Managing Acute Back Pain
Implementing the latest guidelines
Dawn A. Marcus, MD
VOL 113 / NO 4 / APRIL 2003 / POSTGRADUATE MEDICINE
CME learning objectives
- To understand the recommended management of chronic pain, including assessment and treatment of comorbid psychologic symptoms and disability
- To develop realistic treatment goals for patients with chronic nonmalignant pain
- To identify appropriate candidates for long-term opioid therapy and determine treatment compliance and success
The author discloses no financial interests in this article.
Preview: Recently revised guidelines from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) call for an increased awareness of the impact of chronic pain and recommend that physicians assess and treat pain complaints seriously. Although significant and persistent chronic pain is a common reason for primary care visits, the incidence of psychologic distress and personality disorder in patients with chronic pain often makes this population a difficult one for physicians and staff to treat. This discussion offers practical tips for managing patients with chronic pain and reducing staff burnout. The author also dispels various myths about chronic pain and focuses on the effective management of its comorbidities.
Marcus DA. Tips for managing chronic pain. Postgrad Med 2003;113(4):49-66,98
Pain is the chief complaint in 40% of primary care visits. Of these visits, persistent chronic pain is reported in 20% (1). A sample of primary care practices identified that chronic pain required pain medications and treatment in 14% of patients, and 6% of patients reported high levels of disability because of pain (2). Back pain is the most common chronic pain in the United States, affecting about 59% of adults during their life (3).
Traditional teaching suggests that acute back pain typically resolves rapidly. This hypothesis was tested in 463 new consultations with a primary care physician about acute back pain (4). Only 32% of patients made return appointments for back pain after 3 months, and 8% made them after 12 months. This low percentage of return visits seemed to support the view that chronic pain is rare. When the health of patients was periodically reassessed by phone interview, however, only 21% reported resolution of pain by 3 months and 25% by 12 months. Pain and difficulty in performing activities of daily living were reported by 73% of patients at initial evaluation and by 50% after both 3 months and 12 months. In addition, 29% of patients continued to report ongoing pain or disability at 3 months and 25% at 12 months. Although patients did not return for appointments, pain or significant disability, or both, continued in 79% of cases after 3 months and 75% after 12 months. These data suggest that significant pain often does persist, despite lack of reconsultation.
The recently revised JCAHO guidelines for management of pain (5) have increased awareness of the impact of chronic pain and the requirements for pain treatment by healthcare providers. Educational initiatives typically describe the importance of recognizing and treating chronic pain and present the latest medical treatments and interventional procedures. Although healthcare providers are becoming better educated about the science of pain management, there is an educational void about the art of caring for patients with chronic pain, who make up a population that is often difficult to treat (6,7). A recent survey of primary care physicians (8) noted that only 15% enjoyed treating patients with chronic pain. Primary care physicians were also uncomfortable about having an expanded role in prescribing opioids for patients with chronic pain, and 41% of physicians waited for patients to initiate requests for pain medication before prescribing it.
At times, healthcare providers become overwhelmed with the management of chronic pain because of two major issues: persistent myths about the nature of chronic pain and lack of knowledge about dealing with chronic pain comorbidities. This article addresses those issues and provides tips to increase the healthcare provider’s comfort level in managing chronic pain.
Three myths of chronic pain
The first myth of chronic pain is that pain is easy to treat. Primary care physicians often believe that medication will completely alleviate pain. The reality, however, is that long-term significant pain relief and a return to work each occur in only about half of patients who receive treatment for chronic pain with comprehensive multidisciplinary pain rehabilitation (9,10). Complete relief of the symptoms of chronic pain is rare.
The second myth is that as pain improves, disability and depression will resolve spontaneously. This may be true if the levels of disability and depression are mild. Typically, however, depression and excessive disability must be addressed simultaneously with efforts to reduce pain symptoms. Moreover, undertreated psychologic symptoms can reduce motivation to adequately comply with treatment recommendations.
The final myth is that patients who have pain are easy to manage. In reality, even the best-staffed medical practice often finds the management of patients with chronic pain difficult and time-consuming. Recognizing the complexity of caring for these patients can lessen staff burnout, and appropriate expectations of treatment can help reduce excessive demands for complete symptom relief.
Pathophysiologic factors
Rodent pain models help explain how acute pain develops into chronic pain (11-14). A common model involves exposing the sciatic nerve, tying a ligature around it temporarily, and then removing the ligature and allowing the nerve to recover. This model may be compared with a patient who has a herniated disk or other nerve impingement removed. In the rodent model, motor and sensory functions return, but pain develops. (Studies evaluate pain in rodents by monitoring pain behaviors–eg, gnawing the presumably painful extremity.) Autopsy results of these rats with chronic pain show microscopic neural changes in the dorsal horn, spinal cord, and brain. Neural connections are altered, resulting in central plasticity. These changes result in a reduced pain threshold (equivalent to hyperalgesia), connection of mechanoreceptive neurons to pain pathways (equivalent to allodynia, in which nonpainful stimuli are perceived as painful), and increased receptive field size for pain neurons (equivalent to the spread of pain).
Persistent changes seen in rat anatomy and physiologic characteristics after effective treatment of a pain disorder help predict similar changes in humans who also report hyperalgesia (eg, a pinprick feels excessively sharp), allodynia (eg, bedclothes touching an affected foot cause pain), and the spread of pain to contiguous, undamaged areas. These studies provide evidence to both patients and their physicians that persistent pain can follow a remote injury because of neural system rewiring.
Psychosocial issues
Physicians and staff should be aware of psychosocial issues that may impact the care of patients with chronic pain. Meeting patient needs for education and reassurance, recognizing psychologic comorbidity, and using appropriate behavior modification techniques are important aspects of the treatment of chronic pain.
Meeting patient needs
Lipton and Stewart (15) recently questioned specialists and patients about what patients want most from the physicians who care for their headaches. The No. 1 response of the patients was education. Answering patients’ questions was rated as important by 86% of patients but only 15% of physicians.
To address patient needs, patient education must be a top priority. Patients who feel ill-equipped to managed their pain tend to overuse healthcare services (16). Patients with pain who receive educational treatment that emphasizes self-management techniques report less pain and disability than those who receive standard medical care (17). Handouts, commercially prepared pamphlets, Web sites, and discussions with healthcare providers are all effective educational tools (see box after article).
Patients with pain typically understand that their condition may be difficult to treat, and they often have been transferred from one practice to another. It is essential to show these patients that their healthcare providers care about them. Providers can convey this care by being seated during history taking and by asking the patient to disrobe for the physical examination. These two simple techniques show the intent of the healthcare provider to perform a detailed evaluation.
Patients who have chronic pain should not be treated like adversaries, nor should they be treated like consulting colleagues. Rather, we physicians can think of patients with pain as being similar to relatives–people who are part of our life as a result of circumstances beyond our control but for whom we have been given responsibility. Like our relatives, these patients deserve our serious interest and concern.
Recognizing psychologic comorbidity
Coexisting psychologic distress predicts the development of more recalcitrant chronic pain problems (18-20). Depression or anxiety is diagnosed in 58% of patients with chronic pain (21). Moderate or severe symptoms of depression and anxiety require evaluation, and possibly treatment, by a psychologist or psychiatrist.
All patients who complain of chronic pain should be screened for psychologic distress. Good screening tools include the Beck Depression Inventory (22), the Hamilton Anxiety Rating Scale, and the quality-of-life measures in the Medical Outcomes Survey short form (SF-36). Patients may also use screening tests found on the Internet (see box after article).
Physicians should learn to recognize personality disorders that can complicate medical treatment (23). In one study (24), almost 60% of chronic pain patients seen at a university pain clinic could be diagnosed with an Axis II personality disorder. Sansone and associates (25) identified features of borderline personality disorder in 47% of patients with chronic pain who attended a family practice clinic.
