Pain Management Pitfalls
Much has been written about the controversy surrounding prescription of appropriate pain medications, the issues involved in prescribing, and effective risk-management prescribing procedures that help physicians implement an effective approach in working with chronic pain patients. However, little has been said about how this approach can complicate the provider-patient relationship to a degree that everyone involved in the process, including the patient, feel frustrated and misunderstood. There is, however, clear research in psychology that can help in the difficult and complex situations of professional interactions with pain patients. These studies have implications for physicians, psychologists, psychiatrists, clinical social workers, physical and occupational therapists, and other providers of care who offer treatment or independent evaluations for chronic pain patients.
Impediments to Patient-Doctor Interactions
The management of chronic pain patients has been the subject of much debate over the years. The public has been concerned about inadequate pain medication prescribing for those suffering from chronic pain conditions or those who have terminal conditions and are struggling with adequate pain control during their last days. Medical licensing boards, physicians, and the Federal Drug Enforcement Administration (DEA) are concerned about inappropriate or over-prescribing, addictions to opioids, and drug diversion. This has resulted in physicians losing their license to prescribe, some physicians being jailed for prescribing opioid pain medication,1 and many physicians who are, as a result, extremely reluctant to prescribe any type of pain medication beyond the use of NSAIDs. Tensions and concerns are high among the DEA, physicians, and licensing boards. Patients respond to these tensions in negative ways by withholding information, trying to manipulate patient-physician interactions, or by being tense and angry in interactions with providers.
The American Pain Society, the International Society for the Study of Pain, and the American Academy of Pain Management, have all worked hard to change the environment and to present realistic approaches to prescribing for chronic pain patients. Pain medication prescribing is now seen as a basic patient right, but many physicians are still concerned about what this means for them as professionals and their practice. There are those who continue to have lingering suspicions that patients who are seeking pain medications are ‘drug seekers’ who only want to obtain legal prescriptions to satisfy their drug habits. To combat this, specific guidelines have been established to assist the prescribing professional working with chronic pain patients. These guidelines include a pain contract, specific documentation, follow-up, and monitoring for diversion or overuse of medications.2
Complication of Managed Care
The managed care model in which the physician is the ‘gatekeeper’ of medical care has further complicated the relationship between doctors and pain patients since this model is based on limiting services, watching for ‘over-utilizers,’ and keeping the costs of care down as much as possible. As a result, physicians involved in treating chronic pain patients now feel that they must be constantly on guard for patients who will misuse services in some manner — even though only a small percentage of patients fall into this category. Even psychologists are being recruited by Independent Medical Examiner (IME) panels to detect deception and malingering rather than focusing on assisting patients in finding the most appropriate focus for care. Patients often report that they feel ‘talked down to’ and have assumptions being made about them without an attempt to understand them as individuals. These pain patients feel that medical appointments are more like interrogation sessions where they are under investigation and are dictated to about how to live and function, rather than being ‘listened too.’
This charged environment, especially in the pain patient’s case, often transforms the character of health care relationship from a relaxed atmosphere where one can feel safe in expressing fears and struggles, into a one-way dictation. Humor has often gone out of these interactions and the ‘curative factors in the professional relationship’ — central to psychological care and improvement — have been lost. This has fostered a professional relationship filled with misunderstanding, distance in relationship, and has left some physicians and patients, alike, feeling like criminals.
Social Situational Blocks
Psychological researchers have identified blocks to effective provider-client (i.e. doctor-patient) relationships and shed light on the struggles pain physicians face in providing services. Though many positive changes have happened in the field of pain management, including the importance of a multi-disciplinary approach to care, there are still blocks that often complicate the health care relationship.2-7 Psychological research has repeatedly demonstrated that people tend to underestimate how the influence of social situations can dramatically impact their behaviors. Studies — conducted in the 1960’s and 1970’s — tested the social functioning of roles in situations with outside controlling authority and great power differential, respectively. The insight from these studies is directly applicable to pain management physicians in that similar social forces are at work, namely DEA, licensing boards, and the legal system, on the one hand; and the great power differential existing between doctor and patient, on the other.
What both studies have demonstrated is that powerful situations can cause anyone to perpetuate cruel acts — all the while justifying their behaviors and viewing the clients as ‘the enemy’ and therefore deserving of punishment. It particularly becomes a problem when the situation is focused on specific ‘situational myths’ that identify the clients in a negative manner. This can be aggravated when one is functioning in an environment of mistrust, frustration, stress, suspicion, anxiety, fear, or concern about complying with authority. Following are brief synopses of each situational study.
Impact of Outside Authority
A series of studies by Stanley Milgram, PhD, at Yale University in the 1960’s showed the impact that outside authority can have on human behavior, in particular where it relates to a relationship of power over others. This series involved 1,000 individuals participatinge in role playing as either a “teacher” or “learner.” The teachers were to administer increasing electric shocks to learners (actually hired actors) for any mistakes. The teachers could hear the screams of the learners (actors) in a separate room. Dr. Milgram wanted to see if the teachers would continue to administer increasingly lethal shocks to learners when told to do so by an authority figure in a ‘white coat.’ The result was that two thirds of the teachers continued to administer shocks with increasing voltage levels — up to 480 volts — despite screams and then total silence from the other room. In all, 100 percent of the teachers — although to varying degree — were obedient to the authority figures in administering shocks to the hapless learners.8-19