Persistent Pain

Prevalence of Pain in the United States

Pain is the most common reason patients seek medical care, accounting for 80 percent of total visits to physicians’ offices (1, 2). In most cases, the patient understands the underlying disease process (e.g., pharyngitis, gastroenteritis, migraine headache). Pain associated with these disorders causes the patient to seek help from his or her physician. Although it is difficult to determine the prevalence of pain in exact numbers, recent surveys suggest that 75–105 million Americans experience pain daily or intermittently (3, 4, 5). The management of persistent pain is a complex enterprise. Pain management remains an elusive and frustrating goal despite a growing knowledge about the pathophysiology of pain.

Chronic Pain Management: The Status Quo

With the onset of pain, most patients attempt self-care with over-the-counter products and/or self-help techniques (e.g., distracting activities, rest). When these methods fail to afford adequate relief, the patient generally seeks help from a medical professional. In many cases — and particularly in healthcare systems with limited access to specialty care — the gatekeeping primary care provider is the first medical contact. The primary care provider recommends treatment and refers the patient for appropriate specialty care, such as a physical medicine assessment for low back pain.

When pain becomes chronic, and specialty care is ineffective in improving the underlying condition, care management becomes more difficult. In a recent survey, only 34 percent of internists reported that they felt comfortable with their abilities to manage patients with chronic pain (6). In a related article, Ballantyne wrote that the most difficult issue now facing physicians is “whether and how to prescribe opioid therapy for chronic pain that is not associated with terminal disease, including pain experienced by the increasing number of patients with cancer in remission” (7).

In part, physicians are hesitant to prescribe opioids because they lack both the understanding of how to accurately assess pain and the knowledge of available pain therapies.

Primary care physicians struggle with unexplained variability among pain patients. Physical abnormalities are not predictive of pain severity or dysfunction (8). Large numbers of patients experience pain that may be constant over long periods of time, and yet their life functioning is not changed in major ways. Conversely, there are other patients with similar structural abnormalities who suffer substantially more and cannot maintain their usual levels of activity (9). Patients whose lives are significantly disrupted by pain engage in behaviors that are maladaptive, anticipate more distress, amplify sensations associated with pain, spend more time resting, and complain of less ability to control pain (10, 11).

At the same time, surveys evaluating the adequacy of pain treatment demonstrate that the current system is broken (12). Patients report that they are not asked about pain, that they are afraid to report pain to their primary care providers, and that they are not offered treatment. In one recent survey, 22 percent of pain patients reported being uncomfortable discussing pain with their personal physicians, 13 percent said they were denied pain medication or referrals to pain specialists, and 70 percent reported experiencing continued pain despite treatment (13). Much of this system failure can be attributed to the treatment at the primary care level.

Searching for Solutions

There have been tremendous advances in the knowledge of pain patho-physiology, the understanding of treatments for pain, and recognition of the value in an interdisciplinary approach to pain management. On the scientific front, there has been an explosion in pain research, and new pharmaceutical agents have become available for treating different types of pain. Complementary and alternative therapies for pain management have gained recognition. Novel interventional techniques and surgeries have been introduced. Professional pain societies have sprung up, and training is now available to provide physicians and other healthcare professionals with expertise in pain management. Despite this unprecedented progress, pain care remains grossly inadequate and under-treatment of pain is still considered pandemic. The reasons for this continuing failure are varied, but it is clear that new solutions must focus on primary care.

Barriers to Treating Pain

Many barriers to the management of pain have been well documented in this text and others (14). The obstacles relate to the medical system, providers, patients, and regulatory and governmental agencies.

Barriers to Management of Pain

Medical System:

• Access to Medical Care
• Access to Specialists
• Denied Coverage of Medication or Procedures
• Denied Coverage of Complementary and Alternative Medicine (CAM) Therapy
• Preauthorization Requirements

Patients:

• Poor Lifestyle Choices
• Fear to Accept Proven Treatment
• Expectation of Cure
• Stigma of Psychiatric Care
• Beliefs About Aging

Providers:

• Lack of Knowledge
• Bias Toward Treatment
• Failure to Refer
• Nialistic Care
• Beliefs About Aging

Regulatory and Governmental Agencies:

• Lack of Medicare Reimbursement
• Oversight of Opioid Prescribing

Many physicians are often uncomfortable treating patients with persistent pain. In addition to a relative lack of knowledge, there are a number of other underlying reasons for this.

