Patients whose pain persists for years pose a special challeneg. An internist describes an approach that works for all but the toughest cases.
Nearly one in 10 adults reports that pain has a major impact on her life. That won’t surprise you; chances are you see at least a couple of patients every day who suffer chronic nonmalignant pain (CNMP) from mus-culoskeletal problems, diabetes, shingles, or rheumatologic conditions, to name a few.
Primary-care physicians (PCPs) have assumed a central role in managing this common problem, and with that responsibility come significant challenges: absence of adequate research; lack of curative therapy compounded by the lack of precise measures to gauge patient improvement; complex comorbidities; and, invariably, patients with substance abuse problems trying to manipulate you.
Development of a standardized, practical approach to managing CNMP offers PCPs the best opportunity to improve care and satisfaction — both patients’ and their own. Here’s my step-by-step guide.
Take adequate time to develop an individualized treatment plan.
CNMP is never an emergency, and it is not simply a prolonged version of acute pain. It is best thought of as a poorly understood disease state with little correlation between pain complaints, physical exam findings, and results of diagnostic tests. The differences between CNMP and acute pain and cancer pain are several: First, the treatment horizon is much longer. Second, treatment goals need foremost to focus on improved functional status rather than comfort. Thus, the goal should not be “no pain.” Third, because CNMP is a stable or slowly advancing condition, there is no need for rapid adjustments in treatment strategy (and, as a corollary, little to no role for breakthrough medications).
Most importantly, the physician and patient should take adequate time to develop a working relationship and negotiate a comprehensive treatment plan over a series of visits.
Validate the symptoms and empathize with the patient, then focus on eliminating reversible physical causes.
It is important to validate the pain at the initial visit. This visit is also an opportunity to explicitly commit to helping, which focuses on relationship building from the start. There is substantial literature highlighting the importance of the patient-provider interaction on satisfaction with treatment.1
After listening to the patient’s story without interruptions, you can say sincerely, “I am sorry that you are in pain. I want to help you, and I’ll do what I can to improve the quality of your life.”
Once you establish the foundation for the working relationship, start the clinical evaluation by seeking to eliminate reversible physical causes. Review all previous medical records, as the majority of CNMP patients have had extensive evaluations.2 Pursue further testing only if there are gaps in earlier evaluations; there has been a significant, acute change from baseline; or several years have passed since the last comprehensive evaluation.
Initial assessment of the pain should include location, quality, average intensity on a 1-10 or visual analog scale, maximum intensity, and frequency of pain reaching maximum intensity. However, pain severity should not be used as the sole or principal metric of clinical improvement.
Address all components of the problem, recognizing that psychiatric comorbidity is common in pain patients.
It is important to understand the impact of pain in the context of the patient’s life, giving particular attention to psychological well-being and previous history of substance abuse.
Studies of CNMP patients have documented lifetime prevalence rates of 50% for depression, 20% for anxiety, 40% for alcohol abuse or dependence, and 30% for narcotic abuse or dependence.2 A World Health Organization (WHO) survey of primary-care patients in 15 countries reported that chronic pain patients have more than four times the chance of having anxiety or depressive disorder than nonpain patients.3 A comprehensive literature review of depression and pain comorbidity summarized that the concurrent prevalence of major depression with CNMP is as high as 85%.4
All patients with CNMP should be screened for affective disorders using such available screening tools as the Beck Depression Inventory. I advise physicians to say to patients, “I don’t think your pain is psychological, but since depression can magnify your pain, it is important that I ask about your overall mood.”
Proceed to a detailed assessment of functional status, and establish a timeline for achieving specific, realistic goals.
Perhaps the most overlooked aspect of chronic pain management in the primary-care setting is the need to establish a concrete metric of functional improvement. Significant reduction or complete resolution of pain is generally unrealistic. The overarching goal of treatment is a better quality of life by improving a patient’s functional status while minimizing pain intensity.
