The Invisible Foe: Challenges in the Treatment and Management of Chronic Pain

by Christina Ansted, MPH

“Does ANY one out there understand pain? Not all sufferers of chronic, long-term pain are 'faking' it!!! Nerve damage and neuromas are severe, debilitating pain that never stops. One can 'breath' the pain away for short periods, but when you return to the real world, there's the pain, waiting for you! I am sick to death, after 45 years and numerous operations, of 'doctors' saying it's all in my head. Because you can't fix it doesn't make it any less real.” – Chronic Pain Patient David N. Hake on October 1, 2008 - 6:26 a.m.(1)

When we think of “pain”, we typically think of a cause (e.g., pain from surgery, pain from a sports injury or broken bone, or pain from a headache or migraine). Friends and family, society at large, and the medical community respond with sympathy and action to pain that has “a reason”. But how do you explain pain for which there is no cause? How do you explain to friends and family that you aren’t just lazy or a complainer, and that your pain is real and not imagined? Welcome to the world of the patient with chronic pain.

According to the American Pain Foundation, more than 50 million Americans experience chronic pain. The most common types of chronic pain are headaches, back pain, and arthritis pain. Other common types include neck pain, fibromyalgia/fibrosis, myofascial pain, TMJ pain, "whiplash" pain, sciatica, carpal tunnel syndrome, pelvic pain, neuropathy and neuralgia pain, and phantom limb pain. Chronic pain can also result from illness or conditions such as osteoporosis, lupus (SLE), rheumatoid arthritis, scoliosis, endometriosis, and scleroderma. In many cases, unfortunately, the underlying cause of an individual's chronic pain is unknown.(2) Pain is not always visible, so when there is no physical cause or reason, complaints of pain tend to be ignored. In fact, chronic pain, especially chronic pain unrelated to cancer, is notoriously under-treated.(3)

In a recent study published by Pain Management Nursing in 2009, Susan Shaw and Alison Lee investigated the misconceptions exhibited by nursing students treating patients with chronic nonmalignant pain. Data were collected from a cross-sectional sample of student nurses (n = 430) using a specially designed survey. The student nurses who participated in this study demonstrated that they held misconceptions about adults with chronic nonmalignant pain to a considerable degree. Students enrolled in semester six held the misconceptions to a slightly lesser degree than those enrolled in semesters one and four.(4) The process of undergraduate education needs to equip nursing students with accurate knowledge about chronic nonmalignant pain and encourage them to develop the appropriate attitudes for working with patients experiencing it. Specific strategies must address gaps in knowledge and attitudes, with the aim of improving patient care.(4)

If the misconceptions and gaps in knowledge exist at the student level, to what degree is the stigma associated with chronic pain eroding communication between patient and caregiver at the professional level? Many clinicians were trained years ago, when little was known about pain. The rapid expansion of knowledge about pain mechanisms challenges healthcare practitioners to keep their knowledge base current. Myths, misconceptions, and the resulting fears often bridge gaps in this knowledge. Lack of knowledge limits treatment choices and may hinder desired patient outcomes by allowing pain hypersensitivity and progressive dysfunction to develop (see Table).(5)

Chronic pain is a clinical challenge for the practicing physician. Lack of knowledge about opioids, negative attitudes toward prescribing opioids, and inadequate pain assessment skills combine to create major barriers to pain relief. Patient-related barriers such as lack of communication and unwarranted fears of addiction further complicate pain assessment and treatment. The healthcare system itself can hinder pain relief through practical constraints in the community and fear of regulatory scrutiny by the physician.(6) Strategies for the clinician therefore must include a thorough assessment not only prior to diagnosis, but ongoing assessments to monitor improvement and setbacks. Communication is critical. Clinicians must take the time to hear what their patient has to say, and also help their patients to describe what is happening. As stated earlier, pain that doesn’t have a visible cause can be hard to explain, and even harder for a clinician to pinpoint a cause. That being said, clinicians must also be aware that although there may not be a physiological cause, the patient is telling the truth (barring patients with known substance abuse issues) and is in pain.

In a one-year pilot project conducted by the Alberta HTA Chronic Pain Ambassador Program, 147 participants responded to an online survey consisting of 50 true/false questions on demographics, barriers to care, low back pain, and headache knowledge. Health professionals rated three factors as the most important barriers in the management of chronic pain: ready access to pain management guidelines, accessibility to pain management specialists, and concern about patient drug-taking behavior.(7) In 2009, The American Society of Interventional Pain Physicians (ASIPP) announced the release of the updated Interventional Pain Management (IPM) guidelines. Laxmaiah Manchikanti, MD, primary author of the guidelines, stated: "The purpose of the IPM guidelines is to address the issues of systematic evaluation and ongoing care of chronic or persistent pain, and provide information about the scientific basis of recommended procedures. The guidelines are expected to increase patient compliance, dispel miscommunications among providers and patients, manage patient expectations reasonably, and form the basis of a therapeutic partnership between the patient, the provider, and payers."(8)

In recent years, knowledge of chronic pain and pain management has been gaining ground in terms of awareness and treatment solutions. Take for example a recent newscast titled “Let’s Talk Pain”,(9) the first-ever show devoted to issues of pain, sponsored by the Let’s Talk Pain Coalition. Yet with all the “buzz” surrounding chronic pain and pain management in general, clinicians, nurses, and medical support staff alike must learn to see beyond stigmas and stereotypes associated with sufferers of chronic pain. Workshops to address and dispel preconceived ideas attributed to the chronic pain patient, an increase in continuing medical education activities dedicated to this topic, and availability and awareness of treatment guidelines are essential to improve remission and recovery rates and streamline continuity of care over the long term for those patients dealing with chronic pain.

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References

1. Comments on "Chronic pain versus the brain: and the loser is.” Psychology Today 2008. Available at http://www.psychologytoday.com/blog/overcoming-pain/200808/chronic-pain-versus-the-brain-and-the-loser-is/comments
2. Types of chronic pain! Chronic Pain Outreach. Available at http://www.chronicpain.org
3. Schneider JP. Addiction and chronic pain. National Pain Foundation 2009. Available at http://nationalpainfoundation.org/articles/134/addiction-and-chronic-pain
4. Shaw S, Lee A. Student nurses’ misconceptions of adults with chronic nonmalignant pain. Pain Management Nursing 2009. Available at http://www.painmanagementnursing.org/article/S1524-9042%2808%2900170-7/abstract
5. Whitten CE, Donovan M, Cristobal K. Treating chronic pain: new knowledge, more choices. The Permanente Journal 2005;9(4):9-18.
6. Glajchen M. Chronic pain: treatment barriers and strategies for clinical practice. JABFP 2001;14(3):211-218.
7. Lopatka H. Alberta primary care practitioner knowledge assessment for low back pain and headache management: summary report. Institute of Health Economics 2007. Available at http://www.ihe.ca/documents/Knowledge-Assessment-Survey.pdf
8. New Interventional Pain Management Guidelines released by The American Society of Interventional Pain Physicians. Medical News Today 2009. Available at http://www.medicalnewstoday.com/articles/159102.php
9. “Let’s Talk Pain” newscast. Available at http://news.prnewswire.com/DisplayReleaseContent.aspx?ACCT=104&STORY=/www/story/08-11- 2009/0005075417&EDATE