Treating Chronic Pain: Focus on the Disability
Student Scholarship – 1st Place Research Review
Cecilia L. Stevens, PhD
Shabita Teja, BPharm, ND
Chronic pain is commonly defined as any pain lasting longer than 12 weeks in duration. This informal definition was developed to describe neuralgia that lingered after physical tissue trauma had been resolved. Theoretically, there should be no residual tissue trauma capable of causing pain 12 weeks after a successful course of treatment, thus leading to the conclusion that the pain being considered is both incurable and chronic.1 Unfortunately, the concept that 12 weeks of suffering defines chronic pain has been widely adopted and is now erroneously used in clinical practice as well as in popular culture. The formal definition of chronic pain is much more comprehensive.
Formally, the definition of chronic pain is pain where therapy may provide some relief but the underlying cause of the pain cannot be resolved.1 This certainly applies to the lingering neuralgia that was included in the informal definition, but it also extends to medical conditions that cause ongoing tissue damage, such as osteoarthritis or autoimmune disorders, as well as to the pain of cancer or other terminal illnesses. Chronic pain can theoretically be diagnosed after only a few days of suffering. The commonality between these definitions is that chronic pain is incurable. This difficult reality adds an enormous mental and emotional weight to the pain along with its physical consequences. In order to holistically treat chronic pain, it is imperative that all aspects of this complex condition be considered.2,3
The Experience of Pain
Pain of any kind has strong mental and emotional components. This is evident clinically when observing patients’ different reactions to the same procedures; a blood draw, for example, can cause one patient severe discomfort yet leave the next patient unaffected. Although the physical stimulus is the same, it represents only 1 component of pain. Cognition, expectation, memory, and emotion also play a part in the actual experience of pain.4,5 This suggests that the experience of pain can be diminished through learned attitudes and behaviors.2,6,7
On the neurological side, pain “lights up” the same parts of the brain, as do depression, anxiety, fear, stress, and social isolation, all of which are frequent comorbidities with chronic pain.2,6,8-10 Treating the mental and emotional aspects of chronic pain includes tracking these potential comorbidities.11 One of the simplest ways for a primary care physician to do this is to chart a Mini-Mental State Examination (MMSE) at each visit.2,12 It doesn’t have to be extensive, but recording a patient’s affect, mood, and orientation to time and place at each visit can be a valuable tool in identifying these comorbidities as well as for establishing a baseline from which the effectiveness of various treatment plans can be evaluated. Moreover, this examination proves to be useful both in directing counseling efforts and when referring to a mental health specialist.12
Pain is Not the Root Problem
One of the biggest failures in the treatment of chronic pain patients arises from both patient and healthcare provider focusing on treating the wrong problem. People consider pain to be the problem and thus focus on analgesia while curing the underlying cause if possible.4,9,13 As mentioned earlier though, chronic pain is not curable. What these patients and their well-meaning doctors are doing is called misdirected problem-solving.4 The biggest problem for chronic pain patients, or any patient with a chronic illness, is disability.2,6,8 A successful treatment plan will include analgesia and treatment for the underlying physical condition, but will primarily focus on healing the disability rather than attempting to cure an incurable condition.9,13
A cure is what most patients expect: you go to the doctor, there is an intervention, and you are cured.4,6,14 It’s a physician-driven process where all decision-making is in the hands of the doctor. Patients can actually get very invested in this concept, to the point of playing the “Good Patient” role where they refuse to make any of their own medical decisions. This is seen most severely in marginalized ethnicities, cultures, and socioeconomic groups, but can be found anywhere.15 For chronic pain patients however, being cured is not an option. Instead they need to heal. Healing can be defined as “the personal experience of the transcendence of suffering.”16 Healing is patient-driven, although the doctor plays a key role. Patients have to rewrite their personal story, where they advocate for themselves, and instead of casting their illness as the villain to be conquered, they include their illness as a side note to a rich and rewarding life.4,14 This degree of counseling may require referral to a psychotherapist; however, in all cases, the primary care physician plays a very important role.11,16
Rewriting the Story
Patient education and beliefs about their underlying condition are the strongest indicators of positive outcomes for chronic pain patients.8,13 Here, the doctor is an incredibly powerful co-author in writing or rewriting the patient’s personal story. Listening to the patient’s story with respect is a big part of helping them heal,16 and a key task for a primary care physician is to gently correct misinformation. Every patient with a complex medical condition has had it explained in lay terms at some point and very often has come away from this conversation with misinformation. Correcting this can be enormously helpful when rewriting the patient’s story with accurate beliefs and, as a result, improving their health outcomes.
