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Assessment and Treatment of Chronic Pain

A physician’s guide to a biopsychosocial approach.
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Pain is arguably the most common condition seen in primary care, and the most costly one as well. Although estimates vary, the National Center for Health Statistics concludes that fully 80% of all physician visits involve some complaint of pain.1 Another study found that 38% of patients presenting in primary care were reporting chronic pain, but the prevalence of acute pain was not assessed.2

A research study at a large HMO studied the costs of chronic pain and other common chronic conditions. Using the data from this study, the estimated cost of each chronic condition was calculated by multiplying the average cost per patient for each condition by the prevalence of the condition. A chronic pain category was formed by combining patients with complaints of back pain, neck pain, headaches or facial pain. Using this approach, the cost of treating chronic pain exceeded the costs of all other chronic conditions that were assessed, including heart disease, respiratory disease, or cancer (see Table 1). The costs of chronic pain to society is also large, as chronic pain has been identified in some studies as the leading cause of disability in working age individuals.4 However, unlike most medical diagnoses which can be diagnosed by objective medical findings, pain is a subjective experience.5

Despite the high costs noted in Table 1, pain can usually be treated easily and inexpensively. The problem is that the small percentage of patients who go on to develop chronic pain are extraordinarily expensive to treat. One study found that 10% of back pain cases with chronic pain accounted for around 79% of the costs,6 which would make this group of chronic patients 34 times more expensive to treat than the other patients. Similarly, another study found that 5% of chronic back pain cases accounted for about 85% of all medical costs for this condition,7 making this group of chronic patients 57 times more expensive to treat. One of the reasons that chronic pain is so expensive is that it is a classic example of a biopsychosocial disorder.8,9 Due to the complex nature of chronic pain, medical treatment alone may not be effective, and multidisciplinary treatment may be needed.10 The purpose of this article is to focus on the psychological and social dimensions of chronic pain and to offer suggestions as to how these two dimensions can be combined with the medical dimension to improve care.

Most Expensive Treatment Costs In Primary Care
Rank Diagnosis Cost in $ millions
1 Pain $198.0
2 Heart disease $170.1
3 Hypertension $112.3
4 Respiratory disease $90.2
5 Diabetes $85.6
6 GI disease $67.5
7 Arthritis $64.4
8 Cancer $55.0
9 Depression $44.8
10 Pregnancy $42.2
Table 1. Most Expensive Treatment Costs In Primary Care. Adapted from Fishman, et al 19973

Phases of Pain Treatment

The treatment of pain generally proceeds through several distinct phases. Following the onset of a painful condition, the treatment of acute painful conditions is driven by medical factors. Although the entry point for evaluation and treatment of pain conditions may be the emergency room or urgent care physician, it is typically the primary care physician (PCP) who manages the acute phase of treatment. The PCP generally begins with conservative care and, in most cases, patients recover as expected.

In the initial phase of treatment, normal medical treatment protocols are indicated. Routine diagnostics, medications, restriction of activity, and physical therapy are often used. During this phase, psychological and social factors generally play a much more limited role. However, there are some exceptions to this. If a patient with a mild injury appears severely depressed or unreasonably angry in the days following an accident, demands a high level of opioids, refuses examination, or is grossly noncompliant, the role of psychosocial complications should be explored. Behaviors such as these are uncommon in patients with acute conditions. When they do occur, they should not be overlooked as they may indicate that a biopsychosocial condition is already starting to evolve.

The subacute phase of pain, from one to six months post-injury, is the period during which transition from acute to chronic pain is most often observed. It has been theorized previously that biopsychosocial pain disorders occur in different forms with a distinct natural history. This natural history often involves a “downward spiral,” in which a medical condition becomes progressively more enmeshed with psychosocial complications.9 Using this model, one of the first signs that a biopsychosocial pain disorder is developing in the subacute phase may be an observed deviation from the expected course of recovery. If, after a month or so, the severity of the reported pain or disability is difficult to explain given the objective medical findings, this increases the risk that the acute condition may be evolving into a chronic biopsychosocial pain disorder. Beyond the severity of the pain, it has also been observed that a prodromal sign of chronic pain is when the pain unexpectedly begins to spread to other body areas, even when there is no pathophysiological explanation for this.11

In the chronic pain phase, the full biopsychosocial spectrum is often seen. As noted elsewhere however, biopsychosocial disorders occur in different forms.9 For example, in some cases, there is a clear pathophysiological explanation for the patient’s pain. The patient may have sustained a catastrophic injury, or there may be an identifiable disease process. A patient who has a life changing, painful medical condition will often need to contend with the social impact of being disabled. Given this kind of medical condition, some have commented that it is surprising when depression does not occur.12 This associated distress can lead to additional stress-related symptoms, and to a worsening of the patient’s pain and suffering.

Last updated on: January 5, 2012
First published on: March 1, 2006