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14 Articles in Volume 12, Issue #2
Chronic Pain in the Elderly: Special Challenges
Chronic Pain School
Diagnosis and Management Of Myofascial Pain Syndrome
ECG Screening Prior to Initiating Methadone: Is it Really Necessary?
HCG and Testosterone
How to Manage Unmotivated Pain Patients
March 2012 Pain Research Updates
Methadone for Pain Management
PPM Editorial Board Discusses Methadone Prescription Safety Measures
PPM Launches Online Opioid Calculator
Spontaneous Low Back Pain, Radiculopathy, And Weakness in a 28-Year-Old
Tapering a Patient Off Opioids
The Comorbidity of Chronic Pain and Mental Health Disorders: How to Manage Both
What Are Best Safety Practices For Use of Methadone In the Treatment Of Pain?

How to Manage Unmotivated Pain Patients

The role of the pain psychologist in identifying and treating the unmotivated patient can be critical for a patient experiencing repeated treatment failures.

How do pain patients become unmotivated? Are they unmotivated before the onset of treatment or do they become unmotivated as the treatment process progresses? The focus of this article is on how to identify and treat the unmotivated chronic pain patient, and it is based on my personal experience in this area.

Patient Referral
This initial step in the process usually starts with the primary care physician (PCP). The PCP starts the ball rolling after conducting a history and physical examination and establishing a preliminary diagnosis, which can influence the direction or path the patient will follow. The PCP may treat the patient’s pain initially, which can also include adjunctive supportive care. The numbers are impressive; according to a recent report by the Institute of Medicine of the National Academies (IOM), chronic pain conditions affect at least 116 million adults at a cost of up to $635 billion annually in direct medical treatment costs and lost productivity.1

How many of those 116 million could be classified as difficult or unmotivated patients? That depends on a number of factors. Some patients start the process with existing emotional issues, such as anger, anxiety, or depression, which may predispose the patient to transition from acute to chronic pain. Based on my experience, the process of the initial referral and subsequent treatment can greatly influence the patient’s outlook or attitude. Remember, pain generally produces a fear response. If the fear response is recognized early and treated appropriately, it can assist in mitigating subsequent emotional consequences.

I suspect that most difficult or unmotivated patients are the conditioned result of negative repetitive treatment outcomes. The hope or optimism that may exist in the beginning stages is negatively conditioned over time and results in despair and pessimism. Pain medicine by its nature is a trial-and-error process. Therefore, the more negative trials the patient experiences, the more difficult and unmotivated he or she becomes. If providers recognize and understand this process early and incorporate the services of adjunctive support personnel, including the utilization of a pain psychologist, the outcomes can improve greatly.

The PCP usually has a number of options of where to refer the patient for more specialized pain care. These options can include private pain clinics, medical school–based pain programs, and the individual pain specialist. The referral may be further influenced by insurance coverage or location. In the rural setting, options may be limited unless the patient is willing to travel long distances.

The secondary referral to a pain specialist is an important step in the process, whether it be for a diagnosis with a recommendation to go back to the PCP for follow-up care or a recommendation for repeated visits for further invasive diagnostic procedures. It is important that at this point in the process, the patient is introduced to adjunctive support care.

Multidisciplinary Team
When I was part of a medical school pain program at Oregon Health & Science University (OHSU), a patient was required to be evaluated by all of the adjunctive staff, including a board-certified pain physician, psychologist, and physical therapist. The advantage of the multidisciplinary pain program is that all issues impacting the patient are addressed early and are incorporated into a comprehensive treatment program. If the patient has a positive and supportive experience, then the potential for hope is reinforced and counterproductive issues, such as anger and frustration, are mitigated. If the secondary referral is based on the premise that, “I have nothing further to offer; go see a pain specialist,” the patient then feels like a failure and the trial-and-error process of negative reinforcement begins.

