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Chronic pain has a broad impact on an individual's life as well as those
closest to them. It can adversely affect a person's ability to function
and their emotional wellbeing as well as having social and financial
The best practice management of
chronic pain requires a biopsychosocial
approach. This means understanding:
• what is happening to the body
• what is happening to the person, and
• what is happening in the person's world.
Also referred to as a multidimensional
approach, biopsychosocial management
of chronic pain involves consideration
of three aspects of the patient's health:
biological, psychological and social.
Assess all contributing pain diagnoses.
Take a detailed pain history and conduct a
physical examination. What is the location
of the pain (anatomical)? What is the pain
mechanism, for example, neuropathic or
inflammatory? Rule out red flags such as
cancer, infection or fracture.
Consider all medical comorbidities that
could influence the presentation of
pain, such as diabetes, dementia or its
management, renal impairment and
Assess psychological contributors,
documenting psychological responses
to pain such as catastrophising, coping
style (active or passive) and low
self-efficacy. Identify any yellow flags
(for example, attitudes and beliefs
about pain, behaviours, and emotions)
that may impede the rehabilitation
process. Identify the presence of major
depression and general anxiety disorder.
Socioeconomic assessment requires the
documentation of the socioeconomic
consequences of pain, such as
impact on employment and finances,
social isolation or levels of support.
Consider extrinsic factors that will
affect pain, such as physically strenuous
employment or adaptable work
Conduct a risk assessment for
medication misuse. Assess the risk of
developing problematic behaviours with
medications such as opioid analgesics.
Assess the impact of pain on the ability
to function and perform normal tasks.
In instances where there is no cure
for the pain, a biopsychosocial
approach can still be applied to pain
management. The aim then becomes
shifting the patient's focus from having
a pain-centred life to improving function
despite persisting pain.
Paradigm shifts that will help enable
the application of a biopsychosocial
approach to the management of
patients with chronic pain include:
• changing the aim of treatment
from seeking a cure to optimising
rehabilitation and function despite
the pain. This includes acceptance of
• broadening the management target
from simply reducing pain severity to
also improving function
• moving from analgesics as the
primary focus of therapy to
multimodal therapy (i.e. using a
combination of physical and cognitive
therapies in addition to medications
to manage the patient's chronic pain)
• encouraging patients to not be treated
passively, but enabling them to take an
active self-management role.
ACCREDITED PHARMACIST SPECIAL INTEREST GROUP
BY OLLY ZEKRY
Olfat (Olly) Zekry is a NSW medical centre pharmacist
and the Pharmacology Unit Co-0rdinator for
the Masters of Pain, Faculty of Medicine, Sydney
University. She has a Masters Degree in Pain
Management through the Faculty of Medicine,
University of Sydney. She is the 2014 PSA QUM Award
in Pain Management winner.
Health literacy and advice
Australian research suggests that the use
of active self-management strategies by
patients with chronic pain can be improved.
A telephone survey of people with
chronic pain investigated the use of active
and passive management strategies
to manage chronic pain. This research
identified that passive strategies were
more common than active strategies.
The most commonly used therapies were
medication use (47%), rest (32%), exercise
(26%) and heat or cold packs (23%).1
A study of chronic pain management
among GP patients investigated the
associations between treatment modality
and pain-related disability.2 This research
found that people who employed active
management strategies were less likely
to have pain-related disability (adjusted
odds ratio 0.2).
I advocate strongly for pharmacists to
play a key role in pain management
and in preventing the progression of
acute pain to chronic pain by clinical
interventions and patient education.
1. Blyth FM, March LM, Nicholas MK, et al. Self-management of
chronic pain: a population-based study. Pain 2005;113:285--92.
2. Henderson JV, Harrison CM, Britt HC, et al. Prevalence,
Causes, Severity, Impact, and Management of Chronic
Pain in Australian General Practice Patients. Pain Medicine
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