How do you get started with patients with chronic pain?

Dr. Link is a 35-year-old primary care physician, who recently joined an academic faculty practice in a new city. Today, she is seeing Martha, a 70-year-old woman, who has been cared for by this clinic for >10 years. She has chronic pain in her back from osteoarthritis, diabetes (A1c 7.5), obesity, depression, hypertension, and sleep apnea. Her prior PCP prescribed oxycodone for back pain flares and gabapentin for occasional shooting pain down her right leg. She also takes metformin and lisinopril; her CPAP stopped working 2 years ago.

Dr. Link runs through her typical new patient introduction, “I want to get to know you and your medical history today…I read the notes by your previous doctor…Is there anything pressing that you want to make sure we cover as well?” Martha notes her back pain is worse today. Dr. Link and Martha move through the appointment, cover quite a bit of ground, and begin to build their therapeutic alliance. Yet, Dr. Link notes to herself on her way into the next patient’s room, “I skirted past her pain today. There was just too much to cover…”

How do you get started with patients with chronic pain?

A study evaluating the implementation of a chronic pain screening program in primary care shared, “A PCP noted that ‘[our] tepid response [to the new process] may be due to pain fatigue — we don’t know what else we can do to treat patients’ pain’” (Bifulco, 2021); this “pain fatigue” may be contributing to Dr. Link’s hesitation as well. However, reconsidering Martha’s history and reminding oneself of the numerous tools available to treat chronic pain might offer a path forward. 

Qualitative interviews demonstrate that patients with chronic pain hope for empathic encounters with their clinicians, during which they are listened to carefully and asked about what is important to them and their recovery (Evers, 2017). Patients sought validation for their pain experience, clear and specific diagnosesaction to address immediate pain, and information on how to avoid worsening their condition and what to do if it did worsen (Evers, 2017). 

Using the ACT-UP framework, Dr. Link can ask Martha about her pain and its effect on her life (Fidler, 2022). The ACT-UP framework provides Dr. Link the opportunity to affirm the hard work Martha has already been doing to cope with and control her pain. 

ACT-UP stands for:

Activities: How is your pain affecting your life (sleep, appetite, physical activities, relationships)?

Coping: How do you deal/cope with your pain? What are times when your pain is better/worse? 

Think: Do you think your pain will ever get better?

Upset: Have you been feeling worried or depressed?  

People: How do people respond when you have pain?

Treatment for chronic pain includes psychological approaches and physical modalities (described in more detail below), medications, invasive interventions, and self-management skills, and often requires a multi-disciplinary and multi-specialty team. Even with limited access, Dr. Link can get started in addressing Martha’s concerns.

Dr. Link can engage Martha in a discussion about her past pain experiences and social support. Additionally, Dr. Link can explore parts of Martha’s history that may be contributing to her pain, like depression and sleep apnea. After discussing the vicious cycle between pain, poor sleep, and depression, Dr. Link and Martha can explore treatments for depression like antidepressants and/or psychotherapy, or work with the sleep medicine team to navigate the insurance paperwork for a new CPAP machine. To characterize the pain today, Dr. Link can use the PEG 3-item scale (Krebs, 2008), which includes measurements of pain level, pain interference, and general activity. The PEG was derived from the Brief Pain Inventory (BPI) to be very brief and sensitive to primary care (Krebs, 2008); the PEG scale gives Dr. Link a great tool to assess treatment effectiveness over time.

Patients also expected a thorough assessment of their pain, including a physical exam and imaging, and they appreciated specialty referrals once the physician reached the limits of their knowledge (Evers, 2017). Clinicians and patients differ in their priorities for pain discussions; while patients ranked reducing pain intensity and diagnosing the cause of their pain as top priorities, clinicians ranked improving function and reducing pain medication side effects as their top priorities (Henry, 2017). 

Dr. Link can feel confident in offering non-opioid treatments that are effective for chronic pain. A 2020 Cochrane Review on all types of physical activity for chronic pain demonstrated favorable results for reducing pain severity and improving psychological function, and statistically significant improvement in physical function (Geneen, 2020). Similarly, a 2022 Cochrane Review on yoga for chronic pain found that yoga resulted in improvements in back function and pain (Wieland, 2022). 

Cognitive Behavioral Therapy (CBT) and Mindfulness-Based Stress Reduction (MBSR) can also improve chronic pain. CBT for chronic pain aims to teach self-management tools to develop effective reactions to pain and improve one’s quality of life (Baker, 2016). A 2020 Cochrane Review found a small beneficial effect of CBT on pain and disability outcomes at the end of treatment compared with active care or treatment as usual (Williams 2020). A 2022 randomized controlled trial found that MBSR reduced pain intensity and pain interference, and improved physical functioning (Burns, 2022). MBSR provides training for participants in mindfulness through body-scan meditation, sitting meditation, and mindful movement.