Follow-up analysis of the WHO survey revealed a strong and symmetrical relationship between persistent pain and psychological disorder. Notably, impairment of patients’ daily activities appeared to be a central component of that relationship, so additional psychosocial history should include an assessment of functional status with a focus on routine daily activities.Ask patients suffering from CNMP, “What are you hoping to get done today that your pain prevents you from doing?” The principal metric of treatment success then becomes the ability to accomplish this activity. Specific improvements in functional status can be as mundane as walking the dog, doing the laundry, or going to the park with grandchildren.
Longer-range treatment goals should include increasing physical activity, decreasing reliance on the health-care system by encouraging strategies for self-management, decreasing suffering and pain, improving interpersonal relationships and psychological integrity, and returning to a functional role in society. Physicians should ask the patient to list one objective within each area that he hopes to meet within a specific time frame.
Educate about the core strategy, including a treatment plan with regular clinical follow-up.
Since the duration of CNMP often exceeds 10 years,2 patient expectations about the magnitude of relief are realistic. That said, it is always worth reinforcing that complete resolution of pain is unrealistic. I advise physicians to tell patients, “At most, we hope to get your pain out of the driver’s seat and into the backseat or perhaps the trunk.”
Like other chronic diseases, chronic pain requires a comprehensive approach that involves lifestyle modification, emphasis on coping skills, nonpharmacologic and pharmacologic modalities, and, for complex cases, referral to specialists. Optimal management requires patients to participate in all facets of the treatment plan, and failure to do so can be considered grounds for limiting other therapy.
Review with patients the clinical responses to previously tried treatments, and then negotiate a new plan that may include elements of those earlier approaches combined with untried therapies. The plan should always include increased physical activity.
Incorporate nonpharmacologic approaches in the treatment plan, emphasizing regular physical activity.
Nonpharmacologic approaches for managing CNMP include alternative therapies. There is evidence that acupuncture, added to other conventional therapies, relieves chronic low back pain and improves function better than conventional therapies alone, although the magnitude of the effects is generally small.5 The beneficial effects of massage in patients with chronic low back pain have been observed to last up to one year.6
The mainstay of nonpharmacologic approaches is physical exercise. Clinical data demonstrate the benefit of exercise, particularly for chronic low back pain and fibromyalgia. Experts postulate that exercise may retrain the nervous system to re-establish normal neural connections affected by chronic pain.
Having the patient keep a daily diary of physical activity may help assess adherence. Behavioral therapy and psychotherapy can be useful in addressing other aspects of CNMP in the same way that nutritional counseling can help manage diabetes.
Recommend evidence-based pharmacotherapy and re-evaluate polypharmacy.
Medications for the treatment of CNMP include nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, antidepressants, anticonvulsants, anesthetic medications, and opioids, although none has been shown to result in dramatic improvement. Many patients will try a host of different medications — often in combination. PCPs need to be aware of the potential problems of polypharmacy. Tapering or stopping all clearly unhelpful medications is important.
The benefit of NSAIDs is limited by a ceiling analgesic effect and the risk of substantial adverse effects, including GI toxicity. The efficacy of these medications for controlling chronic pain is not well established except in rheumatoid arthritis and osteoarthritis. NSAIDs should be used with caution or not at all in patients with cirrhosis, kidney disease, and previous GI bleeding. Acetaminophen’s mild-to-moderate analgesic effect and low risk of toxicity at dosages as high as 4 g per day make it a possible, although probably less effective, substitute.
Antidepressant therapy deserves special attention. Meta-analyses and systematic reviews have demonstrated the analgesic efficacy of antidepressant medications (tricyclic antidepressants in particular) across a broad range of underlying conditions.4 Furthermore, depression in the setting of chronic pain, as in other settings, is probably undertreated.
Antidepressant therapy, therefore, should be considered in all patients with CNMP and clinical depression as well as in all chronic pain patients who have not responded adequately to other therapies. Tricyclic antidepressants should be considered first, but anticholinergic effects and arrhythmogenic potential may limit their use, in which case, consider a newer antidepressant agent. Serotonin norepinephrine reuptake inhibitors, such as venlafaxine (Effexor) and duloxetine (Cymbalta), may be more effective than selective serotonin reuptake inhibitors.
