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10 Articles in Volume 15, Issue #10
2015 Has Been a Good Year for Clinical Progress
Addison’s Original 1855 Cases Reveal Stories of Chronic Pain
Can We Prevent Chronic Pain?
Letters to the Editor: Nerve Fiber Testing, Fibromyalgia
Medication Guide for Pain—A Short Primer for Primary Care
Odd Pet Behavior During SCS Trial—Case Report
Opioid-Induced Constipation: New and Emerging Therapies—Update 2015
Palliative Care: Dying With Dignity
PPM Editorial Board: Year in Pain Management 2015
QT Intervals and Antidepressants

Can We Prevent Chronic Pain?

This paper reviews the strategies needed to combat chronic pain, including shifting the model to patient-centered care that engages, educates, and empowers patients.

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.

Transformative Care

Several new strategies are needed in our care model to improve outcomes of chronic pain, including:

  • Recognizing the role of the health care provider as an agent of change
  • Employing an inclusive problem list (physical diagnoses, protective factors, and risk factors)
  • Determining the complexity of the patient with risk assessment to personalize care
  • Provide patient training on a equal and integrated basis with evidence-based treatment
  • Following a decision process (tree) to stratify care and increase the potential for successful management

Combining evidence-based biomedical treatments with robust patient training to reduce risk factors and enhance protective factors can transform a person’s life from one beset by illness to one characterized by health and wellness.38-40 This is the basis for a transformative model of care. When self-management is combined with these evidenced-based biomedical treatments, outcomes can be dramatically improved and the patients is less dependent on the health care system.

Transformative care includes the use of risk assessments to identify risk factors as part of the problem list. Personalized care strategies include integrative teams that can be supported by health coaches, social support networks, on-line and in-person patient training programs, and dashboards to document patient engagement and patient-centered outcomes.

Since patients often expect to have a passive role in care, these new paradigms need to be conveyed to the patient as part of the evaluation (Table 3). Embracing patient-centered health care paradigms that foster responsibility, education, motivation, self-efficacy, social support, strong provider-patient relationships, and long-term change will encourage a passive, dependent patient to become an empowered, engaged, and educated patient.1,2

Clinicians as Agent of Change

The health care provider needs to recognize that he or she is part of the patient’s system of health and/or illness. In some cases, dependency on medications, repeated use of interventions and surgery, secondary gain from care seeking behavior, and rebound pain from drugs can be part of the patient’s cycle of problems.

If clinicians understand their integral role in the cycle of self-perpetuating illness, they can be part of the solution and help initiate change.

Determine Complete Problem List

The first step for patients as they shift their understanding of their illness to how to achieve health and wellness is to establish a complete problem list. The problem list includes both the physical diagnoses—the physical problem responsible for the chief complaint and associated its symptoms—and the list of contributing factors that initiate, perpetuate, or result from the disorder and complicate the problem. Multidimensional risk assessment will help determine which contributing factors are present.

Specific risk factors for chronic pain are included in Table 4. These may range from peripheral factors, such as repetitive stress-strain and postural habits, to central mediating factors, such as anxiety and depression, comorbid conditions, somatization, and catastrophizing. Protective factors, such as level of exercise, healthy diet, sleep, coping skills, self-efficacy, patient beliefs (eg, perceived control over pain), and social support, will reduce vulnerability to chronic pain and can create more positive outcomes.

Matching Patient Complexity With Complexity of Care

Successful pain management is enhanced if the level of complexity is determined and matched to the complexity of the treatment strategy.

Single treatment strategies can be quite successful for simple patients with few contributing factors, but often they fail for complex patients due to longstanding maladaptive behaviors, attitudes, and lifestyles. Thus, it is helpful to follow a decision-making process that can distinguish simple from complex patients and direct the treatment strategy.

Decision Tree

The decision tree for sequencing evaluation and management of simple and complex cases is illustrated in Figure 4. The listed problems can be used as criteria to distinguish simple and complex patients. Complexity increases with multiple diagnoses, persistent pain lasting longer than 3 months duration, significant emotional problems (depression, anxiety), frequent use of health care services or medication, daily maladaptive habits, and significant lifestyle disturbances.

In addition, there are some complex patients whose primary issues (ie, primary chemical dependency, psychiatric disorder, lack of motivation, time management issues) need to be addressed first. Once complexity is determined, the hope is that the simple cases can be treated successfully by a single clinician, with resolution of pain in 2 to 3 months. More complex cases, however should be managed by a team of clinicians, with improvement in the condition typically achieved in 3 to 6 months.

Interdisciplinary Individualized Integrative Care

Integrative care combines the practices and care strategies of a team of several health professionals. Different aspects of a problem can be addressed by different specialists including physicians, dentists, health psychologists, and physical therapists to enhance the overall potential for success. A health coach may be an excellent addition to a busy practice to support the patient in learning successful self-management for preventing chronic pain.

Providers must present a consistent philosophy and message to the patient about the importance of self-care, self-responsibility, and training using the concepts of a human system approach, cybernetics, chaos theory, positive psychology, and the transformative care model. Success depends on consistent communication of these concepts, integration among clinicians, and patient understanding, engagement, and motivation.

Summary

To prevent chronic pain, clinicians must evaluate and manage the whole patient. By not addressing underlying risk factors, medical treatment alone is unlikely to succeed long-term. A transformative care approach, as described here, that combines robust self-management training with evidence-based pain treatments through a multidisciplinary team approach is the key to successful pain management. By accomplishing these goals, we will be able to address the Institute for Health Care Improvement’s triple aim to improve the patient’s experience of care, enhance the overall health of the patient, and reduce the cost of health care.50

Last updated on: September 27, 2017
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