Chronic Pain Overview

INTRODUCTION

At least one member of almost half of America’s 44 million households (43%) suffers from chronic pain due to a specific illness or medical condition.⁷ Chronic pain is pervasive in all age groups, including children. According to the American Pain Society, chronic pain is estimated to affect 15-20% of children.⁸ In the general population, it is estimated that 25-50% of the elderly suffer chronic or intermittent severe pain:⁹ in the nursing home population, the percentage could be anywhere from 45 to 85% (often untreated). ¹⁰

There are many conditions/diseases that cause chronic pain, including

• Arachnoiditis
• Arthritis
• Crohn’s disease
• Irritable bowel syndrome
• Low back pain
• Cancer
• Diabetes
• Migraine headaches
• Muscle pain
• Shingles and post-herpetic neuralgia
• Fibromyalgia
• Complex regional pain syndrome
• Chronic pain symptoms
• Pelvic pain
• Interstitial cystitis
• Systemic lupus
• HIV/AIDS

Chronic pain can be caused by nociceptive, neuropathic, idiopathic or psychogenic mechanisms. In many cases, a complex interplay of one or more of the mechanisms is at work, particularly in cases where there are other comorbid conditions. A growing tumor mass, for example, may initially activate nociceptive pain, with remote effects of the malignancy producing neuropathic pain syndromes over time. Included as Appendix A is an excerpt from the “Pathophysiology of Pain,”¹¹ published on the One Voice Website of the Pancreatitis Association International. The complete document can be accessed at http://pancassociation.org/pain_pathophysiology.pdf.

Clinicians who seek to improve their chronic pain management programs and minimize liability risks should consider the following questions:

1. Do beliefs, attitudes, fears and/or lack of knowledge impede optimal pain care?
2. Do you hold any age, gender, or racial/ethnic biases that may negatively influence your decision-making process?
3. Do you view pain management as a priority?
4. Do you understand the physical, emotional and cognitive components of pain and how they interact?
5. Do you believe a patient’s self-report of pain?
6. Do you carefully assess how chronic pain affects a patient’s quality of life?
7. In an effort to restore a patient’s quality of life, do you take advantage of a variety of pain management modalities and seek the expertise of specialists?
8. Do you educate patients on pros and cons of treatment options, compliance issues, side effects, pain record keeping?
9. Do you involve patients and family members in the decision-making process?
10. Do you understand the laws and guidelines governing the use of controlled substances for legitimate medical purposes?

These are key issues to explore in examining the efficacy of current chronic pain management practices and identifying opportunities for improved outcomes.

Acute vs. Chronic Pain
One of the shortfalls in chronic pain management is the lack of defined therapeutic goals. Unlike acute pain, in which a realistic therapeutic goal is 100% relief, chronic pain does not offer such a neat or predictable formula for resolution. It is important for physicians to understand the differences between acute and chronic pain in setting realistic goals for pain relief.

Acute Pain: Acute pain is the result of body tissue damage directly caused by an injury or illness. From a biological standpoint, acute pain warns of the potential for, or the extent of injury. Acute pain is usually nociceptive, but may be neuropathic. Nociceptive pain can be aching, throbbing or sharp. Common causes of nociceptive pain include burns, bumps, fractures, sprains, bruises, and myofascial pain.

Neuropathic pain is generated by nerves. One of the most unusual forms of neuropathic pain is “phantom limb syndrome”, in which a patient feels pain in a limb that has been amputated and is no longer part of the body. Other causes of neuropathic pain include alcoholism, chemotherapy, diabetes and HIV and AIDS.

The usual therapeutic goal of acute pain is total pain relief in one to two weeks, or at most two to three months.The damage heals and the pain resolves. Sometimes the report of pain stops even before the healing has been completed.

