What Should We Be Doing to Prevent the Development of Chronic Pain?

LAS VEGAS—What, exactly, is chronic pain, who develops it, and can it be prevented? Simply stated, the definition of chronic pain is “severe, long in duration, and associated with impairment,” said Michael R. Clark, MD, MPH, MBA. However, that definition is “not helpful,” especially when faced with a patient with new chronic pain. What defines that person?

Acute pain, he said, begins with some type of tissue injury. What is not yet understood is why some people develop chronic pain and others do not.

“The issue we're getting at is, what should we be doing to prevent the development of chronic pain?” asked Dr. Clark, who is Vice Chair, Clinical Affairs, and Director, Pain Treatment Programs, Department of Psychiatry & Behavioral Sciences at Johns Hopkins Medicine, Baltimore, Maryland. More linkages—albeit “silent”—exist between acute and pain “than many of us realize.”

Using eight different risk factors in four domains, Dr. Clark illustrated how clinicians should formulate the treatment for patients with acute pain to prevent development into chronic pain.

The four domains—diseases, dimensions, behaviors, and life stories—help frame the case. He outlined what clinicians should do for patients for each of the four domains.

  • For diseases, the clinician should “search for all possible broken parts causing pathology, fix as many broken parts as completely as possible to minimize pathology, and select treatments that will minimize new damage and subsequent pathology.”
  • For dimensions, descriptions of who the patient was before the illness should be obtained; how much of each individual trait a patient possesses should be recognized; and the strengths of each trait should be matched with specific tasks to optimize capabilities.
  • For behaviors, “point out problematic behaviors every time they occur,” he said. “Insist the patient take responsibility for his choices and acknowledge goals.” Productive behaviors should be emphasized and reinforced whenever possible.
  • For life stories, “expand the history to include every aspect of the patient's life; understand what it means to the patient to suffer from pain; and help the patient find an answer to the question, ‘what good does life hold for me?'”

He provided a case example that illustrated these points: a 45-year-old Korean woman had her foot crushed by heavy equipment at work. Although she had immediate reconstructive surgery for stability, her compliance with physical therapy was poor and she had high levels of acute pain both pre- and postoperatively. She was treated with short-acting opioids and acetaminophen and prescribed multiple agents for insomnia and anxiety. After 6 months, she was referred to orthopedics for a below-the-knee amputation as well as for a psychiatric evaluation.

Dr. Clark said although he tried to convince her not to have the operation, the amputation was performed. In addressing the four domains in her follow-up care, he treated her for major depressive disorder and post-amputation pain (diseases), she got a puppy and received a prosthetic and physical therapy (dimensions), had her opioid tapered and joined support groups (behaviors), and eventually returned to work and divorced her husband for infidelity (life stories).

He summarized by noting that hope for preventing chronic pain includes recognizing profiles of risk for new chronic pain, preventing the transition from acute to chronic pain, treating specific causes of new chronic pain, and addressing the nature of barriers to restoring health.