Noon conference this week was about safe opiate prescribing. I hope that some of you were there and enjoyed it. As I was making the talk, I felt that I also wanted to learn/teach more about chronic pain and how to treat it.
Most of this information comes from a great TMS (no really) course on Complex Chronic Pain. If you are interested in the topic, I recommend the course. TMS is here, and you can find the course by searching for V07 Complex Chronic Pain Course. Of course you have to be a VA employee to access TMS.
Do you have patients in your clinic that carry a diagnosis of “Chronic Pain.” Not chronic back pain, or osteoarthritis, or fibromyalgia, but just “chronic pain.” It has been a pet peeve of mine, to label the pain but not the etiology, but turns out that it is a real thing, and our traditional biomedical model just doesn’t do a great job at addressing the issue. We start out with the right things: history and physical, careful testing, conservative treatment. When that doesn’t work, we might refer to a specialist, or PT, or send the patient for injections. Slowly we tread into unproven, non-evidence based therapies, which often don’t work either. Or, the patient feels a little better; often because they felt that they were heard and they believe in the treatment plan, not because the therapy worked. We keep doing the same things and expecting a different result. the patient feels that their life is on hold while their doctor gets their pain under control. Eventually, the patient gets frustrated with us, we get frustrated with the patient, and the relationship becomes strained. Often, the patient finds a new doctor and the cycle starts over again. We are all frustrated and unsatisfied, and we resolve not to do that again. But we do, because the tools we have are insufficient for the problem
A new way to think about this is from a biopsychosocial model. The root cause of the pain is as much psychosocial and emotional as it is biological, and emotional and social stressors make it worse, just as lifting a refrigerator would. In this model, the doctor has to give up some control, it is really up to the patient to get better. We become the coach, the therapist, rather than the omniscient expert with the prescription pad. The goal shifts from relieving pain to restoring function and improving health. Patients move away from a focus on ending pain and minimizing symptoms to “expecting pain” and living their life in spite of that. The office visit is less about pain control and more about setting and achieving functional goals. Your job is to teach patients that you hear their frustration and believe that they have pain, but there isn’t a medical solution to this problem, and the two of you are going to work together to help them move on with their life.
Chronic pain is aggravated by a variety of things. If you can identify these in your patient, you may be able to help them move forward in recovery. The first is deconditioning: think like an athlete in spring training, they don’t expect to come in at mid-season form. Second is poor coping skills and ineffective stress managment techniques. We should teach that pain is not necessarily leading to more damage, but represents a bump in the road that they will move past. Pain is inevitable, but misery is optional. Finally, outright mood disorders can aggravate pain. It is reasonable to aggresively seek out and treat these, but in such a way so that the patient doesn’t come away feeling that you don’t believe their pain.
How to help the patient set goals. These need to come from the patient, not you. Ask about what they want to do, but can’t now. Listen carefully and pick up on anything that the patient identifies, then try and troubleshoot the barriers. If they want to exercise, but always have increasing pain, then try and reduce the intensity back to a level that they can acheive. Set goals that seem too easy, too simple, so that you can build on successes- first you have to have successes. If the patient is not even getting dressed every day, make that a first step. Later they can work toward the gym membership, but if you try and do it all at once, they will end up hurting and less likely to try again.
If you have access, pain psychology or mental health providers can help with cognitive behavioral therapy around coping mechanisms, goal setting, and stress managment techniques. You can also teach your patient some simple stress managment. Deep breathing and meditation is a simple concept to understand and provides a coping strategy for the patient to deal with pain. There is an app “Breathe 2 Relax” that teaches deep breathing and website calm.com that does guided imagery relaxation.
The trick for all of this is getting patients to buy in. They are doing all of the work and the motivation has to come from within. So long as you really listen to their pain story, and have done an adequate evaluation, you don’t necessarily change the treatment plan because of resistance. However, don’t become confrontational, don’t fight. Pushing hard for patient self managment strategies will often backfire. Use your best Motivational Interviewing jujitsu to roll with resistance and put the onus to change back onthe patient. They can certainly stay the same, but you might point out that isn’t getting them anywhere.