Pain on the CCFP exam

Approach

• Offer pain relief at first contact. The patient does not have to earn it with a diagnosis.
• Pick the drug for this patient: age, kidney function, other illness and other drugs.
• Recheck the pain after each dose, and keep looking for the cause.
• A healthy, well-looking child over 6 months with mild ear pain and sure follow-up: treat the pain and watch for 48 to 72 hours.
• Limit antibiotics to severe or complicated illness. Consider them if the child does not improve, or if a child under 2 has both ears infected.
• If acute pain is bad enough for an opioid, give the lowest dose and the fewest doses. Usually 3 days or less, rarely more than 7.
• No codeine under age 12, in any setting.

Approach

• Ask where it is and where it spreads. A band on one side that stops at the midline points to a nerve.
• Ask what it feels like. Burning, shooting or electric pain is nerve pain. A deep ache is muscle. A dull pain that is hard to place is from an organ.
• Ask what brings it on and what eases it. Movement and pressing point to muscle. Pain on walking that stops with rest points to poor blood flow.
• Ask about numbness, tingling, or pain from a light touch. These fit nerve pain.
• Ask what comes with it. Sweating, nausea or shortness of breath point to an organ such as the heart.
• Pain in a one-sided band, then blisters days later, is shingles.

Approach

• When the cause is unclear, name the deadly causes for that body site before the common ones.
• Chest: heart attack, a torn aorta, a clot in the lung. Reflux and chest wall strain come after those are cleared.
• Back: cancer, infection, fracture, and cauda equina syndrome (nerve roots squeezed at the base of the spine). Known cancer puts spread to the spine first.
• Low back red flags that call for imaging: suspected cancer or infection, cauda equina syndrome, severe or worsening nerve loss, suspected compression fracture.
• Without red flags, do not image the low back. Before 6 weeks it does not improve outcomes. After 6 weeks, a suspected slipped (herniated) disc or narrowed spinal canal is imaged only if surgery is being considered.
• Suspected abscess or bleeding near the spine needs urgent imaging, even before any nerve signs.

Approach

• Stay calm and kind. Name your concern plainly, and keep the door open.
• Examine again. Look for a new cause, a complication, or disease that has progressed.
• Ask whether the dose matches the pain. Pain that outruns the dose can look like drug-seeking.
• Tolerance and physical dependence alone are not evidence of addiction.
• Worry about misuse should not stop proper pain treatment. Take more care with a past of alcohol or drug misuse.
• If opioid use disorder is likely, offer opioid agonist therapy (methadone or buprenorphine), the gold standard. Do not stop buprenorphine just because acute pain needs more opioid.

Approach

• New to opioids, or older: start low and raise the dose slowly. Breathing risk peaks at the start and after each increase.
• Weak kidneys let drugs and their breakdown products build up. Adjust each dose for kidney function and review every drug.
• Avoid NSAIDs with high blood pressure, heart failure or kidney disease. They raise pressure and worsen kidney function.
• Check addiction risk before you prescribe. Past alcohol or drug misuse raises it. Watch for misuse at each review.
• Codeine works mainly after the liver turns it into morphine. Ultra-rapid converters can stop breathing at usual doses.
• Severe pain offsets an opioid's effect on breathing. If the pain suddenly stops, sedation and slow breathing can appear. Lower the dose.
• Avoid adding benzodiazepines or alcohol. Together they deepen sedation and slow breathing.

Approach

• Recheck the diagnosis. Repeat the history and exam, and look for red flags you missed.
• Look for complications of the illness or of the treatment.
• Review each drug: the dose, how it is taken, side effects, and whether it still helps.
• Pain that grows, spreads, or hurts with light touch on a steady or rising opioid dose, without disease progression, may come from the opioid. Lower or taper it.
• Ask where tablets are kept and who else is in the home. Store them in a safe place, out of the sight and reach of children.
• Return unused tablets to a pharmacy take-back program as soon as they are not needed. Never put them in the trash or the toilet.
• Opioids for acute pain rarely run past 7 days. Pain that needs them longer needs a fresh look.

Approach

• Name the drug and its class: acetaminophen, or NSAIDs such as ibuprofen, naproxen and ASA (acetylsalicylic acid).
• Acetaminophen: no more than 4,000 mg a day, counting every product and every route.
• On an acetaminophen-codeine tablet, warn against other products with acetaminophen, an opioid or codeine.
• Store codeine products often add acetaminophen, ASA or an NSAID. High doses of that partner drug cause harm. Advise against them.
• Write the tablets per dose and the most tablets a day on the prescription.
• Ask her to bring every product she uses, store ones included, to the next visit.

Approach

• Make physical activity the base of care for osteoarthritis and long-lasting low back pain.
• Exercise programs give real pain relief in low back pain and osteoarthritis.
• Offer physical therapy, cognitive behavioural therapy (talking therapy for coping with pain) or acupuncture, before or alongside drugs. This matters most where drugs are risky, as in kidney disease.
• Set goals for function: walking, work, sleep, a hobby. Track them, not only the pain score.
• Teach self-care: pace activity and keep moving on bad days.
• Ask what the patient already does and what has helped.

Approach

• Notice when pain outlasts normal healing. Tell the patient, and call it long-term pain.
• Reset the goal together: better function and coping, not zero pain.
• Do not start long-term opioids for chronic pain. In osteoarthritis and low back pain, they help no more people than placebo after 4 weeks.
• If an opioid no longer helps, taper it slowly, with supervision. Stopping suddenly brings withdrawal.
• Warn that tolerance falls after a taper. Any restart begins at the lowest dose.
• Build the plan on activity and exercise, with non-drug and non-opioid options.