A Practical Approach to Multimodal Management of Chronic Pain in Primary Care

Abstract

Introduction

Chronic pain affects approximately 20.9% of adults in the United States, surpassing the prevalence of diabetes and posing a substantial burden on healthcare systems. Patients with chronic pain often experience frequent healthcare visits, comorbid mental health disorders, and diminished quality of life. Primary care providers (PCPs) play a pivotal role in managing these patients, yet they encounter multiple challenges, including limited appointment times, inadequate training in pain management, and concerns about opioid prescribing. As the opioid crisis continues to shape pain management policies, an emphasis on multimodal, evidence-based strategies has emerged as a critical approach. Integrating pharmacologic, non-pharmacologic, and interventional techniques can improve patient outcomes while reducing the reliance on opioids.

Methods

A comprehensive literature review was conducted using the latest guidelines, including the CDC’s 2022 opioid prescribing recommendations, the American Academy of Pain Medicine guidelines, and systematic reviews on interventional pain procedures. Case studies are presented to illustrate practical applications of multimodal pain management in primary care, emphasizing scenarios where early referral to interventional pain specialists may be beneficial.

Results

Non-Pharmacologic Approaches: Evidence supports the use of physical therapy, cognitive behavioral therapy (CBT), mindfulness- based stress reduction, acupuncture, and spinal manipulation in chronic pain management. Exercise therapy has shown sustained benefits in osteoarthritis and chronic low back pain. Multidisciplinary rehabilitation programs are associated with improved functional outcomes.

Pharmacologic Approaches: First-line medications include NSAIDs, serotonin-norepinephrine reuptake inhibitors (duloxetine), tricyclic antidepressants (amitriptyline), and anticonvulsants (gabapentin, pregabalin) for neuropathic pain. Acetaminophen has a limited role in osteoarthritis but may be useful as adjunct therapy. Opioids should be reserved for select cases, with clear treatment goals and an exit strategy.

Interventional Pain Management: Epidural steroid injections provide short-term relief for lumbar radiculopathy, while radiofrequency ablation is effective for facet joint and sacroiliac joint pain. Neuromodulation techniques, including spinal cord stimulation, show promise for neuropathic pain and complex regional pain syndrome (CRPS). Regenerative therapies such as platelet-rich plasma (PRP) injections are emerging as potential adjuncts.

Bridging Primary Care and Pain Medicine: Many primary care providers feel unequipped to manage chronic pain beyond pharmacologic interventions. Establishing referral pathways for interventional procedures can optimize patient outcomes. Collaborative care models, including co-management with pain specialists, enhance continuity of care and reduce unnecessary opioid prescribing.

Conclusion

Multimodal pain management offers a comprehensive strategy to improve function and quality of life while minimizing opioid use. Increasing access to interventional pain techniques through enhanced primary care–pain specialist collaboration can bridge the gap between conservative and advanced pain management. As interest in interventional pain medicine grows, fostering interdisciplinary partnerships will be crucial in shaping the future of chronic pain care.