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16 Articles in Volume 19, Issue #2
Analgesics of the Future: Inside the Potential of Glial Cell Modulators
APPs as Leaders in Pain Management
Cases in Urine Drug Monitoring Interpretation: How to Stay in Control (Part 1)
Complex Chronic Pain Disorders
Efficacy of Chiropractic Care for Back Pain: A Clinical Summary
Hydrodissection for the Treatment of Abdominal Pain Caused by Post-Operative Adhesions
Letters: The Word "Catastrophizing;" AIPM Ceases Operations; Patient Questions
Management of Severe Radiculopathy in a Pregnant Patient
Managing Pain in Adults with Intellectual Disabilities
Pain in the Courtroom: An Excerpt
Q&A with Howard L. Fields: How Patients’ Expectations May Control Pain
Special Report: CGRP Monoclonal Antibodies for Chronic Migraine
The Management of Chronic Overlapping Pain Conditions
Vibration for Chronic Pain
What are the dangers of loperamide abuse?
When Patient Education Fails to Improve Outcomes: A Low Back Pain Case

The Management of Chronic Overlapping Pain Conditions

The clinical state of overlapping pain conditions among patients with chronic pain is often overlooked.
Pages 7-9

Summarized in this guest editorial is content from a new CME, A Biopsychosocial Approach to the Clinical Management of Chronic Overlapping Pain Conditions, to be released online this spring. To be notified upon release, please email cveasley@ cpralliance.org.

 

Susan, a 40-year-old wife and mother of two, has progressively developed persistent pain in several areas of her body over the past 20 years. What began as intermittent head and neck pain – manageable with self-care, physical therapy, and chiropractic care – transitioned into chronic pain in multiple locations, along with an associated sleep disorder, depression, and fatigue. Although she utilizes a combination of pharmacological and nonpharmacological treatments, she still experiences disabling chronic pain, which has impacted all aspects of her professional and personal life. She describes her immense frustration with a fragmented healthcare system and lack of a medical home for people like her, where providers from different disciplines could work collaboratively as a team to manage various chronic pain and associated comorbid disorders. She tells me, “It’s like a maze that I just can’t seem to figure out how to navigate, with uncertainty at every turn.”

The Number of Patients with COPCs is Multiplying

Susan is far from alone. Mounting evidence shows that millions of people, particularly women, suffer simultaneously from multiple pain conditions that share similar disease mechanisms – mainly of the neurological, endocrine, and immune systems – which are frequently associated with sleep, mood, fatigue, and cognitive disorders.1-6

The clinical state of overlap of these conditions – recently termed by the NIH as Chronic Overlapping Pain Conditions (COPCs, see Figure 1) – is gaining increased recognition and for good reason. Ample data demonstrate a number of deleterious effects as an individual’s number of COPCs increases, including: worsening of localized and systemic pain symptoms, decreased treatment effectiveness, reduced health and psychosocial outcomes, increased levels of disability, increased personal and societal costs, and markedly diminished quality of life.7-20

This broad impact comes as no surprise and follows a national trend toward increasing rates of not only chronic non-pain conditions among Americans, but also comorbidity of those conditions. One in four Americans and 75% of those aged 65 or older suffer from multiple chronic conditions. What’s more, US costs associated with comorbidity are skyrocketing – approximately 66% of total healthcare spending is for those with multiple chronic conditions.21,22

It has become clear that our current healthcare system has to change in order to improve care and reduce costs for patients like Susan. This step begins with promoting an understanding of the pathophysiological complexity of COPCs. Evidence suggests that COPCs are not just an extension of acute pain but a complex multisystem illness. Genetic predisposition and environmental exposures combine to increase the risk of developing and maintaining COPCs through abnormal pain amplification and emotional distress, moderated by factors from multiple body systems.23 A prominent NIH-funded, multisite study found that COPCs comorbidity is associated with abnormalities in two general constructs – Generalized Sensory Sensitivity and SPACE, as described in Figure 2.24,25

Figure 2. Constructs associated with COPC comorbidity.

