Can We Prevent Chronic Pain?
It is estimated that 120 million adults in the United States suffer from chronic pain. Chronic pain conditions have become the most prevalent chronic conditions and the primary driver of health care, costing more than diabetes, cancer, and heart disease.1-4
Chronic pain also is the most common cause of work loss and disability.5-11 On a societal level, the prevalence and financial burden of chronic pain is staggering, but the personal cost of chronic pain—loss of mobility, work, depression, addiction, and lower quality of life—is even more devastating.12-13
Why Not Prevent Chronic Pain?
While major efforts are underway to prevent heart disease and diabetes, preventing chronic pain remains an elusive goal.11-13 If initial efforts to improve pain fail, for example, care often escalates to higher-cost, higher-risk passive interventions such as polypharmacy, implantable devices, injections, physical therapies, and surgeries.1-3,14-19 Most people who have pain that lasts longer than one month still have persistent pain 5 years later, despite extensive treatments.16-17
Although genetic factors may predispose one to chronic pain,18 research suggests that risk factors such as repetitive strain, depression, poor sleep, stress, maladaptive postures, and ergonomic factors are among major factors leading to delayed recovery, failed treatment, and continued pain.18-24 Despite recognition that many of these factors can be improved with self-management strategies, they often are not addressed in routine care, leading to pain persisting for years.1-2, 24-26
Thus, chronic pain has become a major health care problem, in large part due to our lack of engaging, empowering, and educating patients to reduce risk factors and enhance protective factors to better manage and prevent chronic pain.25-38 It is clear from the prevalence and impact data in The Institute of Medicine’s 2011 monograph, Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research, that more effort is needed in preventing chronic pain.1
How to Prevent Chronic Pain
To address the chronic pain problem, a new approach is needed, with a focus on prevention and early interventions.28,29 A human systems approach provides a broader understanding of the role that lifestyle risk factors play in perpetuating chronic pain through recursive feedback cycles that increase peripheral and central sensitization.39-48 A transformative care model is the clinical application of a human system’s approach, integrating patient self-assessment and self-management training with evidence-based treatments.47-49 Self-management programs can train patients to reduce risk factors, enhance protective factors, and halt the cycle of chronic pain.1-3
This can best be implemented through an interdisciplinary integrative team approach that supports patients in implementing the life changes that are needed to achieve long-term prevention of chronic pain. Such an approach requires alterations of the conventional health care approach to pain management and can be challenging for even the most innovative health care professional.
For this reason, additional training is recommended. Health professionals can review the fundamentals of this new approach to care via a open on-line course on preventing chronic pain (www.coursera.org/course/chronicpain). The goals of the Campaign for Preventing Chronic Pain (www.preventingchronicpain.org) are 3-fold:
- Expanding research with the development of the Chronic Pain Research Network, as well as developing strategies and tools that health professionals can use to improve the prevention and early management of chronic pain conditions
- Expanding education of both patients and health professionals about how to prevent chronic pain and implement a transformative care model using Toolkits for Preventing Chronic Pain that include risk assessment, on-line training and health coaching.
- Advocacy to increase awareness and provide toolkits to health plans, businesses, government agencies, and communities to improve their efforts to prevent chronic pain.
Human Systems Model
The traditional biomedical model is based on a one dimensional, reductionistic, and inflexible scientific paradigm, based primarily on understanding the underlying pathophysiology (Table 1).
Health care professionals tend to see what they treat and treat what they see. If they see only the pathophysiology, they miss the complex set of risk and protective factors, which if not addressed, may lead to treatment failure. For example, systematic reviews of biomedical treatments for chronic pain have found that even with the most efficacious treatments, improvement is only slightly above placebo.1,36,37
In contrast, a human system’s approach assumes that humans are complex, multidimensional, dynamic, and live within an ever-changing social and physical environment.41-46 A person’s physical characteristics, lifestyle, emotions, relationships, environment, as well as spirituality, thoughts, and mindfulness determine whether they are at increased or decreased risk for developing chronic pain following an initiating event (Figure 1).
The concepts of cybernetics, chaos theory, and positive psychology can help explain the relationships and self-perpetuating nature of these factors and how they contribute to chronic pain (Table 2).
Preventing chronic pain includes preventing the progression of acute pain to chronic pain, and the progression from chronic to intractable, as illustrated in Figure 2. Pain conditions begin with initiating factors, such as acute physical injury of the muscles and joints. In most cases, the pain condition is transient and resolves without complication or persistence. However, if sufficient numbers of risk factors are present, even if small, it can shift the balance from healing to delayed recovery and chronic pain (Figure 3). The presence of protective factors and early intervention in the cycle will have the greatest impact in normal healing and resolving the condition.
Several new strategies are needed in our care model to improve outcomes of chronic pain, including: