As primary care physicians when we encounter a patient requesting opioids for pain we ask ourselves, is this patient really benefiting from the medication or is there a larger problem? My goal is to help providers better understand the complex biopsychosocial nature of chronic pain.
Many of us will experience some degree of chronic pain as defined as pain lasting longer than 12 weeks by the NIH. It is not entirely known how acute pain develops into a more complex chronic pain syndrome. With acute pain there is an initial pain signal- whether visceral, somatic, or neuropathic- consistent with tissue damage. The central nervous system then interprets the pain signal to elicit a protective response. With repetition the pain signal can either be increased (sensitized) or be decreased (desensitized) by the individual’s central nervous system. The increasing or decreasing of pain signals has a both an intrinsic component (think naturally occurring endorphins) and a behavioral component which can be learned (think Lamaze/hypnobirthing).
When working with chronic pain it is important to understand the interconnection of behaviors, emotions, medications and changes in activity level that patients experience as a reaction to their pain. These factors can all contribute to the sensitizing effect on the central nervous system and therefore the worsening of pain. We call this the chronic pain cycle:
Why does an individual’s pain system become sensitized or desensitized? While there are still many unknowns there are common psychosocial factors often associated with chronic pain: personality disorders, depression, anxiety disorders, somatoform disorders, substance use disorders and a history of growing up in family with substance, physical, emotional or sexual abuse. Other contributors can be chemical (for example opioid hyperalgesia), behavioral (belief systems or expectations about managing pain and stress), physical (deconditioning) and social (loss of income and resultant financial stress) which can all play a role in developing a chronic pain syndrome.
Maladaptive and illness-focused expectations frequently seen in patients with chronic pain include
- Believing that medication is the only thing one can do for pain
- Not recognizing the connection between emotion and pain
- Feeling one has no control over their pain
- Undergoing multiple procedures and tests looking for a cause and a “cure”
- Feeling trapped in a sick role/seeing oneself as totally disabled because of pain
- Feeling others are responsible for one’s pain and suffering
- Fear that any movement will worsen pain
We may promote these unhelpful expectations in our primary care offices. Many of us feel inadequately trained and lack sufficient resources to manage chronic pain patients. The medical system has moved from the collaborative multidisciplinary pain clinics of the 1980s to the primary care physician directing the pharmaceutical and procedural treatments of today. But focusing only on biomedical and pharmacological management of pain disempowers patients and frequently worsens their chronic pain. This may be why they rarely seem to get better in our offices! In addition to medication and procedural interventions, many patients require targeted behavioral interventions and a structured physical rehabilitation plan.
At Continuum Behavioral Health the most common pain scenario we see is an individual physically dependent on opioids who is significantly deconditioned and with a strong belief that opioid medications are the only thing they can do to improve their pain. We integrate a combination of Cognitive Behavioral Therapy, buprenorphine if needed, and encourage starting a gentle exercise program to develop pain management skills. Buprenorphine is a partial agonist at the opioid receptor with a favorable safety and side effect profile to the traditional full opioid agonists. The goals of treatment are improved physical and emotional functioning, increased effective strategies for managing pain, and reduced pain intensity.
If a patient has red flags for developing a more complex chronic pain issue consider referral to a behavioral based pain program. Even for the patient that refuses a referral there are many useful books, websites, physical therapists and individual counselors that can help people develop skills to manage their pain. For patients that you do prescribe narcotics utilize a pain contract that includes, as criteria for being prescribed medication, the patient’s involvement in efforts to manage their pain.
For more information or to refer a patient to Continuum for chronic pain feel free to call (401) 294-6170.