Table 3.

Challenges in the management of chronic non-cancer pain in primary care, grouped by dimension, with illustrative participants’ quotes for each dimension

Dimension	Quotes
Knowledge gap
Poor knowledge and lack of training on pain Lack of valid assessment tools Lack of clear treatment protocol	“Primary care does not understand what specialists ask, and patient is caught in this mess.” [Pain specialist] “Physicians are not aware of chronic pain because it is unfamiliar to them and because they don’t have the knowledge; they seem uncomfortable and helpless. The question of training is in my opinion a key element that should be further developed in primary care.” [Researcher] “There are very good screening questionnaires, but people don’t know about them.” [Nurse] “There are [treatment protocols], but they are not well known. The college [of physicians] produced three documents on chronic pain in the last 4–5 years. When you look at the appendices, many could definitely be used, and people don’t use them.” [Primary care physician]
“Work in silos”
Lack of time and resources for physicians Lack of communication Difficulties in managing the medical record	“The main obstacle for me is [lack of] time and isolation. I feel alone working in my office and caring for those patients. Lack of connections with everything: tools, community network, professional network, other physicians.” [Primary care physician] “There is no one linking with family physician, like a care manager, informing patient, coordinating patient care.” [Pain specialist] “I find the multidimensional aspect that comes with chronic pain is not addressed. Following-up on chronic pain cases in private practice is, for me all alone, extremely difficult.” [Psychologist] “It takes a shared electronic file, including the list of medications that have been tried, with failures and secondary effects, to prevent repeating errors. It would also help physicians.” [Nurse] “For the pharmacists to really do their job, they need to have access to diagnoses, laboratory results, and intentions to treat.” [Pharmacist] “I think the problem is record management […] Either we don’t do it, or we don’t do it adequately.” [Primary care physician]
Lack of awareness regarding chronic non-cancer pain
Little or no societal and clinical recognition of pain as a disease	“For many people who do not have chronic pain, the concept of chronic pain is something quite cranky. It is not science. I think perceptions of it are blurred, unproven, unaccepted. We feel it is untrue: those people are not truly suffering. And that’s what patients tell us, they are not believed.” [Primary care physician] “We don’t like to spend time assessing pain: it takes long and it is boring hearing someone in your office saying ‘Oh, I don’t sleep well, and I am not able to do this and that […]’, etc.” [Nurse]
Difficulties in access to health professionals and services
Lack of care paths Lack of information on resources	“Getting to see a specialist takes time. And you see your husband suffering – he can’t be sitting for long. And seeing him suffering, he’s chronic, it’s been going on for a long time.” [Family member] “What is difficult for us, when we need expertise, we can’t access. When we want to send the patients to an expert or to a team who can make an assessment – because we have tried many things we thought could help, and they didn’t work, we haven’t access.” [Primary care physician]
Patient empowerment needs
Patient isolation Lack of community resources Lack of awareness of existing community resources	“Last week, I read an article on fibromyalgia. It was such a relief to read about a public people with a context of chronic pain. It was comforting because I was feeling like I am not alone on this planet.” [Patient] “We have just talked about support and isolation. Well, I think it is the case. There is a need to get together, and not to feel all alone.” [Psychologist] “We have to give patients a sense of being in control again.” [Nurse] “I often realize when patients come to the pain clinic that no one has taken time to explain many things, occupational therapy, posture, self-management of medications. And they are waiting for someone to save them.” [Physiotherapist]