On the Role of Primary Care Within a System of Integrative Multi-disciplinary Pain Management
The past two decades have borne great progress in understanding the complex pathophysiology of different types and manifestations of pain. As summarized by recent work in this journal, we have come to recognize nosologic distinctions between susceptibility to, and presentation of types of pain based upon genomic predisposition, and phenotypic-environmental interactions throughout the lifespan.2,3 As such, we may view certain types of pain as being part of a spectrum disorder that involves differential expression of severity, duration, tractability, and co-morbid neurological and/or psychiatric disorders. Significant to this understanding is knowledge of how neural systems selectively and differentially develop as a consequence of individuals’ experience(s)—essentially establishing each person as unique in cognitive pattern(s), behavior(s) and in response to disease and expression of illness.4 In this light, it can be seen that—through progressively pathological changes in the neural substrates of sensation, perception, cognition, emotion and behavior—pain can be expressed not merely a symptom or sign, but can become a manifest illness (maldynia) that reciprocally involves other physiological functions, both directly and indirectly.5
Thus, while research advances have led to a more complete understanding of pain, the failure to develop and maintain truly translational applications that are articulated within an economically supportive medical system have allowed for an increased prevalence of pain as illness.6 Our contemporary understanding of pain has demonstrated the pathological processes that occur from periphery to brain and, in so doing, acknowledged the reality of complex pain as a disorder capable of uniquely affecting biological, psychological, and social dimensions of each patient’s life. Yet, despite an increase in our knowledge of pain, we are faced with steadily decreasing resources to best treat this problem.
The complexity of maldynic pain cannot be addressed through simple, unifocal therapeutic interventions. To be sure, there has been much written explicating the need for multi-disciplinary approaches to treat the multiple systems affected by, and multiple dimensions of, chronic and maldynic pain.7 While such a conceptual depiction of the complexity of pain would seem to substantiate this multi-disciplinary approach, as a matter of fact, the majority of pain is addressed and managed in a primary care setting, despite the fact that defined limitations upon the scope of primary care practice cannot sustain the comprehensive treatment and care required by the complex pain patient. This does not reflect any distinct inaptitude of primary care as a specialty or practice, nor does it imply any incompetence on the part of the individual primary care physician. To the contrary, we believe that the market forces that have been imposed upon, and exist within the regnant medical culture have both disenabled primary care practice, and threatened the viability of truly integrative care of the patient with durable, intractable pain.
We maintain that these limitations illustrate 1) that the problem of maldynic pain requires a more expansive paradigm of care that enjoins and enables the primary care physician; 2) that the primary care physician, as the first and often most important step in a process of effective assessment and successful referral, must be empowered to act within a larger, multi-disciplinary network of pain practitioners, and 3) that policy must be established that recognizes the epidemiologic, social, and personal burden of pain, and which facilitates both a role for primary care and a larger context of pain medicine in which to function.
In this essay, we present what we feel are the most compelling complex issues arising from, and within, the effective management of durable, maldynic pain. We argue that these issues mandate a greater involvement of primary care in treating pain, not as a stand-alone approach, but as a sentinel toward affording proper, comprehensive care within an integrated system of multi-disciplinary pain therapeutics. We offer suggestions toward maximizing the effectiveness of such cooperativity, and address the need for healthcare policy to fortify this system.
The Problematic Nature of Practical Pain Management
We hold that three interactive “dimensions” create a problematic course for pain management practice, namely the clinical complexity of pain, economic factors, and the current medico-legal climate (See Table 1). At the most fundamental level are those clinical issues that arise as a consequence of the complexity of pain. Pain is not a unitary entity; it can be a symptom of a primary or co-morbidity (vide infra), and as such can be acute and/or chronic. Moreover, chronic pain may reflect an unresolved or exacerbating peripheral pathology, or may be caused by neuropathic changes within, and sensitization of the peripheral and/or central neuraxes.8 Differential diagnosis is not uniformly straightforward and prompt discernment of the type, nature and cause(s) of pain are important to successful therapeutic intervention and management. Indeed, we argue that this may well be the tipping point in determining whether the subsequent course of care is effective and beneficial. Frequently, it is the primary care physician who first encounters the pain patient poised upon the slippery slope leading to maldynic pain, and who is therefore confronted with making a diagnosis that will insure the execution of apt care (whether it be rendered by intervention within the primary care setting or afforded by sound referral). Such diagnoses are frequently complicated by psychiatric pre- and co-morbidities.9 Epidemiologically, the prevalence of certain types of psychiatric disorders and conditions is relatively high within populations of patients presenting with particular types of pain.10
While it is certainly possible that certain psychiatric presentations may be directly reactive to the presence and duration of pain, the coincident patterns of pain and psychiatric manifestations are such that a more intricate relationship is becoming apparent, and we are only beginning to reveal possible mechanisms that subserve such effects.11,12 In many ways, this speaks to the need to appreciate pain as embedded within a larger clinical constellation of somatic, cognitive-emotional and behavioral features including, but not limited to, pre-dispositions to, and expression of mood, anxiety, somatic and substance use disorders.13 Genotypic variations may result in pleiotropic effects that alter CNS structure and function to pre-dispose individuals to (sensitivities for, and types of) pain, neuropsychiatric disorders, as well as altering the kinetics and dynamics of particular pharmacological agents.14,15 Furthermore, as a disease process, particular types of pain can induce neural remodeling to down-regulate endogenous pain modulatory systems, thereby exacerbating both pain and apparent need for escalating doses of analgesic (and/or psychotropic) drugs.16,17 Frequently, such mechanisms drive behaviors that seem to be recidivistic and are often clinically problematic to manage.18