CHRONIC PAIN AND THERAPEUTIC ADHERENCE: PRELIMINARY PHASE OF THE ASST BERGAMO EST PROJECT FOR INTEGRATED TERRITORIAL MANAGEMENT

V. Margosio, R. Tortelli, M. Mauri | Local Social and Health Authority (ASST) Bergamo Est, Bergamo

INTRODUCTION
Chronic pain is a major challenge for community healthcare systems, with a prevalence ranging from 12 to 48% in the European adult population and up to 62% in those over 75¹. It is often associated with physical and psychological comorbidities, significantly impacting quality of life, autonomy and therapeutic adherence². The Local Social and Health Authority (ASST) of Bergamo Est has launched a corporate project to strengthen chronic pain management in the community setting through a multiprofessional approach supported by digital tools. The aim is to explore the relationship between pain intensity and therapeutic adherence, focusing on shared care models involving Family and Community Nurses (FCNs), General Practitioners (GPs) and specialists. The project also aims to identify effective organizational models to foster professional integration and guide the development of a shared, protocol-based, digitally supported care pathway. Special attention is given to the role of digital technologies in pain assessment, data sharing and adherence support.
METHODS
The project is structured in three phases: Literature Review– A systematic review was conducted using PubMed and Cochrane Library following PRISMA criteria. Studies were included based on relevance to chronic pain, adherence, digital tools, and multiprofessional models in primary care. Multidisciplinary Discussion– Findings will be discussed within ASST’s Committee for Hospital-Territory on Pain Management (COTSD) to define priorities and assess feasibility. Proposal of Shared Pathway– A corporate pathway will be developed to improve timeliness, effectiveness, communication, and adherence, promoting structured use of digital tools and integration of clinical data.
PRELIMINARY RESULTS
Three thematic areas emerged: Organizational Models- Effective community-based management of chronic pain requires integrated organizational models that ensure service continuity and interprofessional collaboration. WHO guidelines highlight the value of multidisciplinary teams, shared protocols, and digital tools to improve care access and quality. Psychological comorbidities and pain intensity may affect treatment adherence, but the therapeutic relationship remains a key organizational driver of better outcomes and patient satisfaction^3–5. These findings support the adoption of stable territorial teams, integrated care pathways involving GPs, specialists and FCNs, and structured systems for communication and monitoring. Clinical-Care Strategies- FCNs are central to data collection, patient empowerment, and care coordination^4,6. A strong, trust-based relationship with patients supports continuity of care and adherence. Satisfaction with GPs remains high when communication is clear and supportive, even if treatment efficacy is perceived as low (4). Digital Platforms- Telemonitoring systems and integrated platforms enhance pain assessment, timely data sharing, and therapeutic adherence, especially in home and community settings^6,7.
CONCLUSIONS
Therapeutic adherence in chronic pain patients depends on clinical aspects as well as the quality of professional relationships, team integration, and digital support. These elements improve patient experience and care continuity. ASST Bergamo Est aims to redefine chronic pain management by integrating skills and settings, allocating appropriate resources and designing structured, collaborative care pathways suited to non-hospital environments.