Persistent Spine-centered Chronic Pain Scenarios and Treatment Options
Treating chronic pain is a clinical challenge for most physicians, primarily because it is often perceived as “subjective” experience. Patients often fail to report pain to physicians and, when they do, factors such as sex, age, socioeconomic factors, and fear of addiction often influence what they tell their doctors. Physician-related barriers to pain relief include lack of knowledge about treatment options, negative attitudes toward prescribing certain analgesics — especially opioids — and inadequate pain-assessment skills. Dr. Russell Portenoy, Chairman of Department of Pain Medicine and Palliative Care at Beth Israel Medical Center in New York City states, “Most physicians do not realize how often their patients fail to report pain to them and how often their patients fail to comply with prescription orders.”1 To adequately treat their patients, especially those with chronic pain problems such as cancer, it is critical that primary care physicians become knowledgeable about pain management options available to them.1-5,51
It is clear that physicians must address the needs of patients in pain — especially those who have chronic pain conditions — because lack of adequate treatment options exacerbate medical complications. Unremitting pain is not only associated with a wide variety of systemic complications, but also promotes anxiety, depression, loss of independence, and interference with work and relationships. Chronic pain dramatically affects the quality of life, including the physical, psychological, spiritual, and social components of a normal existence. Any patient who has chronic pain must receive a comprehensive initial assessment, which includes a detailed history, pertinent physical examination, appropriate diagnostic evaluations, and an appropriate neuropsychological assessment. Patients need to be supported and encouraged to maintain and improve their mobility and daily functioning. They need to be fully engaged in an active, productive life with normal interpersonal and social interactions. But the responsibility of physicians to support their patients is made more difficult because many patients do not want to talk about pain. Patients may associate chronic pain with worsening disease, and often express the belief that pain is inevitable and they do not expect medication to relieve it. Studies show that reluctance also stems from the desire to be a non-complaining patient, fear of distracting the physician, and fatalism regarding pain, especially in the context of an illness such as cancer or chronic pain. In contrast, acute nociceptive pain typically has an identifiable cause and may often be relieved by removing the inciting cause. Examples include post-surgical pain, sports-related injuries, or soft tissue trauma. Physicians often manage such acute/subacute pain with analgesic prescription & non-prescription medications, rehabilitation techniques, and other pain-relieving adjunctive modalities.1-5,51
Chronic Pain Challenges
Treating chronic pain — specifically non-malignant pain — is a much more complex endeavor than that for acute pain. Chronic pain has fewer identifiable causes and the focus of treatment is often to preserve functionality and well-being. Examples of these conditions include malignant pain, myofascial/musculoskeletal pain, chronic infections, osteoarthritis/ rheumatoid arthritis, cervical/lower back pain, chronic headaches or migraines. Chronic pain affects millions of people. In a survey in 1999 by the American Pain Society (APS), researchers stated that 9% of the U.S. adult population suffers from moderate to severe non-cancer-related chronic pain, with 56% having suffered for more than 5 years.1 The annual cost of chronic pain (including medical expenses, lost income, and lost productivity) is estimated to be $100 billion (APS data).1 This problem is endemic among elderly and chronically ill patients. The Federal Agency for Healthcare Quality and Research in Rockville, Md., estimates that 45-80% of nursing home residents suffer from chronic pain. The American Cancer Society states that as many as 75% of patients with advanced cancer suffer chronic pain.1 Many patients report inadequate treatment for their pain complaints. In the 1999 APS study of 805 chronic pain patients, researchers found that more than 50% of respondents changed physicians since some doctors were unwilling to treat pain aggressively, failed to take the issue seriously, or had a lack of knowledge about pain management.1-5,51
A number of factors are involved in preventing adequate pain relief. Fear of regulatory scrutiny for prescribing controlled substances discourages physicians from prescribing opioids of sufficient strength for a patient’s pain, especially for chronic nonmalignant pain. Such fears can result in the selection of less effective analgesics and ultimately under-treatment of the patient’s pain. Health plans also present barriers to effective pain relief. Reimbursement policies are a significant factor, especially for older patients whose insurance benefits (i.e., Medicare/Medicaid) do not cover the costs of outpatient prescription drugs. Such patients are required to contribute more for copayments and also have limits on the number of prescriptions they are reimbursed for each month.
Some physicians are aware that they are under-treating chronic pain in their patient population. In a 1998 survey by the Eastern Cooperative Oncology Group (clinical researchers in Philadelphia), approximately 76% of 897 physicians surveyed admitted to a lower competence in patient assessment as a major barrier to effective pain management, with 61% stating their reluctance to prescribe opioids.1 More recently, researchers at Albert Einstein Medical Center found that more than 1/3 (38%) of physician residents-in-training discussed pain management when discharging their patients who had pain and 42% overestimated the threat of opioid addiction.1 The study concluded that educational and behavioral modification interventions are necessary to improve documentation of pain status on hospital admission, increase use of standardized pain scales, and address pain management issues upon hospital discharge.
Chronic Pain Protocols
Communication and documentation are crucial variables for both patient and physician alike. Outcomes should be documented at each clinic session, including pain relief, adverse medication or procedure events, functional status, and drug related behaviors. Patients with chronic pain conditions who have analgesics prescribed should be monitored frequently after initiating treatment. Analgesic efficacy of opioid therapy and the effects of side effects and patient functioning should be assessed periodically to monitor the patient’s activities of daily living. Often, monthly check-ups are necessary for a patient on a newer medication regimen. Then, when a treatment regimen has been established, these follow-up visits may be extended to 2-6 month intervals. At all times, the patient should be encouraged to report progress and any adverse side effects on the medication and treatment regimen.