[A guest post from PRIUM's Medical Director, Dr. Pamella Thomas]
Maybe
the discussion for specialists treating chronic pain should shift away from
what law governs their treatment plans and toward what they should really be
treating in chronic pain patients.
The
traditional biomedical model of chronic pain assumes chronic pain occurs
because of deviations from normal and measurable biological (somatic)
variables. In other words, there is always a direct causal relationship between
a specific pathophysiological process and the presence and extent of a
particular symptom.
Physicians
are not, by and large, viewing the individual patient through the
biopsychosocial model, which sees pain and disability as a complex interplay of
biological, psychological and social factors that, when properly understood, can
be assessed and managed. The operative word here is ‘managed’ as any other
chronic disease would be managed, instead of trying to treat as you would an
infection which is acute and can be cured with the correct medications. Treating
chronic disease starts with objective measures of current status and function followed
by a treatment plan to manage any distortions. Looking at these treatment
records with the paucity of adequate clinical evaluation data and any objective
supporting documentation, it is not surprising that continuing opioids is the
only constant treatment plan. The patients are all "constant and
stable"!
Some
physicians unwittingly miss this distinction and do not educate the patient to
set the right expectations. This leads
to failures, delayed recovery, and unnecessary disability and cost. For example, neuropathic pain which
traditionally was thought to develop in a primary peripheral nerve is now seen
with recent investigation (using functional neuroimaging techniques) to have a
large centralized nerve component (in conditions such as chronic low back pain,
fibromyalgia, irritable bowel syndrome, and CRPS).
Pain
psychopathology and physiology have to address the various components
generating this pain. This may include cultural background, belief systems, relationships
and interactions with the environment, including home, work, and social environments,
as well as their interactions with the disability system and their health care
providers. All of these interactions contribute
to the continuing pain when not recognized and managed according to evidence
based guidelines.
This
leads to neurobiological causes of persistent pain, when structural and
functional CNS changes may amplify and maintain the experience and disability
of certain pain conditions. We know
stressful stimuli can trigger potent analgesia, mediated by endogenous opioid
systems in the CNS. The large prolonged levels of opioids being prescribed in
these conditions are more than likely increasing pain from hyperalgesia, leading
to intractable pain conditions. These
patients usually do better when weaned and adjuvant and/or co- analgesics are
used along with integrated multimodal non-pharma therapy that addresses the
pain triggers in the individual patient.
Along with patient education (emphasizing that pain is a perception that
needs to be managed without opioids long term), this usually leads to a 'cure'
and return to function.
