Chronic pain, physicians can help - article

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Patients with Chronic Pain: Physicians Can Help

Sri Vasudevan, MD, Wisconsin Medical Society

Date posted: Tuesday, May 25, 2004

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Pain is one of the most common reasons individuals seek attention

from physicians and other health care providers. A 1999 Gallop Survey

revealed that nine out of 10 Americans, age 18 or older, reported

suffering from pain at least once a month, and 42% of adults report

experiencing pain every day. Some 75 million Americans experience

chronic pain and at least 9% of US adults are estimated to suffer

from moderate to severe non-cancer pain.

Patients with chronic pain not associated with cancer present a

unique and difficult challenge to the treating physician and the

health care system. Many organizations have addressed this problem by

issuing guidelines and monographs. The American Medical Association

has developed a four-part monograph dealing with issues of " pain

management " with input from primary care physicians and multiple

specialty societies.

The latest issue of the Wisconsin Medical Journal includes the work

done by the Wisconsin Medical Society's Task Force on Chronic Pain

Management, which has been approved by the Society's Board of

Directors. It addresses the evaluation and management of nonmalignant

chronic pain - a complex group of disorders that may be a) related to

specific disease, following injuries to bone, joint, soft tissue,

viscera, or nerves, and/or c) poorly understood conditions. With

input from specialists in anesthesiology, family medicine, internal

medicine, neurology, neurosurgery, physical medicine and

rehabilitation, pharmacology, psychiatry, and psychology, as well as

medical directors of three large insurance companies, the task force

developed suggestions for treatment of individuals with chronic pain.

These guidelines provide broad " guiding principles " in the different

methods that should be used in an integrated, coordinated approach to

managing the individual with chronic pain. They include

pharmacological, interventional/anesthesiological,

psychological/psychiatric, rehabilitation, and surgical approaches.

Similar to the fable of four blind men feeling different parts of an

elephant and having divergent opinions regarding what they are

feeling, physicians evaluating the same patient with chronic pain,

with identical history, clinical and radiological findings, will

diagnose and treat the patient in different manners. Commonly seen

problems, such as low back pain and headaches, may result in

differing opinions and approaches to treatment when viewed by

anesthesiologists, chiropractors, family practitioners, neurologists,

physiatrists, psychiatrists, psychologists, or surgeons. Could

communication between these practitioners and physicians lead to

better outcomes for our patients? The task force definitely believes

it can.

The field of pain medicine has evolved since the early 1960s, with

recognition of these different approaches. There have been

significant advances in the last three decades in the understanding

of the neurophysiology of pain and significant advances in the

pharmacotherapy of pain. Pain is clearly recognized as a combination

of biological/medical factors, psychological and social factors, and

patient personality, as well as political and legal influences that

impact the perception and reaction to pain and pain-related

disability.

A combination of factors has led to a unique time for physicians to

work together with other practitioners to make a significant impact

in improving the quality of life of our patients with chronic pain.

The factors include 1) rapid advances in understanding the

neurophysiology of pain processing, 2) improvements in technology, 3)

improvements in selective pharmacological agents that can be used on

the basis of the mechanism of pain causation (nociception/tissue

injury versus neuropathic or due to a nerve dysfunction or injury),

4) availability of a newer class of drugs specifically targeting pain

and depression (cox-II inhibitors, SSRIs, Triptans, antiepileptic

drugs, controlled release formulation, and topical agents), 5)

increased interest in the medical community regarding " pain medicine "

as a specialty area, and 6) public awareness and empowerment.

I would suggest physicians managing individuals with chronic pain ask

themselves the following questions:

1. Would I recommend the same test, procedure, medication,

surgery, or any other course of treatment for myself or my family

that I am recommending for my patient?

In a recent editor's message titled " put yourself in your patient's

shoes, " Dr Weinstein noted that over 30% of surgeons who had just

recommended a variety of surgical procedures during a conference on

" controversies of the lumbar spine surgery " indicated they would not

undergo any surgery on themselves if the same situation applied to

them. One of my colleagues refers to this as the " Yo-mama test. "

2. Does my practice change significantly depending on who is the

insurance carrier?

My personal observations and anecdotal information suggest that

physicians tend to treat individuals who are covered under Workers

Compensation Insurance with more diagnostic tests and intervention

than they would with somebody with limited (HMO/ Medicaid) or no

insurance. This may be realistic based on 'covered services,' but the

physician's philosophy of treatment should be consistent regardless

of insurance coverage and should not vary widely depending on the

payor source.

3. Do I understand the long-term implication of placing

permanent restrictions or recommending disability rating on my

patient?

Clearly, some individuals with injuries or illness, despite optimal

treatment of the pathology, may have to be " restricted " permanently

from certain activities to prevent them from harming themselves or

aggravating, precipitating, or accelerating an underlying condition.

However, providing permanent restrictions to an individual with the

self report of pain without objective findings may restrict the

patient significantly in future employment or insurance coverage and

also leads to iatrogenic disability.

These guidelines represent a consensus of the group of clinicians and

are not evidence-based. The task force believes this is an evolving

process and expects comments and suggestions from readers. It is our

hope that physicians and other practitioners will find these

guidelines of value in recognizing the complexity of chronic pain and

utilize these guiding principles to improve the management of

individuals with chronic pain.

Dr. Vasudevan, of the Wisconsin Medical Society of Wisconsin,

practices physical medicine and rehabilitation in Milwaukee and

Sheboygan. This column is an excerpt from an editorial published in

the latest issue of the Wisconsin Medical Journal.

Note: This and other columns represent the professional opinions of

the authors and are not necessarily those of the Wisconsin Medical

Society.