LAS VEGAS—Chronic pain can sometimes be too complex a challenge to easily fit into a strictly reductionist biomedical model of care, according to Michael Saenger, MD, FACP.
A “find it and fix it” reductionist model has produced many advances in diagnosis and therapy, Dr. Saenger said to attendees at PAINWeek 2014, but it “may miss the complexity of the whole.”
Unlike acute pain, which is usually transient, simple, biomedical in origin and readily curable, complex chronic pain is usually long-lasting, complicated, “bio-psycho-social-spiritual” in nature, and “manageable, not curable,” he said.
Diagnostic clues include “enigmatic” presentations to multiple primary care physicians, declining function over time, severe emotional distress and disability that has not responded to conventional treatment, and “significant dissatisfaction with medical care,” he said.Chronic pain is often driven by stress and poor coping skills; deconditioning; anxiety; depression; central sensitization; and substance use disorders, he said.
Applying a biomedical reductionist model to complex chronic pain sidesteps addressing psychosocial factors that can meaningfully contribute to pain management. That needs a rethink, he argued.
There is an important gap between apparent biomedical causes — objective underlying signs and evidence for subjective pain – and the pain experienced by patients, he noted. “Pain is what the client says it is,” he explained. “Psycho-social pain is real pain, but chemical coping worsens problems.”
The search for quick fixes to complex pain leads to a “treatment trap” or “dependency and disability trap,” he argued—and ultimately, a growing sense of frustration, helplessness and hopelessness.
Patients are often trapped in a cycle of frustration, he said: a hopeful phase with a new treatment, followed by doubt and eventual hopeless phases, and finally, rejection. That cycle is repeated as additional or alternative pharmacotherapies and treatments are attempted.
A biopsychosocial alternative to this approach, for chronic pain, is to treat the “total person,” mind and body, says Dr. Saenger. Diagnostic strategies should include comprehensive psychosocial assessments rather than high technology tools alone, for example. Emphasis should be on assessments of patient anxiety, depression, and substance abuse disorder, rather than repeated diagnostic imaging exams, he said.
“Hear the client’s life story,” he said. “Gather a detailed social history.”
The treatment goal should not be to “cure” pain but to restore function. And rather than unrealistic expectations of immediate pain relief, therapeutic goals should be the long-term restoration of function.
Rather than being passive or helpless recipients of medications, patients should be encouraged to become active, co-responsible participants.
It is important to validate – to convey to the patient that their pain is real and believed – before educating them about a collaborative biopsychosocial model of care. Motivational interviewing enhances this message, he said.