Chronic Pain: Chronic pain is not acute pain that simply lasts longer. Chronic pain may begin as acute pain, but it continues beyond the normal time expected for resolution of the problem, or persists or recurs for other reasons (e.g., stress, environmental/affective factors). With chronic pain, pain transmission and the nervous system are altered to promote pain transmission and lower pain thresholds.

The commonly accepted time frame for a pain condition to be considered chronic is 3 or 6 months beyond onset or beyond the expected period of healing. In differentiating chronic pain from acute pain, time is not the only criteria. Chronic pain is not only pain that extends beyond the normal resolution time, but also pain that is hard to explain based on the identified pathology. According to the American Pain Society, chronic pain is also defined in terms of its effect on a person’s quality of life – sleep, emotional well-being and normal functioning in day-to-day life are all impaired. Chronic pain serves no biological protective purpose, as does acute pain.

Chronic pain may be caused by accidents, malignant conditions, diseases such as arthritis, neuropathy and fibromyalgia, and surgery. The reasons for some non-malignant pain to become chronic are not entirely clear; the pain exists with no apparent cause. An example is Chronic Pain Syndrome (CPS).

With chronic pain, the therapeutic goal is not 100% relief. Instead, the goal is to achieve the highest level of function and independence possible, while improving the overall quality of life—physically, emotionally and socially.

PUTTING THE CHRONIC PAIN PATIENT IN PERSPECTIVE

Consider this chronic pain scenario.

The alarm clock goes off in the morning and Raymond feels like he never slept. He is exhausted. He gets out of bed and his pain makes it hard to walk to the bathroom. He has not been able to go to work for several days, nor has he been able to help out with any of the household chores (or anything else for that matter). His pain literally consumes him. He doesn’t feel like joining his family for breakfast; all he wants to do is get back in bed. His wife is asking him to help her make decisions about a refinance on the house, and all he wants to do is scream. His children are tired of hearing about his pain, and avoid him. “You’re so crabby and sad” they intone over and over. (By the way, his friends agree with the kids, despite the fact that they “empathize” with his pain, and hope he feels better soon; Raymond sees through the social posturing.) His wife, before leaving the house to go to work, reminds him that his doctor wants him to get out and exercise. Why doesn’t she get it? he thinks. That is the last thing he wants to do.

Raymond gets back into bed because that is his only refuge. There is no future or past, just the reality of his pain, at that moment. The curtains are drawn and he wonders how on earth he can still be in pain when he’s been to so many doctors and tried so many medications. He can’t help running the same old questions through his brain…Why won’t my doctor prescribe something stronger than Ibuprofen? Is this ever going to end? Will I ever be able to think straight again? Be productive at work? Make love to my wife? Be a good father? Play golf? See my friends? Raymond is angry and grief stricken. “I want to die,” he says, not for the first time.

The scenario above is fictional but not unrealistic. According to “What You Need to Know About Managing Your Chronic Pain”¹² published by the Cleveland Clinic, the effects of chronic pain are physical, emotional and cognitive. Often roles change, and patients can no longer participate as healthy, contributing individuals. Other people have to take care of them, and self-esteem plummets. Chronic pain patients often feel that family and friends are tired of hearing about their pain-related problems. Each time they visit the doctor’s office, they feel their complaints of pain are no longer heard. They shut down. Depression and feelings of isolation cast a dysphoric shadow over these chronic pain patients. In some cases, where the cause of pain is undiagnosed (but real nonetheless), the psychological effect of pain can be devastating.

The Cleveland Clinic recommends the following general treatment approaches for the effects of chronic pain:

Physical – A program of cardiovascular strengthening, stretching, improved nutrition, adequate rest and pacing (not overdoing it on good days). When necessary, treatment also includes smoking cessation and decreased alcohol consumption.

Emotional – A program of patient education that teaches relaxation techniques and how to seek support. It also includes deep breathing and other stress management techniques.

Cognitive – Patient education to teach patients to set achievable goals, stay active, remain flexible and engage in positive, personal affirmations.

