Tell Me Where It Hurts

MDNG Pain Management, January 2009, Volume 2, Issue 1

What your patients can't or won't tell you about their pain can be a significant barrier to effective treatment.

What your patients can't or won't tell you about their pain can be a significant barrier to effective treatment.

It’s an age-old joke: a person meets a doctor at a party and says, “Doc, it hurts when I do this,” to which the doctor replies, “Well, don’t do that.”

Hopefully, real doctors don’t say that, or at least not too often. But most doctors, from primary care physicians to top anesthesiologists, admit there is room for improvement when it comes to talking to patients effectively and productively about pain. The National Institutes of Health (NIH) recognized the complexities of diagnosing pain and deciphering its cause years ago with the creation of the NIH Pain Consortium, giving rise to hope that pain would earn a more prominent place in medical research. Recently, however, this hope suffered a blow. Federal funding for pain research, according to a December 2008 article published in the Journal of Pain, has declined more than 9% per year since 2003, with grants for pain research accounting for less than 1% (0.6 percent) of all grants awarded by the NIH. “This startling finding shows the government’s meager investment in pain research is seriously out of proportion with the widespread chronic pain incidence in our society, which is estimated at one in four Americans and accounts for more than 20% of all physician office visits,” said Charles E. Inturrisi, PhD, president of the American Pain Society and professor of pharmacology at Weill Cornell Medical College, New York.

But when those one-in-four Americans (roughly 60 million) show up at their doctor’s office with pain, as Inturrisi and his colleagues estimate, how do they talk about it? The answer is surprisingly complex. Patients may make it as far as the doctor’s office, but their pain complaints often stop at the door.

Diagnosing the doctors’ view of pain

Low back pain, severe headache or migraine, neck pain, and facial aches and pains are the most common ailments people report experiencing, according to the US Department of Health and Human Services’ National Center for Health Statistics. About one-third of patients describe their pain as disabling enough to impact their daily life. The cost of chronic pain in the United States, including healthcare expenses, loss of income, and loss of productivity, is estimated to be around $100 billion annually. Many factors contribute to the challenge of treating pain effectively, including lack of medical and prescription drug coverage, and doctors who depend only on their patients’ description or report of pain.

“There’s a host of reasons why many patients may not talk to their doctors about pain,” says Scott Fishman, MD, chief of Anesthesiology and Pain Medicine at the University of California (Davis) and a member of the American Pain Foundation’s board of directors. “Maybe they feel there isn’t enough time during their visit, or maybe they feel that if they bring it up the doctor will think they’re a complainer or a drug seeker.”

That leaves the burden on the physician to bring up the subject. “When doctors don’t speak to patients about pain” Fishman says, “we create the least satisfied patients and the highest resource seekers.”

Gender differences: Not all pain is equal

Research during the past decade indicates that not only do people experience pain differently according to their age, sex, gender, and ethnicity, but they describe it to their doctors differently as well. A 1998 NIH study of gender and pain, for example, was one of the first scientific studies to show that women experience pain differently than men. According to the authors of the report, women were more likely to have more severe and more persistent pain than their male counterparts, had a lower pain threshold, and were better able to discern between different types of pain experiences.

“Women are truly their own creations,” says Mark Young, MD, head of the Baltimore-based Oasis Center for Natural Pain Management and author of the book Women and Pain: Why It Hurts and What You Can Do. “They have different hormonal and genetic constitutions, making it important for them to be evaluated differently than men.”

Women often can and will tell doctors about their pain, Young says, but despite this willingness to talk about their pain and seek treatment for it, physicians are too frequently unresponsive or dismissive. In his book, Young describes the case of an athletic woman who was experiencing chronic pain with no immediately apparent cause. After several extensive diagnostic tests failed to reveal a problem, she was essentially told her pain was psychological and stress-related. After making the rounds of several doctors, Young eventually rooted out the elusive, but real, physical source of her pain.

“It’s not so much that women are ‘bearing with’ or ‘hiding’ their pain,” Young says. “But they often feel they are being dismissed or told it is all in their head. So they end up feeling foolish or hysterical.”

There are very real physiological differences in the way women experience pain versus men, and the way women describe the experience to physicians makes matters even more complicated. While a man with a potential cardiac problem may describe a pain in his chest, for example, a woman may report a pain in her back, neck, or jaw for the same condition. It is important for doctors to be alert to these differences.

Just getting old: Pain in the elderly

Getting elderly patients to talk with their physician about pain presents a different set of challenges. “Elderly patients tend to have a lot of aches and pains as they get older, so they may not bring it up in the office,” says Bruce Ferrell, MD, director of geriatrics at the University of Southern California in Los Angeles says. “They can be a bit stoic and think their pain is just a normal part of aging when it may actually be a serious problem.”

Deciphering the cause of an elderly patient’s pain if they do describe it presents another challenge to the physician. “It is hard sometimes for patients to determine the significance of a pain problem,” Ferrell says. “Is it simply a nuisance problem, or is it an indication of heart disease or cancer? Is it a life-limiting or selflimiting pain? That’s a doctor’s job to find out.”

