Chronic Pain Treatment Often an “Imperfect Solution”

LAS VEGAS — The desire of healthcare providers to come as close as possible to providing the “perfect” solution—completely relieving their patients’ chronic pain—may set the stage for unrealistic expectations of pain treatment. 

These unrealistic expectations could, in turn, lead to patient frustration, lack of adherence to treatment plans, and other nonproductive or negative outcomes, according to Kevin L. Zacharoff, MD, of PainEDU.org, who spoke on this topic during a session here at PAINWeek. 

“Thinking about chronic pain treatment as more of an imperfect solution, and one that in many cases may be a negotiation instead of a one-way outcome, has the potential to help patients and healthcare providers look at chronic pain treatment as an ‘aim high but shoot low’ perspective,” Dr. Zacharoff said. 

A significant amount of attention is being paid to helping clinicians avoid the paternalistic approach in managing chronic pain and instead employing a shared decision-making approach, one that is calibrated with realistic goals and expectations, Dr. Zacharoff explained. 

Assessing patients is the foundation of pain treatment, including obtaining information on duration, frequency, and severity of pain. However, there are no objective tests that can quantify pain quality and intensity, so assessing pain largely becomes a “subjective experience.”¹

There is also much that has been written about what Dr. Zacharoff termed “magic solutions,” or those solutions that offer people “complete relief.” He urged clinicians to counsel their patients and help dispel these “complete relief” claims. 

“You want to avoid setting up the situation for unrecognized goals, frustrated patients, and the healthcare provider carousel, where patients go from one clinic setting to another because of unrealistic and underachieved goals,” he cautioned.  

The way to avoid setting up unachievable goals is simple, Dr. Zacharoff said: “Don’t make promises that you can’t keep. Or that others can’t keep. Or that people want you to keep. Or that you don’t know you can keep.” 

Citing published data, Dr. Zacharoff noted that pain has been designated as the “5th vital sign.” ^2,3

He noted that a successful pain control plan generally includes establishing the diagnosis, treating the cause of the pain when possible, optimizing analgesic use, implementing nonpharmacologic interventions, maximizing physical and psychological comfort and function, and referring the patient for invasive pain management options when indicated. 

Positive treatment outcomes in chronic pain management often include some degree of improved function and a reduction in pain scores, Dr. Zacharoff explained. He defined positive functional changes as those that include increased activity and behavioral changes, such as better self-image, coping, and an increase in positive social engagement. 

Discussing what he called a “roadmap” for managing patients with chronic pain, Dr. Zacharoff urged clinicians to “mutually communicate and identify likely and unlikely outcomes of treatment, roles and responsibilities of providers and patients, expectations of all parties, past experiences, and alternative treatment strategies based on mutual decisions.” 

“In many cases the management of chronic pain is a negotiation of pain and function, and not an all-or-none phenomenon. Some of the best ingredients of managing chronic pain are realism, truthfulness, and pragmatism,” Dr. Zacharoff concluded. “We have made pain rating the 5th vital sign, but maybe the pain/function ratio is what the vital sign should have been. It’s not a perfect solution, but it’s possibly a more realistic one.”

References

1. Zacharoff KL, Pujol LM, Corsini E. The PainEDU.org Manual: A Pocket Guide To Pain Management. 4th ed. Inflexxion Inc.; Newton, MA:2010.
2. Lorenz KA, Sherbourne CD, Shugarman LR, et al. “How reliable is pain as the fifth vital sign?” J Am Board Fam Med. 2009;22:291-298.
3. Lynch M. Pain as the fifth vital sign. J Intravenous Nurs. 2001;24(2):85-94.