Pain is one of the most common complaints seen in primary care practices; however, it is still one of the most poorly managed complaints. Back and neck pain, headaches and migraines, joint pain, musculoskeletal pain, facial pain, chest pain, and abdominal pain are several types of acute pain commonly encountered by general practitioners. Typically, the pathophysiology of acute pain is not complex. It is the perception of pain, which can be influenced by a number of psychological, cognitive, hormonal, or biological factors, that makes treating pain less straightforward. Numerous institutions cite pain management as a fundamental human right and providing effective pain management a health professional’s moral obligation.¹ The initiative to make pain the “fifth vital sign” brought well deserved attention to the need for improved pain assessment and treatment; however, it also led to an overemphasis on onedimensional pain intensity scales that lead to an overuse of opioids for treatment and adverse events such as opioid over sedation and death.² We must shift our attention from pain as a 5th vital sign to expanding our education and training in the assessment of pain to improve our treatment strategies.³ Pain left untreated not only can lead to chronic pain but also has effects on mental and physical health as well. The first step in every pain management plan should be a thorough multidimensional pain assessment.⁴ This chapter includes a discussion on pain assessment and education as well as pharmacologic and nonpharmacologic treatments of acute pain in the primary care setting.

The assessment of pain can be challenging as it relies on patient communication of a subjective perception of an unpleasant sensory and emotional experience. The perception of pain varies widely between patients, and it cannot be objectively quantified. The goals of pain assessment are to gather information from the patient in a standardized way in order to help determine the type of pain, the effect this pain is having on the patient and their daily activities, and a cause of the pain so the provider may develop a suitable treatment plan. Standardizing pain assessments is important to obtain reliable, reproducible data that may be used to guide treatment and determine when changes are needed. Pain intensity and pain relief are the two characteristics typically assessed in acute pain. There are several one-dimensional pain scales physicians may use to assess pain intensity.¹ The Numerical Rating Scales (NRS), Verbal Rating Scales (VRS), Visual Analog Scales (VAS), and Faces Pain Scale (FACES) are the more commonly used intensity assessment tools for acute pain. Examples of these pain scales are shown in Figure 47.1. The NRS, VRS, and FACES scales are relatively self-explanatory. The VAS requires the patient to point to an area on the line, which is then recorded in millimeters as their pain rating. When determining which scale to use, the physician should take into account the patient’s age, cognitive status, and communication barriers. Pain assessment
in patients with cognitive impairment or those unable to report such as unconscious or sedated patients present unique challenges. The tools recommended for these patients use behavioral and physiologic indicators to assess pain. The Critical-Care Pain Observation Tool shown in Table 47.1 incorporates facial expression, body movements, ventilator compliance for intubated patients and vocalization in extubated patients, and muscle tension to determine a pain score between 0 and 8. The Behavioral Pain Scale uses facial expression, upper extremity movements, and compliance with mechanical ventilation to compile a pain rating between 0 and 12 (Table 47.2). Infants and children present another group requiring behavioral and physiologic indicators to assess pain. The Face, Legs, Activity, Cry, Consolability (FLACC) or the Children’s Hospital of Eastern Ontario Pain Scale are recommended for assessing pain in children older than 3 years. Using indicators such as facial expressions, body movements, heart rate, and oxygen saturation is recommended when assessing acute pain in infants.