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5 Articles in this Series
Introduction
2018 IASP World Congress on Pain: A Preview
Informal Social Support for Pain: Moving the Research Forward
Spinal Cord Stimulation Evidence: What's Available and What's Needed
Symptomatic Treatment of Painful Diabetic Neuropathy
Translating Trials into Practice from a Primary Care Perspective

Translating Trials into Practice from a Primary Care Perspective

Blair H. Smith, MD, puts translational medicine for pain care into perspective. A 2018 IASP World Congress on Pain Highlight.

Speaking at the 2018 IASP World Congress on Pain in Boston, Blair H. Smith, MD, clinical director of population health science at the University of Dundee in Scotland, presented “Current Challenges and Opportunities for Chronic Pain Pharmacology in Primary Care Settings.”1 His talk focused on strategies to help clinicians translate the results of trials into practice, as well as how community knowledge can help to optimize analgesic prescribing. Part of the challenge, he noted, are the barriers healthcare providers face with regard to access and implementation.
 

In the United Kingdom, for example, 90% of health service contacts are with primary care, and on average, each individual consults general practice five to six times a year, shared Dr. Smith. Primary care differs in its initial setup, with a common feature being brief consultations—that is, establishing a relationship with a patient within a 10-minute span. This is not always an easy task, as obtaining a clear health education profile of the patient takes time. “Many people think of general practitioners (GPs) as the ‘fat cats’…but at the end of the day, they are pretty stifled and stressed, and this is a genuine problem for recruitment and retention,” he said.

When prescribing for pain in a primary care setting, being educated in pain and pain management is key. “I think many of us are basing our model of prescribing on the World Health Organization (WHO), but, as you all know, [it] was designed for palliative care rather than pain.” According to Dr. Smith, there are few randomized controlled trials (RCTs) to support the WHO pain guidelines, which also seem to ignore the presence and importance of non-pharmacological methods. With the high rate of opioid prescriptions, particularly in the US but also increasing in certain European countries, this is an issue. Scotland, in particular, suffers from the same rates consistent with the other parts of the world.

Referencing a Generation Scotland study, in 2012, 18% of the Scottish population were prescribed opioids. Researchers found that “prescribing is generally appropriate and related to pain severity, and many individuals with severe pain are not receiving any prescription painkillers.” For example, 53% of those who reported severe chronic pain received no opioid after a 12-month period, 40% of which received no analgesic at all during the same period. “This is the other side of the coin, we’re not necessarily overprescribing…it’s how we prescribed; the rationality.” As a GP, one of the many challenges has been that options for prescribing opioid analgesics have been withdrawn due to restrictions or regulatory controls, said Dr. Smith. On the other hand, certain available analgesic options have limited efficacy.

The results of a RCT may not always be suitable for the primary care setting, explained Dr. Smith. A systematic review of the eligibility criteria for patient selection in 200 trials2 revealed that, across all trials, 81% of patients were denied eligibility due to common core comorbidities, and over half were denied on the grounds of concurrent medication. RCTs sponsored in part from pharmaceutical companies, in addition, are more likely to exclude these groups of patients. “I can’t remember the last patient [that] came to me with a therapeutic decision that didn’t have concurrent medication and didn’t have common core comorbidities,” commented Dr. Smith. How then, is one supposed to relay the information to patients, when the exclusion for entry is so high in these regards? Similar figures hold true for diabetes trials as well. “Although RCTs are the gold standard at the top of the mountain, do we have to climb the top of the mountain in order to reach these decisions for pain management? We should think of other approaches to generating evidence.”

How then do PCPs make RCTs relevant to care populations? Dr. Smith suggested a few methods, including:

  • cluster randomization
  • quasi experimental designs
  • synthesizing evidence with systematic reviews
  • and making ongoing assessments and evaluations.

In conclusion, Dr. Smith noted that prescribing for pain in primary care should be guided by the best available evidence, “but when that doesn’t exist, we will still need to prescribe and/or find other ways of generating and interpreting.”

References

1. Smith BH. "Current Challenges and Opportunities for Chronic Pain Pharmacology in Primary Care Settings" presented at 2018 IASP World Congress on Pain, September 12-16, in Boston, MA.

2. Van Spall HG, Toren A, Kiss A, et al. Eligibility criteria of randomized controlled trials published in high-impact general medical journals: a systematic sampling review. JAMA. 2007;297(11):1233-1240.

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