Myths and Biases

Patients: Without conscious intention, people attach meaning to all sensory experiences. The smell of a rose may hold a special meaning to someone who received her first bouquet for the high school prom. The sound of the musical tune “Jingle Bells” may signify happiness, family gatherings, and holiday gifts. Pain, especially when it is persistent, often conveys a sense that the person is being punished for some real or perceived infraction. The common idioms associated with pain seem to confirm this understanding: “No pain, no gain.” “You need to feel this.” “Offer it up.”

Too often, patients with chronic pain believe that they suffer because of some mistake they made — “I had a hard life, Doc. Of course I have pain.” — or that pain is to be expected as a part of aging. There is so much meaning attached to pain, sometimes of a religious nature, that it is difficult to convince the patient otherwise. These beliefs about “needing pain” or “deserving pain” complicate treatment.

Providers: Providers are often suspicious of patients who complain of pain. Physicians understand certain types of pain — cancer pain, end-of-life pain, or acute trauma/illness pain — but are less accepting of the persistent pain that is symptomatic of less-defined conditions. We ask, “Why do some patients complain while others, with the same pathology or anatomy, do not?” “What is the secondary gain?” “Is this pain real?”

When pain is not easily explained, bias leads the primary care provider to suspect psychiatric causes. In addition, psychiatric comorbidities are common with persistent pain. Although specialists are more likely to understand the connection between anatomy and psychiatry, the primary care provider may believe that the persistence of the pain relates directly to the depression or anxiety thereby depreciating the pain complaint. Patients perceive this attitude as devaluing their experience.

New Focus

Persistent pain patients have similarities to and differences from patients with other chronic illnesses. They are both chronic conditions where cure is unlikely. Self-management is the key to success. Denial about the disease and non-adherence to treatment recommendations are common and expected challenges for the provider.

On the other hand, psychiatric issues are more common with persistent pain and interfere with treatment. Patients resist psychosocial diagnosis and interventions. Opioid management that only occurs in persistent pain problems is challenging for the patient and the provider. Non-adherence to treatment recommendations increases morbidity and mortality in diabetes, hypertension, and congestive heart failure. In chronic pain non-adherence increases work stress requiring more office visits, documentation, and medication surveillance. Although regulatory scrutiny does not often occur, the perception of legal difficulties increases practice discomfort.

In managing pain, it is important for the physician to understand that pain scores are highly subjective and that the focus must be on function. Although measuring pain is important and mandated in a variety of settings (15), the provider must not lose sight of the twin goals of treatment: function and adaptation.

A new pain complaint or worsening symptoms do not necessarily mandate more medication. In treating diabetes, a worsening HgbA1C leads the physician to recommend adjustments in diet, exercise, and medication. Similarly, in treating chronic pain, recommendations should take into consideration life stressors, pacing daily activities, depression, anxiety, and worsening of underlying pathology as well as medication. When the primary care provider understands that an increase in pain does not necessarily mean increasing the patient’s opioid drug, treatment issues become easier.

Conclusions

Persistent pain, a highly prevalent condition in the United States, has a significant impact on our health and productivity as a society as well as on our medical and financial resources. The barriers to managing chronic pain are significant but not insurmountable. Persistent pain is similar to other chronic illness but also has many differences, making management complicated and difficult in the busy provider office. A new skill set is required by the provider to help the deplorable under-treatment of pain. Available tools (e.g., questionnaires, pain diaries, pain scales) and techniques (e.g., reflective listening, goal setting) make it possible for the physician to provide management for patients with chronic pain. Diabetes, chronic obstruction pulmonary disease, and other chronic, complicated illnesses require other skills yet have been handled brilliantly in the primary care setting.

Some of the most appreciative patients are those who have a sympathetic provider to help them with chronic pain. Yet treating chronic pain patients is rarely met with enthusiasm. Patients with chronic pain are complicated and rarely cured. They make little progress toward normal life functioning and often have complex psychosocial issues that a physician cannot address. There is never sufficient time to adequately follow up patients with pain. We all have learned how to deal with difficult, complex, and complicated care issues, and we can do the same with our chronic pain patients. We all must accept learning a new skill set; otherwise, there will be no end to the tragedy of under-treated pain.

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