Communication skills, a better understanding of the presentation of chronic pain, and a methodical approach to evaluation and treatment are the keys providing better pain care. Chronic pain is a common clinical presentation, yet many physicians remain apprehensive and feel reluctant about caring for patients with this condition.
Chronic pain is a common clinical presentation, yet many physicians remain apprehensive and feel reluctant about caring for patients with this condition. Much of this uneasiness stems from lack of formal training in this complex issue. This is particularly true among primary care and family medicine practitioners, despite the fact that these clinicians deliver the majority of pain care in the US. These physicians’ inadequate training and knowledge of pain medicine has led many of them to develop an insufficient understanding of chronic pain as a common chronic condition, and contributes to a reluctance to treat patients with chronic pain. The absence of a standardized assessment approach and lack of clinically useful guidelines for evaluating and managing these patients are also key contributing factors. Identifying and breaking down these issues will help us to provide improved care for this complex group of patients.
Pain is one of the most frequently reported medical conditions. Surveys show that up to 30% of people report experiencing some component of pain over the preceding three months; one survey found that more than half of US adults age 20 or over reported experiencing pain lasting three months to a year or more (http://hcp.lv/qZGw77). Primary care physicians typically do not see many patients with acute pain symptoms as these patients often do not seek specific medical care and improve with supportive treatment and time. A subset of patients, however, will develop chronic pain.
There are no set criteria to define when acute pain moves into chronic pain or further progresses into a chronic pain syndrome with additional associated features that may include mood disturbances, sleep difficulties, and disability. As generalist physicians, we often see examples of chronic pain in our daily practice. We all remember our complex pain patients. The picture may be obvious in the young patient asking for another refill for an opioid prescription for chronic back pain. The distinction may be less apparent in the elderly patient requesting a prescription for an undefined headache or arthritis; or in those patients with chronic pain but with limited disability.
As generalists, our difficulty in identifying and assessing pain, understanding its causes and effects, and confidently managing this clinical condition can be traced to the fact that our training during residency focused more on diagnosis and treatment of established chronic disease. This training perpetuates the notion that we should focus on and find a cause for pain rather than treat pain as a symptom. Our training and education has been less robust when it comes to the management of vague concerns and nonspecific symptoms. Few of us studied pain as a separate clinical entity. Furthermore, as we gain experience in clinical practice, it is often difficult in a busy, changing practice setting to synthesize and organize our ongoing experience in handling these patients, and to develop a standardized approach to pain care or compare our approach to available evidence.
Recently, there has been increased awareness in our profession that frontline practitioners lack the skills and knowledge necessary to provide effective pain care. This has been accompanied by improved access to educational opportunities designed to help rectify this perceived deficit in training. Many medical schools are updating their curricula and include more training in pain care and related areas. There are many CME courses that are designed to tackle components of this challenging topic and provide the general practitioner with an improved understanding of this complex yet common condition. Improved access to physician education and evidence-based guidelines allows for a more structured approach to pain evaluation and management and lessens the uncertainty and anxiety involved in caring for patients with chronic pain.
Nearly one in four Americans suffer from chronic pain (http://hcp.lv/hGKq2V). Pain medications are the most frequently prescribed drugs in the US (http://hcp.lv/jzWRP0), with 1 in 10 patients taking prescription medicine for chronic pain. Pain is associated with chronic medical conditions such as coronary disease, cancer, diabetes, stroke, trauma, inflammation, and infection. Chronic pain has been associated with increased overall mortality. This symptom is frequently modified by environmental factors, psychological factors, and a patient’s past experience. Chronic pain is a common, complex entity that should be viewed no differently than the other chronic medical conditions in daily practice that we typically feel more prepared and qualified to evaluate and treat. Given the resources now available to physicians, we should modify our perspective and approach to chronic pain to feel more comfortable in caring for these patients.
Recently, there has been increased awareness in our profession that frontline practitioners lack the skills and knowledge necessary to provide effective pain care.
There are several basic principles that define my understanding and approach to patients with chronic pain in daily practice:
Understanding these principles provides a framework through which one can organize and structure an assessment of patients presenting with chronic pain. Developing a standard differential of common conditions and issues helps communicate a systematic approach to the patient and demystifies the process. Communicating this framework to patients allows them to better understand their concerns.