Primarily focusing on maximizing quality of life, rather than on symptom diminishment, is another important part of healing.4,17,18 For many patients, maximizing quality of life will involve daily choices about levels of analgesia. Many analgesics are soporific and can cause iatrogenic disability in addition to any disability caused by the pain or underlying medical condition. It must be the patient’s choice when deciding whether to take the analgesic and stay at home, or to suffer with the pain and participate in social interactions and hobbies.13,15 Note that distraction can be a very effective form of pain relief. In fact, research shows that participating in physical activity, hobbies, and social interactions will actually diminish pain levels for most patients.4 Mental exercises such as self-hypnosis, meditation, or listening to music can also provide sufficient distraction for many patients, thereby decreasing their need for analgesia.5,9,17,19
An important part of rewriting the pain patient’s story is making a place in it for pain flares.20 Regardless of the underlying cause of chronic pain, there will be days for any patient when the pain becomes debilitating. Many patients start from a place of denial about the fact that their pain is chronic and, as part of this denial, resist planning for flares. This is a recipe for disaster when they suddenly have to call in sick, change childcare arrangements, cancel plans with friends, to name a few scenarios. It is often the stress associated with having to do all of this that frequently compounds the flare. Nobody wants to have a pain flare, but arranging in advance to make up lost work hours with weekend overtime, getting class notes from a friend or having another parent pick the kids up from school will not only alleviate stress but also minimize the negative effects of the flare on the patient’s life. Even something as simple as informing friends about the illness so that dinner plans can be cancelled due to a flare with minimal guilt can alleviate a lot of stress.14,20,21
Any narrative about chronic pain will at some point encounter the question, “Why did this happen?”14,22 Some pain patients have a cultural background where pain is considered a relatively normal part of life or will find an answer to this question in a spiritual context of suffering.15,23,24 Most patients, however, will look for someone to blame. Regarding their chronic pain patients, doctors also frequently look for someone to blame for their incurable condition. Patients tend to blame a healthcare provider, past or present, for failing to diagnose or adequately treat the underlying illness. When doctors blame the patient, it is usually for failing to seek help soon enough, for failing to comply with the treatment plan, or – occurring all too often in the case of chronic pain – for malingering. It is important to be aware of these issues while helping the patient to rewrite their personal narrative.22
Another concern is internalized stigma. About 40% of chronic pain patients are struggling with this, often compounded by the fact that pain is an invisible symptom.25 Not only doctors doubt and blame them, but employers, friends, and strangers on the street can be extremely unsupportive when faced with an inconspicuous physical cause of disability.14 This can be a serious problem in avoiding or treating the common comorbidities of depression and anxiety. Education of the patient’s social support network can help, as can lifestyle counseling for the patient on avoiding unsupportive people.21 As with pain flares, having a plan in place can help. In the case of stigma, a mantra or reassuring activity, such as meditation or calling a supportive friend, can help minimize the social and emotional pain.