Staff members need to be informed of the diagnosis of personality disorder to avoid reinforcing inappropriate or manipulative behavior in the patient and to provide appropriate care. Strict ground rules must be established and adhered to for such patients. For example, if patients with a personality disorder are informed that they need to call the clinic 2 days in advance of routine prescription refills, they should not be given their prescription if they walk into the clinic and request its immediate refill. Similarly, these patients should be seen for their appointment during the scheduled time only and, absent unusual circumstances, should not be seen when they arrive either very early or very late for an appointment.
Another tip for dealing with patients who have a personality disorder is to be aware of patients who flatter the ego of their current healthcare provider by using negative comparisons to previous physicians and staff. This is a strong warning sign of future inappropriate, manipulative behavior.
Using behavior modification
A reward such as increased physician attention should be given to patients who comply with treatment recommendations. Noncompliant behavior should not be supported by an increase in physician visits and treatment. For example, when a patient does not follow a prescribed medication schedule, he or she should receive a written schedule and be asked to follow up after successful compliance with the required medication changes. A lengthy visit discussing the many circumstances that led to noncompliance is generally nonproductive and rewards negative behavior with extra attention. The patient always wins the game of “why I can’t possibly follow your rules because of my unique situation.” Healthcare providers need to offer an appropriate behavior framework by maintaining a clear structure, consistent rules, and rewards for positive patient response.
Before potentially habit-forming medications are prescribed, patients should be informed about expected compliance. A medication contract can be used to clarify the rules of drug use. Alternatively, a description of acceptable and nonacceptable medication use can be discussed with a patient. Once rules have been established, they need to be followed. Repeated episodes of poor responsibility for drug management (eg, medications are lost, stolen, or laundered) need to result in medication discontinuation. In this circumstance, referral to a pain specialist may need to be considered as well.
Medical issues
Medical issues should be addressed when caring for patients with chronic pain. These issues include ruling out the existence of a serious medical problem and identifying the most effective pain medication.
Ruling out medical problems
The care of patients who have chronic pain starts with ascertaining that serious, treatable medical conditions are absent. This step may be difficult in patients who report high levels of pain or show behaviors that indicate great pain and limit the ability for an adequate examination. When a physician is confronted with a new patient who complains of pain, poor patient cooperation may make interpretation of the physical examination difficult. If the patient is not acutely ill, the physician can let the patient know that he or she must receive a proper examination and diagnosis before treatment can be given. If necessary, the physician can require that the patient return for another appointment when he or she is better able to tolerate an examination. No treatment should be instituted until an examination has been performed that is adequate to rule out significant pathologic characteristics and establish a working diagnosis. Outpatients who are not acutely ill should not receive a prescription for pain medication to reduce excessive pain behaviors in order to allow for examination and diagnosis at a later date.
Understanding the treatment options
Every pain treatment has specific indications and expectations for outcome. For example, tricyclic antidepressants and antiepileptics such as gabapentin (Neurontin) are effective treatments for neuropathic pain. However, they are less effective for musculoskeletal pain. Treatment of neuropathic pain with these medications is not expected to reverse numbness or relieve all abnormal sensations, but patients can expect a decrease in the burning quality of the pain. Patients need to understand why particular medications are prescribed. Not only should they be informed about possible side effects, they should also understand expected positive effects. Patients need to know the expected level of relief and the time course over which improvement may occur.
Appropriate treatment goals should be determined with patients before therapy is initiated. These goals can later serve as outcome measures to determine treatment efficacy (table 1). Ideally, all symptoms are eliminated by treatment. This level of improvement, however, does not occur quickly and is usually not achievable. Therefore, reasonable, attainable treatment goals need to be established. The more specific these goals are, the better they serve as treatment outcome markers. For example, physicians should try to identify particular household chores that are problematic for a patient. Specific goals, such as “prepare three meals and do two loads of laundry per week,” are easier to attain than generalized goals, such as “do more around the house.”
