Pain Assessment and Management: An Audit of Analgesic Trends in an Urban Primary Health Centre

Introduction

A Primary Health Centre (PHC) is the first point of contact for vast majority of people from poor socioeconomic background.¹ Pain is the most typical manifestation in a PHC. Chronic pain (CP) is a prevalent complaint that is more frequently mentioned than acute pain. According to a prevalence survey, 19.3% of the Indian adult population suffers with CP.² When left untreated, persistent pain has a large impact on patients' quality of life and is associated with significant mortality, and can be a major source for missing work, lack of productivity, and a reduction in manufacturing.³

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0. Given the subjective nature of pain, a word ‘pain scale’ (mild, moderate, and severe) is commonly used. Considering that a major portion of the population availing services at a PHC are illiterates, this grade can be difficult to comprehend at times, resulting in a misunderstanding. The best case scenario for providing quality care would be to standardise and recommend diagnosis and treatment recommendations. In terms of pain, a visual analogue scale ranging from 0 (no pain) to 10 (worst imagined pain) should be used.⁴ To meet the needs of illiterate individuals, a clear relationship between the verbal pain scale and the visual analogue scale should be established. 

Effective pain treatment necessitates a thorough understanding of analgesic selection and administration. The World Health Organization (WHO) analgesic ladder is a standardised example of a multimodal analgesia method.⁵ According to the severity of pain, analgesics are changed sequentially in this conceptual ladder from weak to strong analgesics (step-up) or vice versa (step-down). In this audit, our aim was to evaluate the trends in pain evaluation and the prescribing practices that surround it.

Material and Methods

Patients treated for hypertension between October 1, 2022 and April 1, 2023 were identified by a retrospective chart analysis of an Urban Primary Health Centre's outpatient record book. According to the review, 368 participants were treated for pain and these patients were enrolled in the study. Records with partial data were excluded, as they did not match the inclusion criteria. Patient records were reviewed for information on patient characteristics, pain characteristics, and pharmaceutical management.

Results

There were 368 records of patients who had presented with a complaint of pain. The mean age of the patients was 54 years (18-84 years, SD 20). The sample included 256 female and 112 male patients. The drugs available at the PHC were Paracetamol and Non-steroidal anti-inflammatory drugs (Diclofenac and Ibuprofen) (NSAIDs). NSAIDs were the commonly prescribed drugs, with diclofenac (N=124) being the most common (Table 1). In many cases, inaccurate pain assessments were discovered. Diclofenac was again prescribed the most for mild and moderate pain, while a combination of paracetamol and diclofenac was prescribed for severe pain (Figure 1).

Discussion

Management of pain should be tailored for each patient, including a review of past medical history, medication history, allergies and pain tolerance. A clear relationship between the visual analogue scale and the verbal scale must be established.⁶ Mild, moderate, or severe scores on the verbal scale should correspond to 0-3, 4-7, or 8-10 on the visual scale. Step 1 of the WHO pain ladder should be used for scales 0-7, with the option of combining step 1 medications. Severe pain (8-10) should be immediately referred to a higher level of care, considering that it usually indicates a serious underlying pathology.

First-line treatment should include paracetamol and NSAIDs. Although paracetamol is well tolerated, lower doses should be used in patients with liver and kidney diseases, severe malnourishment, and alcoholic dependency.⁷ NSAIDs are generally safe and well tolerated, but caution is advised in patients with a history of upper/lower GI bleeding, cardiac disease, or chronic kidney disease.⁸ If the prescribed dosage and schedule of first-line agents are insufficient, a combination of the above may be used for certain conditions. Treatment should be escalated to a tertiary centre for higher management of severe or refractory pain rather than inadequate control at the primary centre.

Conclusion

Painkiller prescriptions are fragmented, with no clear therapeutic recommendations or associations. A large number of prescriptions were NSAIDs, and necessary adjustments were rarely implemented. This advocates for a standardised prescription guideline based on a standardised pain scale and the WHO analgesic ladder. A re-audit is advised six months after the above measures have been implemented.

Conflict of Interest

Nil

Acknowledgements

Nil