The Diagnosis and Treatment of Chronic Pain

In spite of yeoman efforts by the American Pain Society, the American Chronic Pain Association, the U.S. Pain Foundation, the American Academy of Pain Medicine, and many others, there has been no consistent recommendation for treating chronic pain. Compounding the problem, because clinicians are untrained in pain management, opioids have become the major approach by default. Opioids, however, are ineffective in chronic pain, often fraught with harmful and sometimes deadly side effects (1).

A poor man suffering from indigestion. Colored lithograph by C.J. Traviès.

Source: Wellcome Images via Wikimedia Commons/CC BY SA 2.0

Where does that leave America’s frustrated patients—and their equally frustrated clinicians?

I’ll address here an evidence-based approach developed with funding from the National Institute of Mental Health and from the Health Resources and Services Administration (2, 3).

But, first, let’s look at what’s required to diagnose chronic pain. Chronic pain is defined as lasting for at least 3-6 months. While many people have chronic pain, the most troubled patients are those who report that the pain interferes with their enjoyment of life and day to day functioning. Indeed, many are as disabled as patients, for example, with strokes, oxygen-dependent emphysema, or severe multiple sclerosis. We perform a full diagnostic evaluation with a careful history and physical (H & P) examination, which is regarded as the most important evaluation. For the common patients with chronic low back pain, the H & P may suffice. It’s been shown that extensive evaluation by MRI or CAT scans is counterproductive, often leading to unnecessary testing and surgery, the latter then creating complications and worsening of the pain. In many others with chronic pain, some basic laboratory and other testing often is necessary, the specifics depending on the location of the pain. For example, pelvic ultrasound is used to diagnose disabling chronic pelvic pain, or a colonoscopy is used for chronic abdominal pain.

That’s just the physical part of the diagnosis, however. We know that the more severe the pain, the more sites of pain, and the longer its duration, the more likely there is a co-occurring (comorbid) diagnosis of depression. For example, we found in a group of severely distressed patients that 94% had evidence of depression. It’s not surprising. Anyone with such disabling problems would likely be depressed. Depression is easily diagnosed by asking three questions: 1) Do you feel depressed? 2) Do you have trouble sleeping at night (takes more than 30 minutes to get to sleep or return to sleep)? 3) What do you do for fun? (“Nothing is fun anymore” is a frequent answer in depressed patients.)

Importantly, laboratory and x-ray investigations need to be done only once. When studies show no explanatory changes for the pain, a new diagnosis that would be treated in a different way rarely supervenes. Here’s what’s more important. Being reassured that no alternative diagnosis exists is the first step in treating chronic pain. Both patient and clinician must be confident that it’s time to move ahead to treatment.

Now to treatment (2). We have developed what we call the Mental Health Care Model (MHCM). It’s centerpiece is the patient-centered interaction because it establishes a strong clinician-patient relationship, the key to treatment. It has in fact been demonstrated that the relationship is as important to outcomes as the specific treatment itself (4).

Four treatment spokes radiate out from the MHCM center point: 1) Educating the patient; 2) obtaining a Commitment to treatment from the patient; 3) establishing Goals; and 4) Negotiating the specifics of treatment. These four components (ECGN is the mnemonic) complement the patient centered interaction and stem from the motivational literature. They are essential to establishing acceptance of often new approaches to treatment by the patient, such as reducing opioids. Let’s

Title: A woman suffering the pain of cholic; illustrated by demons

Source: Coloured etching after G. Cruikshank after Captain F. Marryat. Iconographic CollectionsCC-BY-4.0

look more closely at these key dimensions.

EDUCATION. We do not tell the patient what the problem is or what needs to be done without first determining their understanding (“What’s your understanding of what’s going on, what treatment do you think should be given?”). We next clarify any misunderstanding (“…No, the OxyCodone will not get rid of the pain with an increased dose.”). We then describe the treatment we believe is needed (“…We’ll want to start an antidepressant, which is a much better pain medication, and slowly reduce your OxyCodone over the next several months.”). To be certain we have not confused the patient, we often ask them to repeat their new understanding.

COMMITMENT. The next step is to get the patient’s verbal agreement to participate in the treatment program. It is essential they know and articulate that they will need to comply with the treatment plan, so that they become an active partner with the clinician in getting better.

GOALS. Patients often are so disabled, depressed, and discouraged that they have forgotten the potentially good things in their lives they’ve had to give up. Establishing goals (for example, see kids graduate; play with grandchildren; rejoin bridge group; play golf; go to church) helps to set a positive tone and facilitates involvement in the program by reminding them of what’s worth living for in a more healthy future.

You can see how using patient-centered skills repeatedly (to be empathic) during often tense periods of education, commitment, and goal setting facilitates patient adherence to treatment. That’s why it is such a crucial aspect of treatment. Without success to this point, the last element is far less likely to succeed.

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NEGOTIATE A SPECIFIC TREATMENT PLAN. 1) Medications, such as antidepressants, slowly reducing the narcotic dose, medication contract, drug screens, non-addicting medications to help sleep, ibuprofen, and acetaminophen. 2) Address physical inactivity: establishing a specific exercise program, physical therapy, osteopathic (not chiropractic) manipulative treatment is helpful but not widely available. 3) Increased social activity. 4) Sleep hygiene. 5) Relaxation or meditation techniques. 6) Involve significant other or other family members in treatment. 7) Identify community resources relevant to the patient, such as AA or a local gym. 8) Set specific follow-up visits at weekly or biweekly intervals initially, increasing the interval as patients improve.

Treatment has another requirement. All medications, physical/social activity, follow-up visits, and other aspects of treatment are scheduled rather than “as needed.” For example, patients do not take extra narcotics when having more pain than usual nor do they omit doses if having less pain. Similarly, one adheres to a specific, agreed upon exercise plan and does not skip it if they have too much pain or do extra if having little or no pain.

Our research demonstrated that this strategy is successful (3). Importantly, some patients cannot completely discontinue opioids. As long as they are adhering to other aspects of treatment, we believe that low doses can be continued after slowly tapering the dose into the safe range, generally no more than 3-4 tablets of most preparations. For those who cannot get down to safe doses, an addiction medicine or psychiatry consultation is advised. In patients who have successfully discontinued opioids, a medication like naltrexone can be helpful is preventing relapse.

To conclude, treatment can be effective. But it requires more than addressing opioids and other medication issues. These are integrated with the other principles of the MHCM to maximize treatment. Only when a good clinician-patient relationship exists in the context of motivational approaches will the now beleaguered chronic pain patient receive adequate care.