A Better Pain Plan

Musculoskeletal pain is one of the most common reasons adults visit their primary care physician, an office encounter that typically starts with a discussion of the patient’s symptoms and physical function, continues with advice from the physician to lose weight and engage in rehabilitation exercises, and concludes with a prescription, initially for acetaminophen or a nonsteroidal anti-inflammatory medicine but often escalating to muscle relaxants and opiates. For many patients, an ongoing cycle of physician and physical therapy visits, pill bottles, and discomfort result, without ever settling on a plan that effectively manages their pain.

In this issue of JAMA Internal Medicine, Bair and colleagues¹ present their findings from a randomized clinical trial in Veterans Affairs hospitals that tested a stepped-care approach to treat musculoskeletal pain, including an analgesic treatment algorithm, self-management strategies, and cognitive behavioral therapy, all led by nurse case managers. Although this intervention may not be entirely generalizable, much can be learned from their approach. Several aspects can be integrated into any primary care practice, including the deliberate analgesic treatment algorithm that requires patients to try several different types of medication therapy before using opiates, the use of nurses rather than physicians to direct and advance treatment, and the importance of treating accompanying mental health symptoms, such as depression, all of which can improve musculoskeletal pain management in primary care.

Conflict of Interest Disclosures: None reported.