Case Scenario

A new patient of mine has presented to my office several times with low back pain. I eventually realized that the pain she describes as heart-wrenchingly acute is actually chronic pain. She wants me to do something to immediately relieve her pain every time she visits. She says she has tried many of the usual things—physical therapy, muscle relaxants, and exercises—all to no avail. I am feeling frustrated that, rather than developing a treatment plan, the duration of our visits is usually consumed with debates about how much pain medication she should be receiving.

Commentary

Nonmalignant chronic pain is a common, yet challenging, health problem.¹ Numerous factors over the past decade have put primary care physicians in a central role in the management of this pain. Challenges include a lack of curative therapy and precise measures to gauge patient improvement; complex comorbidities that exacerbate a patient's sense of helplessness; ² and, as illustrated in the case scenario above, the severe distress with which these patients often present to the physician's office. Managing these challenges demands adequate time and patience to develop a comprehensive, goal-oriented, and participatory plan of care. Remembering a few overarching principles and sharing these principles with the patient can facilitate this process (see accompanying table).

Nonmalignant chronic pain, which is often defined as pain persisting for a minimum of three months, is not simply a prolonged version of acute pain. It is best thought of as a poorly understood disease state with little correlation among pain descriptions, findings on physical examination, and results of diagnostic testing.³ Current understanding suggests that the physiologic underpinnings of chronic pain are related to a disruption in the balance of the nociceptive system and consequent neural remodeling.⁴ Chronic pain is fundamentally different from acute pain and the pain of malignancy in several critical ways; these differences form the foundational principles for its treatment plan.

Nonmalignant chronic pain is never an emergency because its treatment horizon is much longer than for acute pain. Therefore, the physician and patient should take sufficient time to develop a working relationship and negotiate a comprehensive treatment plan over a series of visits. In contrast with cancer pain, nonmalignant chronic pain is a stable or slowly advancing process, so there is no need for rapid adjustments in treatment strategy and little to no role for breakthrough medications.

Although it is not an emergency, this does not mean that pain is not the most important issue. The physician should regularly validate the patient's pain and commit to helping generate a management plan. Affirming the patient's experience of the symptoms and explicitly committing to helping the patient focuses on physician-patient relationship building. There is a substantial amount of literature highlighting the impact of patient–physician rapport on satisfaction with treatment.⁵ After listening to the patient's description of the pain without interruptions, it is advisable for physicians to sincerely respond with something like: “Thank you for coming in today. I am sorry that you are in pain. I want to help you and I'll do what I can. We will need to work together to develop a comprehensive long-term plan over the next few months.” Sometimes it is helpful to add, “I wish I could take your pain entirely away today, but I can't.”

Next, the physician and patient should work together to identify treatment goals that focus foremost on improved functional status, rather than comfort. Although decreased pain intensity is one metric of improvement, it should not be the principal method of measuring progress; a goal of significant reduction or complete resolution of pain is generally unrealistic. Because the duration of pain in patients with nonmalignant chronic pain often exceeds 10 years,² most patients are realistic when it comes to their expectations about the magnitude of pain relief. It is always worth reinforcing that a goal of complete resolution of pain is unrealistic.

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. The principal goal of treatment is an improvement in quality of life by improving a patient's functional status while decreasing pain intensity. One suggestion is to ask the patient, “What were you hoping to get done today that your pain prevents you from doing?” The principal metric of treatment success then becomes the ability of the patient to accomplish this daily activity. Specific improvements in functional status can be as mundane as taking the dog on a daily walk, doing the laundry, or going to the park with grandchildren.

Long-range treatment goals for patients 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 share these goals with patients and ask the patient to list one objective within each area that he or she hopes to meet within a specific time frame. These goals for improvement can be grounded to patients' expectations by saying something like, “Chronic pain often interferes with your ability to remain physically active, sustain interpersonal relationships, and be involved in the community. From this list of possible long-range treatment goals, select a few areas that you think are important to improve, and describe what that improvement might look like.” At this point, it is worth reinforcing that chronic pain is not an easy problem to treat. Rather, like other chronic diseases such as diabetes, it requires a comprehensive, long-term approach that involves lifestyle modification, emphasis on coping skills, pharmacologic and nonpharmacologic modalities, and, in complex cases, the use of specialists in the management of chronic pain.

Finally, physicians should advise patients that optimal management requires participation in all facets of the treatment plan, and that failure to participate can be considered grounds for limiting other therapy. For example, a physician might expect a patient who is depressed and a candidate for opioid therapy to be agreeable to engaging in regular physical activity and taking antidepressant medications prior to initiating opioid treatment. The physician might say to the patient, “Experience shows that patients with chronic pain do best when we address the pain from several angles, including its impact on quality of life. This means we can't just rely on one strategy to treat it, such as a single type of medication.”

Notably, most patients with chronic pain have already tried a host of therapies; therefore, it is valuable to review previous treatments and the clinical response. After gathering this additional history, the physician can negotiate a treatment plan that may include elements of previous plans combined with untried therapies.⁶ The plan should always include increased physical activity and address possible psychological comorbidities.

Ultimately, the development of a standard, process-oriented approach to managing chronic nonmalignant pain in the primary care setting offers the best opportunity for improved care and satisfaction for patients and physicians. In addition, validating the patient's experience while asking for patience, participation, and regular follow-ups that are oriented to improvements in functional status can help to diffuse some of the distress that these patients commonly experience.