A clinical health psychologist discusses how to keep a patient-centered approach for treating chronic pain in today's healthcare environment.
Andrew Philip, PhD
Today’s health care providers may not necessarily think of themselves as chronic pain specialists—in fact, it’s often difficult to recruit budding clinicians into pain-focused careers.
The reality is that nearly everyone serving adults in primary care, behavioral health, and many specialty areas treats patients living with chronic pain.
The opioid epidemic has shined a spotlight on pain and for good reason—as many individuals with opioid use disorders first encountered these medications in the course of medical treatment. But the pain epidemic has been mounting for decades and touches many elements of our patients’ lives and care.
Pain—specifically low back pain—is a top cause of disability in the United States and abroad. Unaddressed chronic pain may underlie weight management and metabolic disorders, depression and isolation, and of special concern, suicide.
Yet identifying the sources of chronic pain can be challenging for providers. Equally difficult (and frightening) for patients is weaning from high-dose opioids, made more complex by lack of provider continuity. Meanwhile, pain often becomes so entangled with other medical conditions and our patients’ lifestyles that it becomes complicated to treat, let alone discuss without engaging in lengthy and potentially fiery conversations.
Four key principles can help guide clinical interactions, each intended to promote healthy, efficient, patient-centered care for chronic pain:The road to treatment can be painful—figuratively and literally—whether resulting from acute injury, a symptom of another illness, or a gradual and progressive onset.
The legitimacy of a patient’s pain, particularly if neuropathic or otherwise difficult to trace to a single origin, has likely been questioned by past medical providers, their families, and potentially the patient themselves. They may have been labeled as “med-seeking” or “malingering” so often that they anticipate needing to defend themselves in every medical interaction.
Asking about and acknowledging this possibility from the start can establish a mutual understanding and set a constructive tone.Chronic pain is still poorly understood by many health care providers, let alone patients. Good treatment begins with helping patients understand not only the intricacy of chronic pain but also the realities of treatment.
For example, is it likely that some pain may persist, potentially indefinitely, even with intervention? Will more surgeries, injections, or medications bring an additive impact on relief, or simply increase the likelihood of complication?
Pain creates a sense of desperation—not just in our patients, but in our own provision of treatment. Resist the urge to be unrealistically comforting, overpromise referral outcomes, or scramble to offer every possible treatment, regardless of what you know to be practical. Patients will do best when they are informed consumers and operating with realistic information.Health care—particularly primary care and behavioral health—is increasingly holistic and integrated, whether intentional or through corporate consolidation. Few clinicians emerge with strong foundational training in chronic pain management.
This is especially true for behavioral health clinicians, who can offer the “gold standard” by being trained in proven interventions such as cognitive behavioral therapy for chronic pain (different from general cognitive behavioral therapy). They can also partner with medical providers to help patients better function and cope. Physical therapists, occupational therapists, pharmacists, nutritionists, and other experts also play important roles.
Above all, it is critical that all members of the clinic—from the front desk staff to the physicians—use similar language and messaging about pain. For example, a provider’s instruction to avoid inactivity and focus on improving function can be instantly undercut by a well-intentioned team member’s suggestion to rest and defer day-to-day tasks.No matter the prognosis, how many referrals are offered, or what the next prescription will be, one action can inspire trust and confidence: a spoken affirmation to work alongside the patient, regardless of the outcome of a given course of treatment.
The cringe-worthy phrase “doctor shopping,” or hopping from provider to provider, most often results in worse outcomes and is a disservice both to patient and provider. However, this may be inadvertently encouraged if a patient perceives that their clinician has only one solution, plans to refer them elsewhere (and not follow up if that referral is not helpful), or is unwilling to work with them until a viable solution is realized.
Expressing commitment to seeing a patient through on their journey—more as an invested partner than as a conventionally detached provider—lends gravitas and clarity.
The answer to helping our patients manage chronic pain is neither a single treatment nor a sole specialty provider. Particularly for those of us at the central access points of health care (ambulatory care), we can build upon the existing momentum around pain without leaving patient-centeredness behind.
Patients are the deciding factor in successful treatment. Creating meaningful partnerships in care begins by changing conversations, broadening the team, and sticking around for the ride.
Andrew Philip, PhD is a clinical health psychologist and the senior director of Clinical and Population Health at the Primary Care Development Corporation. The views presented in this article represent the author's views and not necessarily those of this publication. Health care professionals and researchers interested in responding to this piece or similarly contributing to HCPLive® can reach the editorial staff by submitting a request here.