Pain management in primary care: strategies to mitigate opioid misuse, abuse, and diversion

Pain is among the most common reasons patients seek medical attention, and the care of patients with pain is a significant problem in the United States. Acute pain (mild-to-moderate intensity) represents one of the most frequent complaints encountered by primary care physicians (PCPs) and accounts for nearly half of patient visits. However, the overall quality of pain management remains unacceptable for millions of US patients with acute or chronic pain, and underrecognition and undertreatment of pain are of particular concern in primary care. Primary care physicians face dual challenges from the emerging epidemics of undertreated pain and prescription opioid abuse. Negative impacts of untreated pain on patient activities of daily living and public health expenditures, combined with the success of opioid analgesics in treating pain provide a strong rationale for PCPs to learn best practices for pain management. These clinicians must address the challenge of maintaining therapeutic access for patients with a legitimate medical need for opioids, while simultaneously minimizing the risk of abuse and addiction. Safe and effective pain management requires clinical skill and knowledge of the principles of opioid treatment as well as the effective assessment of risks associated with opioid abuse, addiction, and diversion. Easily implementable patient selection and screening, with selective use of safeguards, can mitigate potential risks of opioids in the busy primary practice setting. Primary care physicians can become advocates for proper pain management and ensure that all patients with pain are treated appropriately.