Not All Practitioners Are Communicating

Due to the inadequate number of pain management specialists in the US trained to address the 100 million Americans with chronic pain, most individuals like Susan are under the care of multiple specialists who may not be aware of the interconnection of these conditions, nor their association with nervous system abnormalities. At one point, Susan was treated by a gynecologist for vulvodynia, a gastroenterologist for irritable bowel syndrome (IBS), an orofacial pain specialist for temporomandibular disorder, and a urologist for interstitial cystitis, none of whom communicated with one another.

It Cannot Be Stated Enough: Always Assess the Whole Patient

Patients with COPCs may have any number and type of conditions, which require a targeted individualized approach. For example, a patient with fibromyalgia, interstitial cystitis, anxiety, and cognitive impairment may require a different assessment and treatment plan than a patient with IBS, endometriosis, vulvodynia, depression, and a sleep disorder. As such, the biopsychosocial model offers the most heuristic approach to COPCs.26 Multimodal, interdisciplinary treatment, based on this model, is vital to addressing the complexities faced by patients with COPCs. Elements of such a plan should include taking a detailed medical history and conducting a physical exam to clarify pathophysiology, if possible, and assessing the critical pain domains and non-pain domains, such as sleep, mood, cognition, and fatigue. Finally, assessment of the pain’s impact on physical, social, and sexual function should be discussed with the patient.26,27

Developing an individualized treatment plan for patients with COPCs should begin by considering the FDA-approved treatment options, currently available for six of the 10 COPCs (chronic low back pain, chronic migraine headache, IBS, interstitial cystitis, fibromyalgia, and endometriosis). Next, clinicians may incorporate other off-label, disorder-specific treatments, as well as universal chronic pain treatment approaches.28 As pain practitioners well know, rigorous data are lacking for most chronic pain treatments, and the best approaches for an individual are typically identified through a trial-and-error process. The most common approaches for the treatment of COPCs include those that target the central nervous system, and may include adjuvant medications, such as tricyclic antidepressants, selective serotonin-norepinephrine reuptake inhibitors, anticonvulsants, and muscle relaxants, specifically antispasmodics. Physical and occupational therapy is often utilized to maximize and maintain one’s functional ability, without increasing pain severity, and to help patients perform activities of daily living. Psychological counseling may be helpful, particularly for those with comorbid mood disorders and/or maladaptive thinking. Interventional pain management approaches may be helpful for some patients after more conservative treatments have failed. Some find various complementary health approaches, such as chiropractic care, massage, yoga, and acupuncture, to be helpful in managing symptoms as well. Treatment of non-pain comorbidities should always be included as part of a comprehensive regimen, which may require referral to other medical professionals.

Finally, something that is often overlooked in managing pain patients, but very helpful in restoring physical and emotional health, is developing functional goals that patients may work toward between visits. In fact, research has shown that doing so also helps to foster adherence to clinician recommendations and improve patient-clinician communication, among other benefits.29-31 Clinicians may find the SMART (Specific, Measurable, Action-Oriented, Realistic, Timed) Goal Setting System useful in helping their patients to narrow down and set specific goals, assess progress, as well as to identify potential obstacles and a plan of action to address them (see Figure 2).32

Although sometimes challenging, providing quality care for patients like Susan is not impossible and may be quite rewarding. As she shared after finally finding a clinician who understood the interconnection of her conditions and began treating her as a whole person:

“It took time to identify the treatments that worked for me without producing intolerable side effects, but we got there. Most importantly, through the process, he took the time to listen and understand what really mattered to me. He treated me with respect and dignity. I cannot do everything that I used to do before the pain began, but we’ve worked together to develop a plan to help me feel as physically well as possible and to engage in the things that are most meaningful to me, which has restored purpose and enjoyment back to my life.”

Last updated on: March 4, 2019
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