Opioid therapy
Isolated treatment with opioids is not effective for management of chronic pain (26). However, opioids can provide a safe, cost-effective adjunctive pain therapy because they result in less morbidity and cost compared with the organ toxicity that can develop from analgesic use (27). For example, gastric ulcers occur in 4% of patients who have long-term therapy with nonsteroidal antiinflammatory drugs, and renal insufficiency occurs in 1% (28,29). Although opioids are relatively safe, they are not a panacea. Opioids may be prescribed to reduce chronic pain to a more tolerable level; they should not be prescribed with the expectation that they will completely alleviate chronic pain, treat depression or a sleep disorder, or relieve suffering.
Long-acting opioids provide more steady pain control and reduce medication overuse behaviors by providing a regularly scheduled dose. Despite an expanded role for opioids in some patients with chronic pain, 35% of primary care physicians report that they never prescribe schedule II opioids for chronic pain on an around-the-clock schedule (8). Physician comfort with opioids prescription can be improved by applying an appropriate-use algorithm (figure 1). When prescribing long-acting narcotics, physicians should use equivalents to the more familiar short-acting narcotics to better understand the amount of medication prescribed (table 2). Long-term opioid therapy should be prescribed like other long-term medications, using a regular schedule that is not adjusted by the patient. Just as antihypertensive or antidepressant medications are prescribed in such a way that patients are not permitted to self-adjust on a daily basis, pain medications should be prescribed using a fixed schedule.
Opioids do not have a ceiling dose to use when setting a maximum dose. Nevertheless, primary care physicians should probably seek consultation with a pain specialist before they escalate opioid doses to high levels (eg, >50 micrograms transdermal fentanyl [Duragesic] or >50 mg morphine sulfate twice daily, >40 mg oxycodone HCl [OxyContin] three times daily).
Patients with chronic pain should be asked about current, recent, and remote abuse of alcohol and drugs. Those patients with no history of abuse are at low risk for abuse of prescribed medications (30). Opioids should be used cautiously in patients with an abuse history, including remote abuse. Patients with current addiction problems should be referred to a drug rehabilitation facility before pain management is attempted. Patients with recent or significant abuse should be referred for evaluation by an abuse counselor.
Although the latest JCAHO guidelines require physicians to assess and treat pain complaints seriously, they do not endorse or require a particular treatment regimen. This position allows physicians to select treatment options with which they are the most comfortable, and these may or may not include use of opioids.
Physicians are often concerned about liability from the prescription of opioids. Interestingly, however, they can be liable for failure to treat pain as well as for inappropriate treatment practices (eg, fraudulent use of opioid prescriptions). In general, liability is minimized by appropriate documentation about patient assessment, previous treatment failures, considerations used in choosing the prescribed therapy, and involvement of the patient in goal setting and compliance maintenance.
Resources for understanding appropriate treatment patterns for patients with chronic pain and for the appropriate use of opioids are available from the Federation of State Medical Boards (see Model Guidelines for the Use of Controlled Substances for the Treatment of Pain, available online at http://www.fsmb.org) and the National Pain Education Council (http://www.npecweb.org). Charting forms to assist with necessary documentation for patients who have chronic pain have been published previously (31).
Collaborative treatment
Management of patients with chronic pain can be both time-consuming and emotionally draining. Many of these patients need a healthcare team to address their medical, psychosocial, and disability issues. Each healthcare provider should determine the part of treatment for which he or she is qualified and refer patients to other providers for additional necessary services. Dividing aspects of care among several healthcare providers also reduces staff burnout.
Other necessary services may be provided by nurses, psychologists, physical therapists, and occupational therapists (figure 2). When healthcare staff, the fulfilling pharmacist, or family members report concerns about medication misuse, consideration should be given to referral to a drug abuse counselor for evaluation.
Summary
Recently revised JCAHO guidelines for increased awareness and management of chronic pain require increased confidence in the treatment of chronic, nonmalignant pain by all healthcare providers. Providers need to recognize the important comorbidities of chronic pain that can complicate treatment and necessitate increased levels of intervention. Treatment plans should address not only symptoms of pain but also psychosocial issues, musculoskeletal dysfunction, and disability. The establishment of comprehensive treatment regimens that include appropriate education, reassurance, and behavior modification techniques improves outcomes and reduces staff stress.
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