A national U.S. Survey of 1,000 chronic pain patients by Partners Against Pain revealed that many of the surveyed patients had suffered pain for years; a majority endured pain for more than five years.¹³

Many reported that first-line (and ineffective) treatments for moderate to severe pain had consisted of over-the-counter medications such as aspirin, acetaminophen, non-steroidal anti-inflammatories (NSAIDs) and physical therapy. These patients were willing to try new treatments and pay more money if they knew it would work.

In seeking pain relief, many chronic patients feel they are on a medical merry-go-round. Dissatisfied with pain relief, they jump from one doctor to another desperately hoping that someone, finally, will be able to get them out of pain. One in four chronic pain patients has changed doctors at least three times. It is not surprising that continued pain suffering is the number one reason for seeking other care. Of greater importance, from a physician’s standpoint, is that these patients claim their pain is not taken seriously or treated aggressively. They are left in a state of hopelessness.

In a U.S. Center for Health Statistics study of chronic pain patients,¹⁴ depression was the most important variable associated with chronic pain.¹⁵ Pain resulting in loss of independence or mobility increased the risk of depression. Depressed chronic pain patients report greater pain intensity, less life control and more use of passive-avoidant coping strategies. Do psychological comorbidities of depression and anxiety contribute to more recalcitrant chronic pain problems? Sadly, the answer is yes. Pain studies consistently draw a powerful correlation between the physical and psychological components of pain.

The statistics speak for themselves. Too many people are suffering from pain, and their lives have lost value. There is much that can be done to change this, through physician education, attitude and commitment.

BARRIERS TO EFFECTIVE CHRONIC PAIN MANAGEMENT

The first step in overcoming barriers to effective chronic pain management is to understand what they are and how they might come into play in clinical practice.

Failure to refer, when appropriate, is one barrier. In a 1999 survey of 805 chronic pain patients, only 22% of these individuals had been referred to a specialized pain treatment clinic for comprehensive multidisciplinary care.¹⁶ In fact, 49% of the patients in severe pain were still being seen by a family doctor or internist.¹⁷

The same study outlined a number of other clinician barriers, which include:

• Gaps in knowledge
• Negative attitudes toward prescribing opioids
• Inadequate assessment skills
• Timidity in prescribing

Erroneous beliefs about the experience of pain as well as ethnic, racial, age, and gender biases also contribute to the problem. Consider your own responses, yes or no, to the following statements.

I believe that:

• children tolerate pain better than adults.
• children have no memory of their early years, and as such, there are no long-term effects of pain.
• children easily become addicted to opioid analgesics.
• as people age, they are less sensitive to pain.
• it is not safe to treat the elderly with opioids.
• elderly people have a tendency to complain more about pain.
• women are highly emotional and tend to exaggerate pain; a woman’s pain is usually “all in her head.”
• women cope with pain better than men, so they don’t need to be treated as aggressively for pain as men do.
• minorities (African-Americans, Hispanics, etc.) are more likely to be substance abusers.

Chronic pain patients themselves contribute to pain relief barriers. Many Americans would rather bear pain than take action to relieve it. They believe pain is a fact of life, think that it is too easy to become reliant on or addicted to pain medications, and assume that medications will not be effective with continued use. Some chronic pain patients simply don’t believe that there really is a solution for their pain. Others simply don’t want to discuss pain because they think they will be considered “weak” or because it might result in a poor disease prognosis. For those patients without insurance, the cost of pain medication or treatments may be prohibitive.

Poor adherence with prescribed analgesic regimen is another factor. When physicians fail to educate patients on the reasons for “staying on the clock” or how to manage possible side effects, there is a greater risk of losing patient cooperation, and placing the patient back in pain.

Traditional views surrounding management of chronic pain without opioids are now changing.The truth is, addiction is rarely seen in patients under medical care with no history of chemical dependency. Safe use of opioids in conjunction with other therapies – adjuvants and non-pharmacologic therapies - is now gaining acceptance. New federal and state laws demonstrate support for patients in chronic pain, and recently published guidelines on pain assessment and treatment endorse opiate use for legitimate medical purposes.

