689 FOCUS | CLINICAL AJGP VOL. 48, NO. 10, OCTOBER 2019 | © The Royal Australian College of General Practitioners 2019 Laura Bruggink, Chris Hayes, Gali Lawrence, Katherine Brain, Simon Holliday Background Chronic non-cancer pain (CNCP) frequently co-occurs with other chronic conditions, resulting in multimorbidity. Objective The aim of this article is to summarise current approaches to CNCP management and explore areas of specificity and overlap with chronic conditions in general. Discussion The biomedical component of the management of chronic conditions may be condition-specific. However, mind– body, connection, activity and nutrition components entail significant overlap and are helpful across conditions. Effective practice avoids overemphasis on medical treatments at the expense of evidence-based, multidimensional lifestyle approaches. CNCP management illustrates the case for reconceptualising chronic condition management using a generic lifestyle-based approach. This capitalises on overlapping treatments, creates system efficiency and allows patients with multimorbidity to be treated more effectively in primary care, with only a small subgroup referred to condition-specific tertiary services. CHRONIC NON-CANCER PAIN (CNCP) is commonplace and costly. In 2018, 3.24 million Australians were living with CNCP, costing the country $73.2 billion. 1 In planning resource efficiency, it is noteworthy that CNCP often occurs in the midst of multimorbidity (Figure 1). A Scottish primary care study found that 23% of patients had multimorbidity and 46% of those presenting with CNCP had three or more long-term conditions. 2 Metaflammation has been postulated as an underlying mechanism contributing to many chronic conditions. 3 This may partly explain the overlap of effective lifestyle- based treatment strategies. For example, increasing physical activity improves multiple chronic conditions. There are potential efficiencies in generic lifestyle- based approaches to chronic conditions. Overinvesting in chronic condition– specific programs may lead to unintended inefficiencies and costs. This article summarises current approaches to CNCP treatment and considers areas of specificity and overlap with generic chronic condition management (Figure 2). Lessons from chronic pain management A major lesson from CNCP is that a predominant focus on biomedical treatment is unlikely to be effective in the long term. 4 ‘Red flag’ conditions need to be screened for, then treatment typically involves medication deprescription, or non-initiation, and transition to multidimensional supported self-management. 5 In this transition, the relationship between health professional and patient is crucial. Empathy supports the therapeutic alliance, which is counterbalanced with therapeutic boundaries. ‘Connect’ first, then ‘redirect’ into evidence-based care. 6 Targeted reassurance 7 that ‘red flag’ conditions have been excluded and that the person is safe to move facilitates exit from often harmful and ineffective investigations, procedures and medications. Patient education plays a central part in treating chronic conditions. In CNCP, an overview of nervous system plasticity informs patients that they can change their trajectory. 8,9 Understanding that pain is generated by the brain, and that nervous system sensitisation can produce severe symptoms that are real but not generally due to structural issues, can be both confronting and liberating. 9 Another lesson is that condition- specific services see only a small subgroup of patients. Only 0.2% of people experiencing CNCP are seen by specialist multidisciplinary pain services Chronic pain Overlap and specificity in multimorbidity management