Reducing Reliance on Pharmacologic Treatment: Difficult Conversations, Part III

This is the first article in a series of eight articles by Ilene Robeck, M.D. regarding difficult conversations a primary care provider may have when dealing with patients with chronic pain. This series is meant to be a guide for primary care providers facing these situations. 

  • Difficult situation #3: Finding a better way to communicate the benefits of lifestyle change

Advice: One of the most important conversations that may be had with patients, regardless of their medical condition, is the notion of limiting reliance on pharmacologic intervention. This is true with patients with chronic pain, diabetes, hypertension, heart disease and many other chronic problems that require life style changes to maximize outcomes.

Whenever opiate therapy is initiated, a discussion about the importance of non-pharmacologic therapy and lifestyle changes should be a mandatory part of that first prescription. An opiate agreement is an opportune time to discuss the biochemical changes that may occur with exercise, proper diet, smoking cessation and proper recreation, in a way that the patient can understand.

Many patients are surprisingly receptive when taught about the role of neurotransmitters and pain, i.e., the body’s own natural pain relieving system of endorphins, dopamine, serotonin and norepinephrine. The following example can be used to explain this, by using an acute pain model in a way that makes sense to most patients.

A practitioner can begin by asking the patient to think back to their childhood and recall how long it took for the severe pain of a skinned knee to subside. Most patients will recall that the pain would last minutes or hours, but not days. It can then be pointed out to the patient that their pain had decreased naturally, without pharmacological intervention, as a result of the body’s innate pain-relieving capabilities. This realization on the part of the patient tends to set up a much more successful framework for discussion of non-pharmacologic pain management strategies. Patients tend to become more receptive to counseling about activities that they can do to stimulate endorphin release.

Remind them that opiate pain medications can actually decrease this response. Because of this blunted response to endorphins, improving endorphin levels must be an active process and some activity level – both physical and intellectual – is mandatory for opiate pain medication to work effectively to improve function and warrant the risks associated with their use.

Ultimately, effective communication is a major part of convincing patients that lifestyle changes are an important component of managing their pain.

Dr. Robeck was a chronic pain consultant for primary care for 25 years prior to joining the Veterans Health Administration. She works at the Bay Pines VA Healthcare System in Bay Pines, Florida. Because of her experience with chronic pain management, her primary care practice has increased to include consulting to other VA primary care providers. To put this article in context please read Dr. Robeck’s introductory article, “It’s Never Too Late to Start All Over Again“.