As clearly stated in the 2004 Federation of State Medical Boards “Model Policy for the Use of Controlled Substances for the Treatment of Pain,” optimal, informed use of analgesic drugs is now an essential goal of chronic pain management. A copy of this Model is included as Appendix B.

CHRONIC PAIN PATIENTS – TREATING THE WHOLE, NOT JUST THE PARTS

Historically, western medicine has been based on a duality of mind and body. Physical ailments were viewed as separate from mental afflictions, and treated that way. Scientific research over the past several decades has debunked this notion, proving that indeed, mind and body are inextricably connected, and that to separate body and mind is counterproductive to any treatment strategy. Nonetheless, there is still a tendency to impose reductionistic paradigms to chronic illness and pain, particularly in light of the high prevalence of comorbidities.

CHRONIC ILLNESS AND COMORBIDITIES

• More than 75% of people with cancer have one or more additional chronic conditions; 27.4% have three or more chronic conditions.¹⁸
• On average, a person with arthritis has at least three other chronic conditions.¹⁹
• Over 81 percent of people with diabetes have one or more comorbidities; 34% have three or more co-existing conditions.²⁰

Suppose a patient has osteoarthritis, diabetes, asthma, and depression: Do you carve out and treat each condition separately? Or do you develop a treatment plan that considers the “whole” patient?

Chronic pain diseases and disorders are fraught with comorbidities. These comorbidities interact to produce a complex and challenging clinical dynamic:

• Respiratory conditions and arthritis make it difficult for a patient with obesity to comply with exercise regimens
• Chronic shoulder pain may interfere with the recommended muscle strengthening goals for fibromyalgia
• Medications for one condition may aggravate other conditions
• Depression and feelings of hopelessness may result in missed physical therapy sessions

In treating patients with chronic pain, clinicians must view the patient as the multi-faceted “whole” person that they are, and develop a treatment plan that reflects the entire constellation of comorbidities.

CHRONIC PAIN MANAGEMENT: THE MULTIMODAL/MULTIDISCIPLINARY APPROACH

Pain is a complex puzzle. No single health care provider holds all of the pieces. From the broad menu of pain management modalities and specialists, clinicians are encouraged to design treatment packages that address medical condition, comorbidities, functional impairment, coping strategies, psychological issues, and cultural and spiritual beliefs.

For arthritis patients, analgesic treatment of pain might be combined with pool exercise programs, body work, cognitive behavioral therapy, topical anesthetics, and participation in a support group.

For patients with intractable arthritis pain, knee/hip replacement can be effective for select patients.

For patients with diabetes, nutritional counseling and an exercise program can be extremely beneficial.

For fibromyalgia patients, stress management programs, biofeedback and motion/strengthening exercises might be used to help control discomfort along with prescribed analgesics.

In addition to opioid analgesics for cancer pain, other pain management and coping strategies might include individual and group therapy sessions, relaxation and positive thinking techniques, and anti-depressants.

Again, each treatment program should be individualized to the patient, and look for the greatest payback in terms of pain relief and restored quality of life. Pain practitioners are encouraged to involve patients in the decision-making process and to provide them with the information and education to be their own advocate.

LEGAL ASPECTS OF PAIN MANAGEMENT

New attitudes, guidelines, laws and professional liability trends reflect a growing intolerance of ineffective pain management. Freedom from pain is viewed as a basic human right, and massive efforts have been launched in the medical industry to improve pain care quality. Nonetheless, current clinical research continues to tell a story of profound suffering.