Over the past 30 years, I have experienced many types of referrals. If my services are incorporated early in the treatment process, then I am more optimistic about the outcome. Unfortunately, this is not always the case, especially over the last 10 years as an independent provider operating in a hostile insurance environment. Many of my referrals have been in the trial-and-error treatment process with repetitive failures. These patients often do not understand why they have to see a pain psychologist. Further, they feel that nobody believes their pain is “real,” and by being referred to a pain psychologist, their pain is “all in their head” or imaginary. So by this time, these patients are often characterized as being difficult and unmotivated.

Assessment Key
The initial visit is critical in establishing a connection with the patient. As noted, at OHSU, patients went through a full day of psychometric testing. For the past 10 years as a solo practitioner, I have relied on the clinical interview as my main source of data. Early in my career, I attended a weeklong workshop with Wilbur Fordyce, PhD. He shared his Behavioral Analysis of Pain, which I still incorporate into my initial interview with a patient. I avoid offering a psychological pain diagnosis in my report to the referring physician. Instead, I offer my clinical impression where I attempt to point out the issues that may be influencing the patient’s pain, including both strengths and weaknesses.

In addition, I utilize the model of chronic pain from Ronald Melzack, PhD, during my initial evaluation in identifying both affective and cognitive factors that are influencing the patient’s perception of pain.2 Keep in mind that a considerable number of pain patients are clinically depressed by the time they are initially evaluated by a pain specialist. I have seen ranges from a low of 60% to a high of 80%. Depression results from profound feelings of learned hopelessness and helplessness. As the patient experiences repetitive treatment failures, this sense of despair accumulates, which—in my opinion—forms the basis of why the patient appears unmotivated. From a learning perspective, this despair or the feelings of hopelessness and helplessness results from classical avoidance conditioning.

Treatment Strategies
So how does a pain psychologist start to treat a depressed, unmotivated patient? The first step is the assessment of the patient’s strengths and weaknesses. Are they open and at least curious about the nature of “their” pain? (See Figure, page 46.) Are they willing to accept that it is their pain, not mine, or their other treating physicians’ pain? From a cognitive behavioral treatment perspective, this is a crucial first step. The patient needs to trust the pain psychologist and realize they are not going to question the validity of their pain. Many patients are cautious and somewhat dubious, especially after experiencing repeated treatment failures.

There are many levels of trust, and the pain psychologist will continue to build trust as treatment progresses. One technique to build trust is a personal phone call to the patient at home to check on how they are doing. In addition, give the patient your personal cell number and encourage them to call if they have a concern or question. I have never experienced a patient abusing this privilege and it facilitates trust building. I am very careful about building trust and not dependence, which I consider counterproductive to the desired treatment process.

Sharing Information
The next phase of treatment is sharing information. Knowledge is a powerful tool that will help the patient begin to achieve some sense of self-control. I often use the metaphor of the pain management toolbox and share with the patient that all of their providers have tools to add to the toolbox. The more tools the patient has, the better they are able to control their pain and subsequently improve the quality of their life.

One of my tools is an excellent workbook titled, Managing Pain Before it Manages You by Margaret Caudell, MD, PhD, MPH.3 It discusses the nature of pain and treatment procedures in a language that most patients understand and appreciate. In addition, I also see it as a test of motivation. Will they read it and, more importantly, will they do the exercises suggested in this workbook?

Because of my interest in applied psychophysiology and biofeedback, I spend a considerable amount of time discussing the sympathetic nervous system and its relationship to pain. There is a large body of research supporting the fact that if you lower sympathetic reactivity, you will lower pain levels. In other words, if the pain psychologist can teach the patient to self-control the sympathetic response by utilizing relaxation techniques augmented by biofeedback, the patient now possesses a powerful tool to control their pain. The more perceived self-control the patient has over their pain, the more their feelings of helplessness and hopelessness will subside. I have used many biofeedback modalities over the years, including respiration, electromyogram, electrodermal response, and skin temperature. All of these modalities were recorded and charted by the use of a computer. In addition, I used computer games tied into sympathetic self-control.

