Issues facing physicians in chronic pain management

Pain is something that we are all familiar with to one extent or another. Unfortunately, nearly a third of the industrialized world suffers from chronic pain, an ill-defined, often nebulous and immeasurable entity, which when we are presented with it in the office setting, often evokes a pained expression on our countenances. Because pain is not a readily quantifiable entity, has potential penalties for both under- and over-treatment, and has inherent variability in both the patient and the treating physician, an entire set of beliefs and attitudes have become entrenched in our thinking as clinicians.

I recently had the opportunity to work with Esmond Nwokeji, Ph.D., and TAFP on a survey to explore family physicians’ real and perceived beliefs and attitudes toward pain. As far back as we are able to go historically, the relief of pain has been at the heart of the practitioners’ capabilities. Relief of acute pain has been the focus of treatment since before organized medicine and perhaps all the way back to the dawn of man. With the advent of improved living conditions, eradication of many public health threats, and an expanded life expectancy and survivability, there is an ever-growing population in need of chronic management of pain. We are now confronted daily with patients who suffer from post-injury pain from accident, industrial or military wound, post-cancer treatment and often from malingering.

In the case of the latter and the massive regulatory and legislative burdens that have resulted, many physicians have grown jaded and weary of treatment of this problem. We have no foolproof tool to detect pain, and cannot witness the headache, migraine or backache that have no measure other than the statements and ratings of the patients themselves. In a time when the word of the patient was sufficient and could possibly be trusted, this was not an issue. Now with prevalent abuse and diversion of drugs we are continuously walking a tightrope of angst over proper prescription practices to ease the suffering and avert the abuse.

In spite of great advances in medicine and the discovery and development of many new classes of treatment and modalities of pain relief, a formidable pillar of treatment exists in the form of opioids. Narcotics have a long-established prime role in the relief of many types of pain, but they have also become the subject of elicit trafficking, misuse, abuse and improper use in the last few decades. This has caused a significant shift in the view of these agents from beneficial to potentially dangerous, and has become complicated by cumbersome legislative and regulatory oversight.

When approached by a patient for the management of chronic pain entities, the modern family physician can become overwhelmed with layers of secondary variables, second thoughts, suspicions and trepidation if the utmost of care is not exercised toward the appropriate dispensation of what, for many, are miracle agents. None of us wishes to harm the patient and we all desire the utmost medical care and pain relief; yet the skills required to ferret out the true character of the visit and the possible secondary gains can at times be overwhelming.

My own experience being in a rural community has been that even the “pain specialists” send patients back and refer them to me when the high-dollar interventions fail. The management from day-to-day, week-to-week and year-to-year returns to the family doctor. It remains well within our skills to do this, but does require constant vigilance—a skill set of new forms, discussions and protocols to protect both ourselves and our patients—and can in fact lead to highly rejuvenating, rewarding and indeed essential component within the armamentarium of the modern family physician.

The important concept to recognize is that as with all agents we customarily use, there are indications as well as contraindications with regard to prescribing. Many newer pain contracts have become available, which protect both parties to the contract from harm. While these are often thought of as cumbersome, they add a layer of informed consent beyond the customary discussion or even some current surgical forms. If used properly, they can enhance the doctor-patient relationship by opening dialogue and clarifying up-front risks, benefits and expectations of therapy for a condition that often has no cure or endpoint, and frequently will require increased dosing and further augmentation along the way. This is not all that different from diabetes, hypertension or myriad other chronic diseases that we now manage at an ever-increasing rate.

Restoring a patient’s ability to function, improving quality of life, and reducing depression and misery are laudable goals that can be obtained with thought, contracting, perseverance and empathy. The god of dreams, son of the god of sleep, is like a double-edged sword, and family doctors need the wisdom, skill set and ability to wield it well, employ it appropriately and withdraw as needed as we treat this growing population of the suffering.