Additionally, a number of elderly patients tend to describe what are in truth psychological problems as physical problems. They may find it more socially acceptable to tell their doctor about headaches, neck pain, or back pain instead of feelings of depression and anxiety. “Elderly patients may not vocalize or express the psychiatric events underlying their geriatric presentation,” Robert Barkin, PharmD, and S.J. Barkin, PsyD, wrote in their letter to the editor “Reexamining the Elderly Patient’s Presentation With Depression,” published in The Primary Care Companion to the Journal of Clinical Psychiatry. This can lead to elderly patients being misdiagnosed or given inappropriate treatments for their condition.

“An additional medication focused at a new complaint, or an attempt to abate the patient’s pain complaints, is often initialed with futile outcomes,” says Barkin, Department of Anesthesiology, Family Medicine and Pharmacology, Rush University, Chicago, and Department of Anesthesiology NorthShore University Health System, Evanston, IL.

Talking with patients, as opposed to talking to patients, according to both Barkin and Ferrell, can go a long way, especially in elderly patients, who may be saying what he or she thinks their doctor (or their caretakers) want to hear. “This isn’t going to be a 10- or 12-minute interview,” says Barkin, who suggests physicians schedule their pain patients at the end of the day. “We have to ask them: What does pain do to you? Does it make you feel sad, anxious, depressed, helpless, or hopeless? This is how we unmask the pain in people who underneath may have symptoms of depression.”

Being mindful of the words some elderly people may use to describe their pain can also help doctors deliver a more appropriate diagnosis. “Elderly people may not describe their pain as pain, per se,” says Ferrell. “I sometimes have patients come to the hospital describing a ‘tightness’ or ‘heaviness’ in their chest when it is really a pain that needs evaluation quickly.”

Barkin, a member of the American Academy of Pain Medicine, agrees. “The elderly patient doesn’t always accurately tell us what their pain feels like,” he says. “They may say it’s ‘excruciating’ or ‘terrible,’ but descriptive characteristics like ‘lighting bolts’ or ‘throbbing’ may lead to a more definitive diagnosis.” Traditional pain scales, Barkin says, only go so far. “We have unilateral scales to measure a multi-dimensional problem. A patient may, for example, augment the number on a pain scale of 1-to-10 if they believe the doctor will drop their meds back. Pain scales lack objectivity, are highly subjective, and are very emotional.”

When a doctor does determine that an elderly patient would benefit from medication, close monitoring is a must. Like women, older people can react to standard medications differently. “Elderly people are more likely to have side effects and more likely to have unexpected reactions,” Ferrell says, “so follow-up is a major issue.”

Follow-up is also important because elderly patients may be seeing more than one doctor who is prescribing pain medication for them, and one may not necessarily know about the other unless the patient tells them. In such cases—or in cases for which a physician suspects that a patient isn’t taking what is prescribed for him or her—state prescription drug programs help doctors keep track of what their patients are taking, as well as urine drug testing by labs like Dominion Diagnostics.

Other faces, other places, other ways of describing pain

Women and the elderly aren’t the only ones who may not explain their pain in ways doctors can easily understand. Children, for example, don’t describe pain symptoms the same way an adult might, making it all the more difficult for doctors to assess what might be wrong. Beliefs about pain conveyed consciously (or unconsciously) to them at home by the adults in their life can also have a significant impact on how they express their pain to a doctor. Or, they may just be afraid of the consequences: a lollipop and a smile, after all, are much more enjoyable than a needle or a bitter-tasting medicine.

Wounded soldiers returning from Iraq and other conflicts, as well as retired veterans, present still more challenges in the doctor— patient pain discussion. According to a recent report on the subject from Veterans for America, “The persisting stigma around pain and pain management is particularly pronounced in the military, and pain is often perceived as a sign of weakness, leading many to choose to suffer in silence.”

The Veterans Health Administration now instructs doctors and nurses who treat veterans to regard pain as a “fifth vital sign,” right along with blood pressure, pulse, temperature, and respiration. Additionally, the Military Pain Care Act of 2008 introduced last February by Rep. David Loebsack (D-IA) would require all Veterans Affairs hospitals to develop and implement a pain care initiative in all of their healthcare facilities.

Black, Hispanic, and other minority patients bring still more complexities to the doctor— patient pain conversation. In addition to having a greater lack of access to appropriate medical care when compared to whites, studies indicate that minority patients are more likely than white patients to have language and “health literacy” barriers that hinder communication with their doctors. Members of minority groups, according to studies cited by the APF, are also more likely to refuse pain therapy or adhere to a prescribed therapy regimen. As the United States becomes increasingly more diverse (minorities make up more than one-third of the country’s population), this communication gap will likely grow wider each year.

Many doctors acknowledge that the only way to better decipher what their patients tell (or don’t tell) them about pain symptoms is to improve their own understanding of how patients communicate with them. Such skills are not typically taught in medical school, and while some states now mandate continuing medical education on the subject of pain, Ferrell and Fishman are among a growing number of physicians who say more proactive efforts within the medical community are needed.

“It doesn’t take a lot of time to ask about pain,” Fishman says. “But it does require a commitment to the answer.”

Diane West is a freelance healthcare journalist.