No article on the mental and emotional aspects of chronic pain would be complete without a few words on addiction, especially given the current opioid crisis. Chronic pain patients have a complicated relationship with analgesics: they often need them in order to function but also need to minimize their use in order to avoid iatrogenic disability from being too drugged to function.14 While the chronic pain population isn’t more prone to the illness of addiction than any other population, it’s safe to assume that any chronic pain patient has been exposed to potentially addictive drugs during the course of their chronic pain journey. This is frequently during the diagnosis or early treatment phase in which patients are exposed to a number of different medications in an effort to achieve analgesia.26 Effective analgesia often requires the use of potentially addictive drugs, leading to 2 main fears about addiction in the chronic pain population: becoming an addict and being wrongly labeled as an addict.27
Many pain patients will become physically dependent on their medications, in the sense that they will suffer withdrawal symptoms if the drug is abruptly decreased or discontinued. This is an expected result of the long-term use of many types of drug (eg, opioids, antidepressants, caffeine) and is not the same as addiction. Addiction is a neurobiological disease characterized by impaired control over drug use, continued use despite harm, compulsive use, and craving. People with this illness can become addicted to activities (eg, shopping, gambling, sex) as easily as substances.26 Educating a chronic pain patient on the difference between physical dependence and addiction can help those patients who chronically under-medicate due to fear of becoming an addict.27
The other fear, that one will be wrongly labeled an addict, is more difficult to address. Part of the difficulty with chronic pain patients and addiction is that chronic pain patients’ legitimate reactions to and feelings about their medications are very similar to addicts’ reactions to and feelings about their drugs of choice: lack of following prescription directions, drug-seeking behaviors, and demonstrable desperation for the medication.3,5,6 The pain patient is avoiding pain, while the addict is seeking a high or avoiding withdrawal symptoms. It can be very difficult for a physician to tell the difference, and many pain patients are consequently labeled as addicts, under-medicated, and turn to cannabis, alcohol, or street drugs to self-treat.26,29,30 When treating a suspected addict, frequent visits and dispensing prescriptions of small amounts of any potentially addictive substance constitute a basic protocol.9,26 Non-addict pain patients won’t enjoy this infantilizing treatment, but will stabilize when they are prescribed adequate analgesia and they won’t perpetually request higher doses. Addicts will generally continue with drug-seeking behaviors unless they are also being treated for their addictive personality disorder.26 Any serious suspicion of addictive personality disorder should be referred to a doctor specializing in that area.
Summary & Conclusion
While chronic pain is, by definition, incurable, it is possible for chronic pain patients to heal by rewriting their personal story into one of a fulfilled life despite pain. Patient education is key to a positive outcome. Anxiety and depression are common comorbidities with chronic pain and should be watched for. Addiction is also a common problem and can be difficult to correctly diagnose. Even if the patient is referred to a specialist for psychotherapy, the primary care physician plays a very important role in helping a chronic pain patient to heal and transcend their suffering.
Meet the Author
Meet the author on June 25th, 7 pm for a discussion at the Boucher Institute of Naturopathic Medicine – 435 Columbia St New Westminster – detail and registration here https://www.facebook.com/events/407767379810056/
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Cecilia L Stevens, PhD, came to naturopathic medicine after a career in research chemistry; she is now a 4th-year student at Boucher Institute of Naturopathic Medicine (BINM) in British Columbia. After her own struggles with chronic pain and Ehlers-Danlos Syndrome, Cecilia is interested in helping patients with chronic pain and illness by harmonizing naturopathic treatments with conventional medical regimens.
Shabita Teja, BPharm, ND, went to the University of British Columbia to pursue a degree in pharmaceutical sciences, and then BINM to study naturopathic medicine. Shabita is both a licensed pharmacist and licensed naturopathic doctor. As someone who has gone through her own health challenges including chronic pain and ulcerative colitis, Shabita has seen first-hand that the balance between acute and supportive therapies is one of the keys to wellness. As such, she strives to bridge the gap between conventional and naturopathic medicine to not only treat but support her patients’ well-being. Shabita practices at Sinclair Wellness Centre; visit www.tejawellness.ca for more information.