Today, I have simplified this treatment modality and now focus on one indicator of sympathetic reactivity—peripheral skin temperature feedback. This is a reliable technique and easy for the patient to understand. More importantly, they can use it at home and it works by the use of a skin thermometer, which costs about $1.50. If I can teach the patient to raise their skin temperature by just a few degrees and trigger the relaxation response, the patient will usually report a lower pain level. I also recommend Herbert Benson’s classic book, The Relaxation Response, to my patients.It provides excellent understandable knowledge about how our physiology works and how we can control our sympathetic arousal.

Relaxation Therapy
My approach to relaxation emphasizes relaxation therapy as the primary modality, which is augmented or reinforced by adding biofeedback. The treatment algorithm I employ starts with teaching the patient to diaphragmatically breathe. Most patients with pain use shallow breaths and will hold their breath when they experience a pain episode. This action coupled with physical tensing and bracing will increase their pain level. If I can teach the patient to breathe diaphragmatically through this pain episode, they will achieve a beginning sense of self-control over their pain. If they can slow their respiration rate to less than 12 breaths per minute, they are now able to begin the process of achieving the relaxation response. A general word of caution regarding diaphragmatic breathing techniques: As the CO2 level changes, the patient may feel dizzy or lightheaded; therefore, they should be well supported in a chair or a bed, and never use these techniques when driving or operating heavy machinery.

The next step in my treatment algorithm is to introduce the patient to progressive relaxation. This technique has been around a long time and is easy to learn. Progressive relaxation is based on isometric contraction, tensing muscle groups, then releasing the tension. After repetitive trials, the muscles will relax. In addition, I will pair deep diaphragmatic breathing with the tensing/relaxing exercise. As the patient tenses the muscle, the patient inhales a slow deep breath through the nose, expanding the chest, holding the breath for a few seconds, then exhaling through the mouth, releasing and blowing away the tension. I will also use the visualization of blowing up a balloon with their pain and then allowing it to float up into the sky and letting it disappear. The visualization of blowing up the balloon helps the patient empty their lungs. A word of caution when using progressive relaxation with pain patients: If it hurts to tense any muscle group, then I ask the patient to avoid that muscle group. I will address painful muscle groups later in the treatment sequence when I introduce visualization and autogenic techniques.

If the patient does well with diaphragmatic breathing and progressive relaxation and they appear open to more abstract techniques, I will then introduce autogenic therapy. This is also a well-known and successful technique that is based on self-phasing using themes of “heavy and warm.” I also consider autogenics as a preliminary step to self-hypnosis. It is more effective if the patient takes some time preparing their body by using diaphragmatic breathing and progressive relaxation to lower their level of arousal. The more relaxed the patient is, the more likely the self-phasing will have the desired impact. The brain will be more open to the self-suggestions.5 If the patient completes the autogenic phase and wishes to experience a deeper level of relaxation, I will add a simple induction procedure. Now the patient has progressed to self-hypnosis he or she can do alone. The next logical step is having the patient join a meditation support group, which will help promote maintenance.

As I mentioned earlier, relaxation skills are powerful tools that the patient can use the rest of his or her life to help control pain, promote sleep, and improve immune response. The main premise of these therapeutic approaches is to give the patient a perceived sense of control over his or her pain. This sense of control helps to counter feelings of hopelessness and helplessness. Further, feelings of hopelessness and helplessness are what I see as the main ingredients in the profile of the unmotivated patient.

Summary
I have provided a snapshot of the pain psychologist’s role in the multidisciplinary approach to chronic pain. The unmotivated patient presents a difficult and unique challenge that takes time and patience to change. The pain psychologist can provide valuable insight and assistance in working with the unmotivated patient. Hopefully, I have stimulated primary care and pain physicians to realize that the referral process is critical in shaping the patient’s attitude toward treatment. Repeated treatment failures have a profound effect on a patient, which in many cases could be avoided. How treatment failures are addressed is a critical step, and utilization of adjunctive support early in the treatment process with pain specialists will achieve more treatment successes.

Last updated on: March 19, 2012
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