The complexities of pain management

The challenge of managing patients with chronic pain is daunting, with clinicians struggling to stay on top of changing guidelines, increased scrutiny and a myriad of sources of information. With the added burden of the opioid crisis in the news and legal and disciplinary considerations, clinicians tell us they sometimes feel overwhelmed and uncertain. Patients also face obstacles, coming with a history of trauma, unequal treatment and reduced function due to their pain. This complex landscape can make navigating pain management difficult for primary care physicians and specialists alike. We spoke to two physicians who practice pain management daily and who have some overarching advice. Dr. Dwight Moulin is a neurologist and chronic pain specialist in London, Ont., and a professor in the departments of clinical neurological sciences and oncology specializing in pain medicine at Western University. He shares the following guidelines. Validate pain “Patients do not feel that they are being taken seriously about their pain and disability. They may magnify their complaints because of comorbid anxiety and depression, but malingerers are uncommon. There’s almost always an underlying legitimate pain problem, and just telling patients that helps them cope.” Establish expectations “Patients come thinking that I’m going to eliminate their pain. I need to know that because if that’s their expectation, almost always, they’re going to be disappointed. Ask the patients what their expectations are, and then create realistic expectations. The realistic expectation is that with chronic pain, we almost never eliminate it. We’d just like to get it down a tolerable level and give them coping techniques so they can get on with their life.” Be specific “Try to make as specific a diagnosis as possible. The pharmacologic management of neuropathic pain is different from musculoskeletal pain. So if somebody’s got musculoskeletal pain, they’re probably not going to benefit from going on an anticonvulsant and anti-epileptic drug because these drugs target neuropathic pain. “First line for musculoskeletal pain would be an NSAID, for neuropathic pain or fibromyalgia it would be either an antidepressant or anticonvulsant. A small subpopulation of patients without a history of substance abuse might benefit from opioids. However, if somebody has a major component of anxiety and depression associated with their pain, a narcotic is not a good choice because they don’t work very well in people with comorbid anxiety and depression.” Apply the 4 Ps of treatment Pharmacological (drugs) Physical medicine approaches (physiotherapy, etc.) Procedures (local anesthetic, steroid injections) Psychological (mindfulness, meditation, breathing exercises, therapy) Dr. Moulin emphasized all of these can play a complementary role in a patient’s treatment for best results. Dr. Alan Kaplan is a family physician in Aurora, Ont., with a focus on pain management. He sees patients with pain daily and believes chronic pain is often undertreated. “There is an increased incidence of chronic pain with patients living to an older age and suffering from conditions like osteoarthritis, post-injury, postsurgical, post-chemotherapy,” he said. “(But) physicians are reluctant to give prescriptions for painkillers. Doctors are worried about the college and getting in trouble for seemingly over-prescribing so then they under-prescribe opioids. They also may then prescribe nonopioids that aren’t helpful.” “Patients come thinking that I’m going to eliminate their pain. I need to know that because if that’s their expectation, almost always, they’re going to be disappointed.” Expect complexity Dr. Kaplan said that treating pain is complicated and time-consuming because of the complexity of pain itself; because pain is personal and experienced differently by each patient; and because of concerns around opioid misuse—all of which adds up to a lot of tough decision-making on a regular basis. “You have to stop, you have to think about it, you have to document.” For the issue of possible addiction or misuse, he said: “There are many available tools, such as the Opioid Risk Tool, to help decide the likelihood of someone misusing their medications. The number of patients that end up as addicts from prescription medication is less than 5%. If you use the Opioid Risk Tool, prescribe small amounts and make sure you’re staying on top of that, then that number can be even lower.” Convey ‘hurt versus harm’ “I talk a lot to patients about hurt versus harm, helping them to understand that just because they are feeling pain, does not mean they are being harmed. It’s their warning system giving erroneous messages. I use the analogy of Muzak in an elevator. It makes some people crazy, others can tune it out. Another example, the smell of a skunk can be unpleasant, but it’s not harmful, and after you’ve been skunked, after a while you won’t notice it. It’s the cognitive side of pain management and it can really help. If a patient can afford or access cognitive therapy, it can be very helpful, too.” Rx for exercise “There are a lot of diminishing returns when it comes to physiotherapy and chiropractor, etc., for chronic pain. It’s more useful for acute pain, but passive therapies don’t work well for chronic pain. People need to exercise and it is virtually always effective for chronic pain, but often patients don’t want to do it.” Dr. Kaplan gives the example of patients strengthening quads or stomach muscles to take the strain off their back. Treat acute pain aggressively “If you don’t treat the acute pain well enough, you will have a problem. That pain is going to linger and become chronic. Pain is felt in the brain, so the more you travel those pain pathways, the more those pathways get set. It’s like walking in the snow. When the snow’s heavy, you have to trudge through the snow and make a path. But once that path is made, it’s easier to walk through it.” Dr. Moulin agreed. “Family doctors are in an important, unique position because they see patients much earlier than specialists. So they’re in a position to try and control the pain early on because the longer the pain is present, the harder it is to reverse.” Both doctors believe that an important part of treatment is also ensuring patients are active participants in their own care. “The passive model of medical care doesn’t work for chronic pain,” said Dr. Moulin. “That means lifestyle changes, like exercising, dietary changes. Activity is still important even if it causes mild to moderate pain. Most people can’t afford a psychologist, but they can still go online and practice mindfulness and meditation. And then there are many self-help groups that are very helpful for musculoskeletal pain, neuropathic pain and fibromyalgia. There are sites like Bounce Back in Ontario, which will provide patients with lots of online material so that people can be actively involved in their pain management.”

The complexities of pain management

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