Chronic Pain Focus
CONJ 657, 695
Introduction to Chronic Pain Track:
"It is more important to know what sort of person has a disease than to know what sort of disease a person has."
- Hippocrates: 5th century BCE
"When the mind is ill at ease, the body is affected."
Ovid: 1st century
"Care more particularly for the individual patient than for the special features of the disease."
Osler: 19th century
"It is of the highest importance in the art of detection to be able to recognize out of the number of facts which are incidental and which vital. Otherwise your energy and attention must be dissipated instead of being concentrated."
Doyle (Sherlock Holmes): late 19th century
"The secret of the care of the patient is caring for the patient."
Peabody: early 20th century
"Acute pain is a symptom of disease; chronic pain itself is a disease."
Bonica: mid 20th century
"There are things we can heal that we can’t cure. We can heal things by making people feel better about what is unfixable."
Kushner: late 20th century
"The problem is simply that most doctors aren't well prepared to manage pain. And who enjoys doing something that they aren't trained to do?"
Fishman: 21st century
Everyone knows what "pain" is, since all people have had a personal experience with painful injuries and conditions. This does not make us familiar with the problem of "Pain," when a pain extends without remission for months to years, or when it has become "chronic." Our own experiences with pain that resolves can mislead and bias us when we encounter patients with continuing persistent Pain. The important focus of much of medical school education is to identify and treat medical and surgical disease, expecting that pain associated with the specific condition will resolve. When it doesn't, physicians need special skills and useful tools to effectively manage this common chronic medical problem.
Chronic non-cancer pain is a very significant problem for patients, their families, their work places, the health care system of delivery and payment, and for doctors of all specialties. Medical management of chronic pain involves all medical, surgical, and behavioral specialties, and has an especially large impact in all areas of primary care.
Epidemiology of chronic pain:
- Pain is primary complaint in 40% primary care visits
- ~30% people report pain during any given day
- 70% patients with persistent pain managed by primary care provider and 25% by emergency departments
- Only 2% of these patients see a Pain Specialist
Common Pain Disorders by presenting site:
- Headache: 45.2%
- Spinal/Axial Pain: 47.8%
- Osteoarthritis: 41.7%
- Chest: 28.9%
- Widespread Pain: 17.5%
The challenge of chronic pain is a problem for patients beyond the pain itself. Dissatisfaction, isolation and hopelessness increase symptoms and distress. Patient responses to recent surveys finds:
- My doctor doesn't think my pain is a problem: 20%
- My doctor doesn't ask me about my pain: 22%
- I don't get enough time to talk to my doctor about pain: 23%
- No one believes my pain is as bad as it is: 29%
- My doctor would rather treat an illness than my pain: 43%
There are also entrenched erroneous patient beliefs:
- Chronic Pain = Prolonged Acute Pain
- Chronic pain can be cured, "If only they knew what was wrong with me"
- Surgery can cut out chronic pain
- Medications alone can cure chronic pain
- Opioids work as well for chronic pain as they do for acute pain
- All patients on opioids are addicts
Challenges for doctors often involves long-standing biases and prejudices about chronic pain patients:
- 15% PCP feel comfortable treating chronic pain
- 80% have a negative attitude toward use of opioids
- 41% wait for patients to request for pain Rx
Many doctors also misunderstand chronic pain, believing:
- Imaging can predict whether pain is “real” or not
- Pain can’t be reliably measured and outcomes assessed
- Treat the "pain generator" and chronic pain will resolve
- Spine surgery cures spine pain
- My nice patient won't become an addict
- Requesting a drug by name means "drug-seeking"
- Chronic pain patients will ruin my day
Primary care and subspecialty doctors have the training and skills to care for many chronic conditions well, such as diabetes, coronary artery disease, hypertension, and depression. Yet, most primary care doctors feel unprepared to provide continuing care for chronic pain even with most of the training and capability necessary to do so, since primary care doctors routinely:
- Conduct patient-centered interviews and examinations
- Diagnose & manage acute and chronic medical conditions
- Perform biopsychosocial diagnosis & management
- Manage pharmacotherapy of ordinary and complex chronic diseases
- Provide entry point to supportive & rehabilitative care
- Offer referral source for subspecialty consultation
- Are able to follow and carry out specialist advice
There are, however, a number of specific deficiencies in the "toolkit" for the proper care of chronic pain:
- Scope of training has been limited/absent
- Linear evidence-based data incompletely addresses complex pain disease and management
- Most guidelines advise multidisciplinary pain care only for aberrancy, such as major psychiatric or behavioral problems, or for detoxification and/or addiction management
- Incomplete awareness of the limitations of medication management alone, and lack of appreciation for the value and approach of psychological, physical and rehabilitative interventions, and the role of complementary and alternative medicine
- Limited understanding of the role and value of precision interventional diagnostic and treatment options in the treatment of chronic pain
Doctors recognize the value of continuity of care, which enables trustful listening and attentive care. Chronic pain management similarly relies on the "whole story" narrative, psychosocial context, long-term outcome assessment, and risk assessment of treatments provided. Practically, chronic pain diagnosis and treatment is usually quite challenging from the perspective of difficult diagnosis and clinical management, since previous measures and specialty assessments have not worked. Chronic pain is, as a result of this challenge, rewarding to manage. A physician can learn to develop the skills necessary to treat chronic pain patients, most who have been told, often many times by many experts, that "there is nothing more I can do for you."
Chronic Pain Track Goals:
- Approaching acute and chronic medical conditions differently, become capable of applying a chronic medical care model that is effective and useful for the treatment of chronic pain.
- Developing special history-taking and specific physical exam skills, be able to identify the clinical presentation and pathophysiology of the many commonly occurring complex pain disorders seen in all specialties of medicine and surgery, especially primary care.
- Be capable of measuring and assessing outcomes of selected pain treatments by systematically evaluating the genetic, biologic, psychologic, and sociologic domains of chronic pain disorders.
- "Stop trying to cure me and start listening." *per patients' request