Anticonvulsant medications, particularly gabapentin (Neurontin), have established efficacy in treating chronic pain that is predominantly neuropathic, including pain associated with diabetic neuropathy and postherpetic neuralgia.
Topical capsaicin cream, usually used as an adjunct to other therapies, can benefit some patients who have neuropathic pain or osteoarthritis. More recently, 5% lidocaine patches have become popular, although published evidence is limited to four small randomized controlled trials between 1996 and 2003. The most recent trial evaluated the use of lidocaine patches in focal peripheral neuropathic pain syndromes and revealed a number needed to treat to obtain >50% relief of 4.4.7
The last decade has seen the reassessment of opioids in CNMP treatment. Data supporting their use include anecdotal case series of carefully selected patients from pain clinics and approximately 15 randomized control trials. The case series did dispel the myths that significant tolerance to the analgesic effect necessitates infinite escalations in dose and that iatrogenic addiction develops at a high rate.
The randomized trials show on average a 30% reduction in pain scores but no compelling, consistent improvement in functional status. Furthermore, all of the randomized trials are severely limited by small sample size (fewer than 1,000 highly selected subjects have been studied to date), a long list of exclusion criteria, short duration of follow-up (on average just over four weeks), significant dropout rates, and lack of generalizability to the primary-care setting.
Nevertheless, PCPs may consider an opioid trial in some patients. Keys to a successful trial include careful selection of patients (see the table) explicitly identified goals for improvement in function and decrease in pain, and monthly visits to monitor effects. Some experts recommend obtaining signed informed consent at the outset of a trial. An opioid trial that does not meet explicit goals after a predetermined time should be stopped. If the opioid will be taken daily, long-acting opioids, such as methadone, are probably more effective.8
In light of the growing problem of prescription-drug abuse in the United States, PCPs should strongly consider using a patient-care agreement. Although such agreements have not been shown to reduce opioid abuse, they are useful for establishing parameters for ongoing use of the controlled substance (see box opposite). In addition, carefully document in the medical record at every visit the location and cause of the pain, the dosage, frequency, and quantity of opioid medication prescribed, and the effect of the medication on functional status.
Dr. Hollon is assistant professor of medicine at the University of Washington School of Medicine in Seattle and actively involved in resident education as the Director of Evidence-Based Medicine and the Director of Behavioral Medicine.
1. Hirsh AT, Atchison JW, Berger JJ, et al. Patient satisfaction with treatment for chronic pain: predictors and relationship to compliance. Clin J Pain. 2005;21:302-310.
2. Reid MC, Engles-Horton LL, Weber MB, et al. Use of opioid medications for chronic noncancer pain syndromes in primary care. J Gen Intern Med. 2002;17:173-179.
3. Gureje O, Von Korff M, Simon GE, Gater R. Persistent pain and well-being: a World Health Organization Study in Primary Care. JAMA. 1998;280:147-151.
4. Bair MJ, Robinson RL, Katon W, Kroenke K. Depression and pain comorbidity: a literature review. Arch Intern Med. 2003;163:2433-2445.
5. Furlan AD, van Tulder MW, Cherkin DC, et al. Acupuncture and dry-needling for low back pain. Cochrane Database Syst Rev. 2005;(1):CD001351.
6. Furlan AD, Brosseau L, Imamura M, Irvin E. Massage for low-back pain. Cochrane Database Syst Rev. 2002;(2):CD001929.
7. Meier T, Wasner G, Faust M, et al. Efficacy of lidocaine patch 5% in the treatment of focal peripheral neuropathic pain syndromes: a randomized, double-blind, placebo-controlled study. Pain. 2003;106:151-158.
8. Toombs JD, Kral LA. Methadone treatment for pain states. Am Fam Physician. 2005;71:1353-1358.