Specifically for Martha, Dr. Link can help in the search for a therapist who is trained in CBT for chronic pain. CBT for chronic pain includes activity planning, cognitive restructuring, and relaxation training (Maikovich-Fong, 2019). While looking for a therapist who has this specific training, Dr. Link may be able to introduce parts of activity planning and relaxation training in their appointments. For activity planning, Dr. Link can encourage Martha to set a specific activity goal, either for an actual physical activity (walking, yoga, etc.) or a social activity. The activity can be modified, scaled down or paced, but Martha should commit to a time and group of people to do it with. Cognitive restructuring lies within the central tenant of CBT – thoughts play a role in pain. Pain catastrophizing (“I will always be in pain”) is an example of a maladaptive pain cognition. Those trained in CBT for chronic pain use cognitive restructuring to identify the maladaptive thought and reshape it; they may ask the questions, “What evidence do you have to support this particular thought?” and “How does the thought itself impact the frequency and intensity of your pain?” Finally, Dr. Link can share relaxation techniques such as abdominal breathing or progressive muscle relaxation that Martha can use when she is at home (Baker, 2016). There are many easy to access, free handouts on both of these relaxation exercises online. 

One activity of MBSR that Dr. Link can walk through with Martha is the body scan. It takes about 20 minutes and involves patients bringing their attention to a sequence of specific body parts, noticing the sensations in that body part and observing them without judgment. For the motivated patient, there are guided body scan meditations available online.

Key Points

  1. Patients with chronic pain hope for encounters with empathic clinicians who ask about the chronic pain’s current character and effect on the patient’s life, perform a physical exam, provide a diagnosis, and offer specific treatment recommendations. 
  2. Clinicians should address comorbid conditions such as mood and sleep disorders, as treating these can have a substantial impact on chronic pain. 
  3. Clinicians can feel confident offering non-pharmacologic based treatment for chronic pain, including physical activity, cognitive behavioral therapy for chronic pain, and mindfulness-based stress reduction.

References:

Baker N. Using Cognitive Behavior Therapy and Mindfulness Techniques in the Management of Chronic Pain in Primary Care. Primary Care: Clinics in Office Practice. 2016;43(2):203-216. doi:10.1016/j.pop.2016.01.001

Bifulco L, Anderson DR, Blankson ML, et al. Evaluation of a Chronic Pain Screening Program Implemented in Primary Care. JAMA Netw Open. 2021;4(7):e2118495. doi:10.1001/jamanetworkopen.2021.18495

Burns JW, Jensen MP, Thorn B, et al. Cognitive therapy, mindfulness-based stress reduction, and behavior therapy for the treatment of chronic pain: randomized controlled trial. Pain. 2022;163(2):376-389. doi:10.1097/j.pain.0000000000002357

Evers S, Hsu C, Sherman KJ, et al. Patient Perspectives on Communication with Primary Care Physicians about Chronic Low Back Pain. TPJ. 2017;21(4):16-177. doi:10.7812/TPP/16-177

Fidler SK. Comprehensive Evaluation for Chronic Pain. Primary Care: Clinics in Office Practice. 2022;49(3):375-385. doi:10.1016/j.pop.2022.02.001

Geneen LJ, Moore RA, Clarke C, Martin D, Colvin LA, Smith BH. Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane Pain, Palliative and Supportive Care Group, ed. Cochrane Database of Systematic Reviews. 2017;2020(2). doi:10.1002/14651858.CD011279.pub3

Henry SG, Bell RA, Fenton JJ, Kravitz RL. Goals of Chronic Pain Management: Do Patients and Primary Care Physicians Agree and Does it Matter? The Clinical Journal of Pain. 2017;33(11):955-961. doi:10.1097/AJP.0000000000000488

Krebs EE, Lorenz KA, Bair MJ, et al. Development and Initial Validation of the PEG, a Three-item Scale Assessing Pain Intensity and Interference. J GEN INTERN MED. 2009;24(6):733-738. doi:10.1007/s11606-009-0981-1

Maikovich-Fong, Andrea Kohn. Handbook of Psychosocial Interventions for Chronic Pain: An Evidence-Based Guide (Clinical Topics in Psychology and Psychiatry. 1st ed. Routledge; 2019.

Wieland LS, Skoetz N, Pilkington K, Harbin S, Vempati R, Berman BM. Yoga for chronic non-specific low back pain. Cochrane Back and Neck Group, ed. Cochrane Database of Systematic Reviews. 2022;2022(11). doi:10.1002/14651858.CD010671.pub3

Williams ACDC, Fisher E, Hearn L, Eccleston C. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Pain, Palliative and Supportive Care Group, ed. Cochrane Database of Systematic Reviews. 2020;2021(11). doi:10.1002/14651858.CD007407.pub4