Establishing Boundaries is Key in Treating Patients with Chronic Pain

A therapeutic relationship is often predictive of a positive outcome.
A therapeutic relationship is often predictive of a positive outcome.

Las Vegas — Physicians need to establish boundaries when treating patients with chronic pain, as this can help improve the provider-patient relationship, according to a presentation at PAINWeek 2016.1

David Cosio, PhD, a psychologist in Chicago, noted that patients and physicians need to establish a collaborative care model.

"Several studies [in psychology fields] have found that it doesn't usually matter what type of therapy was being conducted, what mattered was that the therapeutic relationship was predictive of positive outcomes. It is no different in pain medicine," Dr Cosio said.  

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Part of the collaborative approach to pain treatment, Dr Cosio explained, is sharing responsibility when pain medications are prescribed. He cited data from the US Centers for Disease Control and Prevention (CDC) to underscore the importance of this shared responsibility. In 2014, more people died from drug overdoses than any other year on record and most of those deaths involved an opioid, either a prescription pain reliever or heroin, according to the CDC research.2 The rate of opioid overdoses tripled from 2000 to 2014.

“Sometimes saying no to the patient is the therapy. Sometimes rejection is redirection,” Dr Cosio told Clinical Pain Advisor, adding that while physicians are not obligated to provide opioid prescriptions, they are obligated to provide care. 

There are 4 steps in setting patient boundaries, according to Dr Cosio. First, the physician should name the behavior that is not acceptable. The physician should then express his or her expectations of the patient. The third step is to decide what will happen if the boundaries are not respected. The final step is validation. Dr Cosio warns that establishing boundaries may not always be comfortable, so it is important to become familiar with other tools in pain management to empower clinicians to set boundaries.

Opioid pain agreements, random urine screens, patient pain education, state prescription drug monitoring databases, opioid risk tool assessments, and decision trees are just some of the other tools to help physicians set and maintain patient boundaries, according to Dr Cosio. 

“Due to high demands imposed on providers to provide efficient patient care, providers may overlook or be unaware of the different tools available to them to assist them in pain management decisions,” Dr Cosio said. "It is important to set boundaries early on in the relationship, to keep consistent in your messaging, to document interactions with the patient, and to use policy/procedures as back-up when necessary, as well as other tools available in pain management.”

References

1. Cosio D, The gentle art of saying “no:" how to establish appropriate boundaries with chronic pain patients. Presented at: Pain Week 2016. Las Vegas, NV; September 6-10, 2016.

2. Rudd RA, Aleshire N Zibbell JE, et al.  Increases in drug and opioid overdose deaths—United States, 2000–2014. MMWR. 2016;64(50):1378-1382.

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