Given the often variable presentation and chronic nature of pain, we need to take the time to listen to and review each patient’s concerns and history. A physician’s ability to listen and communicate clearly will help reduce some of the frustrations that patients often voice when describing their experiences with past evaluations and will help foster an improved relationship in the treatment of symptoms. A thorough review of past medical notes, outside records, laboratory studies, and imaging (if available) can offer some insight into a patient’s situation and direct or obviate the need for ongoing additional diagnostic testing. Repeated patterns of focal pain or recurrent pain, a past history of prolonged illness with disability, or current disability may suggest that a patient is at high risk for a chronic pain syndrome. A history of repeat evaluations or past complex testing and consultation for what may be dissimilar complaints may be an additional sign of a chronic pain disorder.
With a new patient, there may be limited time and ability to gather a complete history and review records at the first visit. While there may not be sufficient time during the initial encounter, this process can be extended and pursued at followup visits. Efforts to help a patient prepare for the initial encounter, prioritize concerns, and provide clinically relevant material aids in the process. In my experience, investing ample time up front to review the patient’s history and records minimizes the follow up time, reduces the chance of future misunderstandings, and better directs evaluation and treatment options at follow-up visits. Established patients with a developing chronic pain picture may be more difficult to identify. A well-maintained problem list with associated important studies is essential in evaluating patients with chronic pain. A well-organized flow chart is important in documenting pain and function over time. It takes time not just to gather and synthesize information but more importantly to maintain and update data to better identify patients with chronic pain.
A patient’s report and characterization of the quality and severity of their pain may be initially helpful in identifying the potential cause and mechanism of pain. This includes capturing the predominant features of pain (sharp, stabbing, dull), the distribution of pain (regional, axial, peripheral, dermatomal), temporal patterns of pain (constant, intermittent, waxing and waning), and aggravating and relieving factors or symptoms. This history and approach should be no different than with other chronic conditions we encounter. For patients with a more chronic presentation, it is important to explore any specific changes in their status other than “it is worse.” Identifying a change in pattern may signal a different acute or chronic condition that needs evaluation and treatment.
Documenting the degree and perceived severity of pain and its limitation on patient function is critical during the initial and follow-up visits. This is typically done using a numerical rating scale of 0 to 10 for dimensions of pain, physical, and emotional function (0 representing no pain or functional limitation and 10 severe). This documentation is as important as any objective testing and should be considered a vital sign at all visits. Consistent documentation of this pain and functional score at follow-up visits allows a physician to identify developing patterns over time. Objectifying this value and creating a visual trend of these scores over time is helpful to the physician and patient in understanding response to treatment.
In addition to the initial history and exam, an initial risk assessment to identify those who may be predisposed to chronic pain is helpful. The physician must be aware of these risk factors when considering diagnosis and management options. Risk factors include patients with unrelieved moderate to severe pain, prior episodes of regional pain syndromes, anxiety, catastrophizing, chemical or drug dependency, past history of sexual abuse, poor functional status, and disability.
Major causes of mortality and morbidity in patients under age 50 relate to trauma, accidents, and high risk behavior. In patients over age 50, major causes relate to coronary disease, cancer, and stroke. Identifying potential historical triggers and risks for these common conditions initiates the first part of my workup. The initial history is paramount in helping prioritize and unravel potential causes of a patient’s suffering and concern. As part of this process, sorting out the patient’s symptoms and concerns versus established diagnoses is important. Patients frequently present with broad symptoms, but are concerned they may have a specific diagnosis and try to make their primary symptoms fit that diagnosis. I frequently ask the patient to focus on communicating their symptoms versus concerns for a diagnosis. While ruling out a specific diagnosis can be straightforward, it does not usually address the patient’s primary pain symptoms. Reviewing and excluding major causes of morbidity in the construct of the patient’s concern for chronic pain helps evaluate common causes, assures the patient about basic concerns, and helps structure additional evaluation if needed.
Investing ample time up front to review the patient’s history and records minimizes the follow up time, reduces the chance of future misunderstandings, and better directs evaluation and treatment options at follow-up visits.
Common focal pain presentations include headache, back pain, arthritis, and abdominal pain. Fibromyalgia is the prototypical picture of widespread pain. Common considerations in the etiology of pain relate to mechanical musculoskeletal concerns, infection, potential inflammatory immune conditions, malignancy, metabolic concerns, associated sleep disorders, neurological disease, nerve entrapment syndromes, and vascular compromised states. Reviewing, discussing, and evaluating the patient’s history and risk for these common presentations of pain may provide additional reassurance to the patient and provides the basis and rationale for evaluation and treatment. Evaluation guidelines for common pain conditions are available electronically through the AHRQ National Guideline Clearinghouse (http://hcp.lv/p0LPAx). Additional resources can be accessed through the American Pain Society (http://hcp.lv/nbVRGG).