The consequences of ineffective pain management play a pivotal role in professional liability actions. Unnecessary misery, emotional distress, poor response to curative medical or surgical treatment, greater complications – these are all reasons patients and/or their families bring legal action against health care providers. There are three possible causes of legal action:

• Medical malpractice
• Infliction of emotional distress
• Abandonment

Medical malpractice requires four elements:

1. Provider owed a duty of care to the patient
2. Provider violated that duty by failing to exercise reasonable care in providing treatment
3. Patient’s injury was proximately caused by the provider’s negligent conduct
4. Patient suffered a compensable injury

The provider’s duty to the patient is referred to as the standard of care, and is defined, in large part, by practice guidelines customarily exercised by similarly trained physicians under comparable conditions. In the case of pain treatment, the scope of the provider’s duty is being re-shaped by new practice guidelines. From a risk management standpoint, it is important to understand the duality of these guidelines. On one hand, they are a valuable resource for clinical decision making and patient management strategies. On the other hand, they establish a standard of care against which a physician’s actions can be measured. A plaintiff’s attorney could conceivably use this measuring stick to demonstrate sub-standard performance. Providers should be aware that the same is true of deviations from practice guidelines in place at the health care facility or in the managed care plan.

Another possible cause of legal action is infliction of emotional distress. Recent court decisions support patient charges of negligence based strictly on emotional distress damages. Avoidance of emotional distress due to pain is considered within the scope of a physician’s duty of care.

A third card in the professional liability hand is known as “abandonment.” When a doctor agrees to treat a patient, the doctor is obligated to provide the standard of care as long as the patient requires it and the doctor-patient relationship is in effect (Medical Board Rules/ Statutes). Termination requires formal written notice and continuation of care until the patient has had a reasonable opportunity, sometimes defined as 30 days, to obtain care. The claim of abandonment also requires four elements:

1. There is an established physician-patient relationship
2. The physician terminated or neglected that relationship
3. The termination occurred without sufficient notice for the patient to choose another physician
4. The patient suffered injury as a result

Consider this example:
An obstetrician promised a pregnant patient epidural analgesia during labor and delivery. At the time of L&D, the obstetrician was not on call, and his partner delivered the baby. Without transfer of information on the choice of anesthesia, the partner MD did not administer epidural analgesia. The court found that the patient was not given adequate notice to seek another obstetrician and suffered injury as result. The obstetrician was found guilty of abandonment.

Current liability trends clearly suggest that preconceived notions about the pain experience, lack
of pain management training, inadequate understanding of addiction, and/or fears of regulatory sanctions put health care providers at risk of legal action. All physicians who treat pain should become knowledgeable about effective methods of pain treatment as well as statutory requirements for prescribing controlled substances.

PRACTICE GUIDELINES

Many facilities and institutions have published guidelines for managing chronic pain. In 2004, The Wisconsin Medical Society published its “Guidelines for the Assessment and Management of Chronic Pain.²² These guidelines have been endorsed by the American Chronic Pain Organization. The section entitled “Initial Evaluation of the Patient with Chronic Pain (Assessment and Diagnosis)” has been included as Appendix C. The entire publication can be accessed on the Internet via the American Chronic Pain Organization Website, www.theacpa.org, or directly at the Wisconsin Medical Society, www.wisconsinmedicalsociety.org.

SUMMARY

The chronic pain conundrum—available treatment options juxtaposed with statistical and pervasive under treatment—can largely be explained by the multitude of complexities presented by chronic pain diseases and conditions. Comorbidities, psychological issues, unclear pain etiologies and cultural/language barriers are just a few of the obstacles pain practitioners face.

Perhaps the greater challenge resides in management of the caregiver-patient relationship. What model is created for open and on-going communication of pain? What’s working and what’s not? What’s being done to ensure that a patient feels comfortable expressing his or her pain? How does the physician interpret the patient’s pain? Are faulty paradigms creating false assumptions? Does the physician actively invite patient self-reports of pain? Does the patient feel believed? There is a myriad of “human” dynamics inherent in a caregiver-patient relationship, and careful attention to them will improve a clinician’s success rate in treating pain.

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