Best Practices in the Treatment of Chronic Pain
And understanding the intersection of psychiatric conditions and pain
Posted Jul 12, 2019
One in four Americans—more than 76 million—have experienced chronic pain at some point during their lives. Though many treatments are available, people with chronic pain often go years without effective care. Some avoid treatment, fearing that their only options are surgery or powerful pain killers. But others bounce from provider to provider, desperately in search of help that never comes. Many providers do not know how to effectively treat pain, or ignore evidence-based guidelines for diagnosing and managing the sources of pain.
Pain is both a physical and psychological experience. Effective treatment of chronic pain addresses both components. Effective clinicians should follow the following guidelines for effectively treating pain.
Be Mindful of Bias
Research consistently shows that a doctor’s perceptions of a patient can affect the provider’s willingness to treat that patient. People of color, especially African-Americans, continue to suffer from stereotyping and bias. Doctors are less likely to believe black patients about their pain, and less likely to offer aggressive or effective pain treatment. Women, too, have long suffered from bias. Numerous studies have shown that doctors take women’s pain less seriously, and often believe women are malingering or exaggerating their pain.
Class may come into play, too. A homeless person is more likely than other people to suffer from serious medical issues. Yet some providers assume that poor or homeless patients are more likely to be seeking drugs or faking their symptoms. This leads to worse health outcomes and increases overall health care costs.
This bias isn’t always conscious. Good intentions aren’t enough. Providers must continually interrogate their own biases. If you don’t believe a patient, consider why that might be. Maintain data on your own prescribing practices to check for racial and gender disparities. Providers who are mindful of the specter of bias are much less likely to let it influence their work.
Get Clear Information About the Pain
People dealing with chronic pain may see several providers before they get help. So they learn to speak quickly, and often hyperbolically in an attempt to get help. Get clear details about the nature of the pain, how long it has lasted, where it is located, and what makes it worse or better.
Some patients are fearful that questions from a physician mean that the physician disbelieves them. Reassure the patient that you believe them and that you care, but that you need as much information about the pain as possible. Then make additional testing recommendations based on clear diagnostic guidelines. Even if a diagnosis seems likely, it’s generally worth testing, especially if a patient has been in chronic pain for a long time.
Treat Pain as a Psychological and Physiological Experience
Pain is a psychological experience as well as a physical one. Patients tell themselves things about their pain-- “I can’t cope with this”; “This will never get better”--that can affect their functioning and ability to heal. Psychological distress about pain can make the pain worse. It can also make it difficult for a patient to adopt lifestyle strategies, such as exercise, that will improve symptoms.
Don’t just treat the pain. Treat the underlying psychiatric conditions and/or psychological distress, while reassuring the patient that you know the pain is real. Reassure the patient that even when the pain has a physical origin, psychological distress can make it worse. Cognitive-behavioral therapy (CBT) is especially effective for chronic pain.
Adopt an Integrative Treatment Approach
Chronic pain treatment is more likely to be effective when it blends psychological care, lifestyle management strategies, and medical treatment. Most chronic pain patients must use several treatments—such as physical therapy, CBT, and medication—to see real improvements.
Encourage Lifestyle Changes
Many chronic pain patients are resistant to lifestyle changes for at least two reasons. First, pain saps motivation and can make healthy lifestyle changes such as exercise more difficult. But second, some patients believe that a recommendation for lifestyle changes means that the provider disbelieves them about the pain. Reassurance that exercise, more sleep, and stress management are real treatment for real pain can help. Pain support groups can help with conveying this message, so consider also helping patients find a support group.
Refer to a Specialist
Patients should see a specialist for serious illnesses such as rheumatoid arthritis or other chronic inflammatory conditions.
Be Cautious With Opioids
Physicians who prescribe pain medication face a difficult quandary. They have a moral obligation to help alleviate suffering. But they also must do their part to reduce the risk of substance abuse, which is the source of untold suffering. Opioid abuse claims more than 33,000 lives annually. The decision to prescribe opioids can affect the rest of a patient’s life, so doctors must not take this decision lightly. At the same time, opioids can greatly improve quality of life in some patients.
The CDC makes the following recommendations for providers prescribing opioids for chronic pain:
· Choose nonpharmacologic therapy first. When drugs become necessary, try medication other than opioids before proceeding to the use of opioids.
· Before beginning opioid therapy set clear treatment goals. Evaluate the benefits and risks of opioid treatment, and if the risks outweigh the benefits, discontinue treatment.
· Prescribe immediate-release instead of extended-release opioids.
· Start with the lowest effective dose and gradually increase the dose only as needed.
· Continue evaluating the patient after initiating therapy.
· Offer evidence-based treatment for patients who show signs of an opioid use disorder.
Chronic pain is challenging for providers to treat, but even more challenging for patients to live with. An open-minded, multi-faceted approach is the best option for treating pain and improving quality of life. Providers must be willing to keep trying and to accept feedback from patients.
Campbell, C. M., & Edwards, R. R. (2012). Ethnic differences in pain and pain management. Pain Management, 2(3), 219-230. doi:10.2217/pmt.12.7
CDC Guidelines for Prescribing Opioids for Chronic Pain. (2017, August 29). Retrieved from https://www.cdc.gov/drugoverdose/prescribing/guideline.html
Kiesel, L. (2017, October 07). Women and pain: Disparities in experience and treatment. Retrieved from https://www.health.harvard.edu/blog/women-and-pain-disparities-in-experience-and-treatment-2017100912562
Opioid overdose crisis. (2018, March 06). Retrieved from https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis
Owen, G. T., Bruel, B. M., Schade, C. M., Eckmann, M. S., Hustak, E. C., & Engle, M. P. (2018). Evidence-based pain medicine for primary care physicians. Baylor University Medical Center Proceedings, 31(1), 37-47. doi:10.1080/08998280.2017.1400290
Samarrai, F. (2018, October 19). Study links disparities in pain management to racial bias. Retrieved from https://news.virginia.edu/content/study-links-disparities-pain-management-racial-bias