Managing Patients' Pain: Insights From a Primary Care Provider

Science

Pain interference is a measure of a person’s difficulty with performing daily, social, or work-related tasks that is due to pain. Pain self-efficacy is a person’s confidence in his or her ability to manage pain. A study with participants with high pain intensity aimed to determine characteristics associated with high pain interference. Researchers found that patients who reported low or moderate pain interference also had significantly lower scores of depression and higher levels of pain self-efficacy when compared with patients in a high pain interference group. These results suggest that chronic pain treatments that address symptoms of depression and enhance pain self-efficacy may decrease pain interference and potentially improve function (Adams, Dobscha, Smith, Yarborough, Deyo, & Mirasco, 2018).

Insights From a Physician

William Becker

William Becker, M.D.

Associate Professor, Yale School of Medicine

Core Investigator of Pain Research, Informatics, Multi-morbidities, and Education Center of Innovation
Veterans Affairs (VA) Connecticut Healthcare System

"Managing chronic pain is not much different than other chronic disease management."

"Appreciating the biopsychosocial aspects of the condition and tailoring the treatment plan to areas where the patient is struggling is very similar to most other conditions we treat—especially now that we have strategies to address opioid concerns."

Dr. Becker is the medical director of the Opioid Reassessment Clinic, a multidisciplinary pain clinic within the VA Connecticut Healthcare System. Primary care providers (PCPs) refer patients to Dr. Becker’s team if the PCPs observe that patients are experiencing adverse effects from opioids, like safety issues (e.g., falls, cognitive dysfunction); misusing the medication or developing a substance use disorder (SUD); or not adequately controlling pain within established standard practice. According to Dr. Becker, treating chronic pain is not much different from treating other conditions. This Science to Medicine article highlights insights from Dr. Becker to keep in mind when managing a patient’s pain in the primary care setting. Read below to learn more about his approaches to treating people with pain and special considerations to employ that work to address addiction or avoid it by using non-opioid/alternative therapies, counseling, and other strategies.

Getting Started: Key Considerations for Success

Fundamentals for Providing Care

Learn about assessment and counseling approaches. Dr. Becker recommends that PCPs consider a biopsychosocial assessment for patients because it can help clinicians communicate with patients, accurately assess whether patients need or should continue taking opioids for pain, and develop individualized treatment plans. Recent research also encourages PCPs to use evidence-based counseling approaches (e.g., Five A’s, FRAMES, BATHE) with patients in the primary care setting. Dr. Becker recommends the National Institutes of Health-funded Centers of Excellence in Pain Education modules as a high-quality resource with foundational information on clinical pain management and counseling approaches.

Take a team approach. Dr. Becker emphasizes that developing an interdisciplinary team—for example, one that includes a physical therapist, a health psychologist, an addiction psychiatrist, to name a few—is very helpful because patients typically have complex comorbidities, both medical and psychiatric. A multidisciplinary team allows sharing of knowledge and clinical experience to coordinate a group approach to the most effective management of each patient. However, if your practice does not include these clinicians, consider developing professional relationships and collaborating with others locally or remotely for consultation or referral.

Consider non-opioid pharmacotherapies and complementary health approaches for chronic pain. Dr. Becker recommends talking to patients about complementary health approaches for chronic pain, including health psychology, acceptance of and commitment to therapy, meditation and mindfulness-based stress reduction, yoga, acupuncture, chiropractic services, and physical therapies. Listening, showing empathy, and using positive framing when discussing past experiences and alternative treatment options help patients be more open-minded to alternative methods for their chronic pain treatment.

Monitor patients for signs of SUD and get support to address it. As with any illness, try to determine the cause of a patient’s primary complaint. If you identify that the complaint involves (or is stemming from) SUD, consider offering a new treatment approach. Learn more about addressing addiction from NIDAMED.

During the Visit

Use a patient-centered approach and help motivate change. Persistent severe or chronic pain often results in restricting one’s activities and/or social isolation. Reliance on medication may have fostered a passive approach causing pain to become the focus of a patient’s life. Dr. Becker recommends using a simple tool called VEMA: validating the patient’s pain experience and educating them to help them shift from a passive mindset that something external will relieve their pain to motivating and activating patients to participate in their own pain management and healing. To help support your relationship with patients, which can also make them more amenable to change, check out NIDAMED’s Words Matter which includes tips for language to use and avoid when talking to patients.

Discuss pain treatment options. Consistent with the Centers for Disease Control and Prevention Guideline for Prescribing Opioids for Chronic Pain, Dr. Becker recommends generally avoiding initiation of long-term opioid therapy. However, if non-opioid modalities have not worked, and the prescriber assesses the benefit from medication will likely outweigh harm, opioids could still be considered. Important considerations are to keep doses low, monitor effectiveness and side effects closely, and watch for red flags suggesting SUD or other adverse effects. Other pain treatment options to explore include non-opioid therapies and complementary approaches for chronic pain (see above) and addiction treatment, if a SUD is identified. Use this chart to choose a SUD screening tool that is right for your practice.

Offer a slow taper if needed. When discussing tapering or discontinuation of opioids, Dr. Becker explains to patients that opioids may be doing more harm than good and lets them know that he’d like to work with them to make a change to their pain/opioid treatment plan. If you are considering tapering to a reduced dose or discontinuing opioid therapy for a patient, review the U.S. Department of Health and Human Services Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics for up-to-date information on this approach. Emphasize to patients that you may be reducing their medication prescription but you are not reducing their care.

Visit NIDAMED for additional resources for you and your patients.

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