The Logic of Pain Management

The arbitration of pain, one of the human body’s natural defense mechanisms, and alleviation of patient suffering present an interesting clinical challenge for the clinician. There are few medical conditions where the input of the patient is as crucial to the desired outcome of therapy as that of the clinician. Indeed, most common ailments appropriately rely on the experience and expertise of the healthcare provider to designate the desired target of therapy. When a treatment plan is determined for elevated blood sugar, or hypertension, for example, it is fairly a one-sided, and clinician determined goal-based therapy. The task of when the need to reassess and determine whether success has been achieved or not, falls squarely on the information given by the patient and digested by the healthcare provider. One could make the argument that even though sometimes quite challenging to treat, these conditions pale in comparison to the task the complexity of arriving at a successful outcome when attempting to manage pain.

This article will attempt to put in clear and simple perspective where when managing pain, the patient-clinician relationship aligns itself with other medical treatments, and where it separates itself. If nothing more is achieved, hopefully the logic of goals of therapy of pain will be more easily understood and prioritized.

The complex task of pain must begin with a foundation not unlike that of other medical conditions:

    • A detailed history and physical– It is imperative for this critical step not only to fact find on the clinician’s part, but also to begin the step of cementing a relationship that has the potential to make or break the successful treatment of pain. The clinician needs to establish the hallmark of an effective dialogue, trust and compassion for the patient’s pain. This step also provides the opportunity for the clinician to listen and understand how to explore the impact of pain on the patient’s life.

 

    • Any appropriate testing that can facilitate diagnosis – There may or may not be any testing to be done, depending on the signs and symptoms. A clinician may feel that the history and chief complaint point towards the diagnosis of migraine headache for example, and opt to treat with first-line therapy. On the other hand, a patient that presents with low back pain of sudden onset and acute nature may opt to order radiologic tests of the spine before intervening.

 

    • Establishment of realistic and desired common goals of further treatment and/or evaluation – This would be a point where effective evaluation and treatment start to take a unique path. It is critical for the clinician to understand what the patient is looking for in terms of successful treatment, regardless of the painful condition. In some situations, the diagnostic answers might be clear, as in headaches, but the impact on the patient’s life, quality of life, ability to perform activities of daily living must be identified, documented, and constantly revisited along the continuum of care.

 

    • Formulation of a treatment plan – When treating pain, the clinician and the patient need act as a team to identify measurable, beneficial hallmarks of therapy. The point of this is valuable in many ways, the most significant one being able to measure success or failure, and all parties understanding what those measures are, and what steps will be taken in the event success is not achieved at one point or another. If the patient understands what the alternative plans are up front, and that there indeed are alternative plans, they may be much more inclined to be more patient with therapeutic trials. This would also be the place where the healthcare provider can detail what everyone’s responsibilities are from all perspectives with respect to use of opioids or other controlled substances, such as agreements, periodic testing, and risk management strategies, etc.

 

    • Flexibility in modification of treatment based on periodic assessment, and patient questioning – The idea that the patient may for some reason become unstable in their treatment for pain (e.g., experience periods of breakthrough pain) is something that may require add-on therapy for a short period of time, or even rotation to a different form of drug, or modality. The point is that periodic reassessment is necessary to monitor progress, regress, patient compliance, and even exit strategies when opioids are employed.

 

  • Referral to a pain specialist – The point at which a primary care clinician may opt to refer the patient to a specialist for treatment will vary based on experience, expertise, and comfort level with the medications and modalities necessary for treatment. The specialist may be able to use a more technically complex approach to pain management based on attempting to modify the mechanism responsible for the pain, which might go beyond the scope of a primary care provider. The most successful dynamic between the primary care clinician and the pain specialist is one where once a treatment plan is formulated and implemented by the consultant, and as in all other situations, the information is communicated, and then the patient returns to the well-forged relationship with their primary care clinician.

When questioned about what patients with chronic pain might consider as a successful course of treatment, it may very well be surprising that alleviation of 100% of their pain might not be what they are looking for. The key is to communicate with the patient in order to understand that special characteristic of pain management and through a trusting and caring relationship built on realistic goals and expectations find the path to success. In most cases, success will be the ability to help that person get back to the place they want to be – their life.

A corresponding version of this article that is appropriate for your patients, titled “Control Your Pain by Working with Your Health Care Provider” is available at www.painaction.com.