teaching for healthcare professionals.25 In a study of medical undergraduates, most held negative views about pain management, particularly regarding chronic pain;24 medical students also experience considerable anxiety about encounters with patients suffering from chronic pain.26 Training on pain should address interviewing skills as well as knowledge of pain mechanisms.27
This large survey conducted in 13 European countries has shown that PCPs find CNMP a challenge to treat. Training in the use of assessment tools and the appropriate prescription of strong opioids, and the development of guidelines on primary care CNMP management would be welcomed by European PCPs. These findings should provide the basis for future initiatives by the OMPC and other organizations to support primary care management of chronic pain in Europe.
The findings are presented here on behalf of the OPENMinds Primary Care group: M Johnson, UK; B Collett, UK; JM Castro-Lopes, Portugal; F Corti, Italy; J Draiby, Sweden; F Hirszowski, France; K Kristiansen, Denmark; A Norman Hansen, Norway; U Schutter, Germany; V Simovich, Israel; JMP van Bommel, Netherlands; SF van Laer, Belgium.
The survey was conducted by Ipsos MORI and sponsored by an educational grant from Mundipharma International Limited. OPENMinds and OMPC are funded by educational grants from Mundipharma International Limited. MJ has received consultancy fees, honoraria, and travel expenses from Astellas, AstraZeneca, Grünenthal, Lilly, Mundipharma, NAPP, Nycomed, and Pfizer. BC has received consultancy fees, honoraria, and travel expenses from Astellas, Grünenthal, Lilly, Mundipharma, NAPP, and Pfizer. JMC-L has received consultancy fees, honoraria, or travel expenses from Astellas, Bene Farmacêutica, Grünenthal, Janssen, Mundipharma, and Pfizer. Diane Storey of Direct Publishing Solutions Limited prepared the first draft of the manuscript for the authors’ review and provided editorial support funded by Mundipharma International Limited. The authors report no other conflicts of interest in this work.