Wednesday, June 11, 2014

A Better Approach to Chronic Pain Management

[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.

If the treating physicians are following the science, then the point of governing law becomes moot. Instead, we focus on evidence based best practices.

Dr. Pamella Thomas 
On Twitter @PRIUM1