Even if a physician conducts a thorough evaluation, examining the range of common causes of pain, patients will often wonder about uncommon conditions that may be the cause of their pain. Discussing these concerns rarely provides an additional diagnosis but does move the topic off of the table and allows the patient and physician to focus on the treatment of symptoms versus looking for a cause. Specific concerns may be evaluated in the context of additional specialty consultations if needed. Additionally, one can utilize available appropriate electronic educational resources to help explore the patient’s concerns. Examples of helpful sites include the CDC, Mayo Clinic.com, Pub Med, and other evidence-based sites. I typically will review a website with a patient during a visit to help them engage in their health concerns and management.
Finally, and most importantly, there are common psychosocial and emotional factors in patients with chronic pain, including depression and anxiety. Identifying these potential contributing issues up front is important in the subsequent evaluation and management. Specific screening tools are helpful in this regard and include the Beck Depression Inventory (http://hcp.lv/qlXSbl) and Patient Health Questionnaire (PHQ; http://hcp.lv/pCzDXa). Incorporating this evaluation early in treatment will allow a physician to address the discussion once the major diagnostic concerns have been reviewed with the patient.
Early on in the diagnostic evaluation, treatment considerations should be discussed and reviewed with the patient. I will often start treatment for pain after the initial evaluation, as waiting to begin treatment during future visits while trying to establish a specific diagnosis for the primary cause of pain or ruling out specific disease still frequently leaves the patient with symptoms of pain and disability. Setting patient expectations is important in a comprehensive treatment plan. For most patients, removing all pain is not the goal, but rather providing significant improvement in pain and function. A clinically meaningful improvement in pain can be considered at least a 30%-40% improvement from baseline. Defining this meaningful pain response is important in tracking treatment outcomes and can be documented with serial pain and functional assessment over time.
Patients frequently present with broad symptoms, but are concerned they may have a specific diagnosis and try to make their primary symptoms fit that diagnosis.
Understanding the common mechanisms of pain helps in the selection and prioritization of treatment options for chronic pain. Explaining the concepts of mechanical, proprioceptive, neuropathic, and central mechanisms of pain to patients may additionally improve patient understanding and response to treatment. Medications can be initiated on the basis of the presumed primary mechanism for pain. The typical pharmacological approach includes nonsteroidal medications, antidepressants, anticonvulsants, and opioids. There is a growing body of evidence that support the use of these various medications for pain relief. While guidelines may appear overwhelming and confusing, they are meant to help busy clinicians stay abreast of developing issues. The reader is referred to Cochrane reviews (http://hcp.lv/oHt1vu) for more specific details of various drug options.
The use of opioids for chronic pain presents unique challenges. Although concerns over regulatory requirements, side effects, and abuse potential may limit a physician’s consideration of opioids in chronic pain, opioid analgesics can be a reasonable option for select patients. While many patients are not at risk for opioid abuse or addiction, there are characteristics that may identify patients at increased risk. Factors include a family history of substance abuse, a personal history of drug or alcohol abuse, a mental health history, or prior chronic pain syndromes. Long-term treatment requires an ongoing periodic risk assessment, standardized drug monitoring, and specifying physician and patient expectations through written agreements, which should be reviewed and updated periodically. The use of long-term opioids in chronic pain remains limited by a high attrition rate, weak evidence documenting significant improvement in pain, and inconclusive data regarding quality of life and function.
Nonpharmacological options may include physical therapy modalities, cognitive behavioral therapy, alternative medicine, and interventional strategies. Cognitive behavioral therapy has been shown to improve pain across multiple dimensions and is an important tool in the management of patients who are suffering with chronic pain. While there has been a significant increase in the utilization of interventional techniques for pain management, the impact on pain control remains unclear. Effective management of patients with chronic pain may often require a team approach. A multidisciplinary approach for chronic pain management may include a physical therapist, psychiatrist, psychologist, and pain management specialist. Close interaction and effective communication between primary care and specialty care for opioid management in some patients may be required for patients who need escalating doses of opioids. A comprehensive multidisciplinary pain rehabilitation program is appropriate for patients with chronic pain and poor disability. With a team approach, close communication is vital for coordinated patient care. With any treatment, follow up, close monitoring, explanation, and reassurance foster communication and help build a partnership in managing chronic pain.
Better training and a shift in perspective regarding chronic pain will aid in the development of a standard approach and improve the identification, evaluation, and management of our patients with this common complex condition. Generalist physicians will continue to be the best option for providing long-term, comprehensive, effective care for these patients through communication and established relationships.
John Paat, MD, is an Associate Professor of Medicine and Consultant in General Internal Medicine at Mayo Clinic in Rochester, MN.