One of the most fearful and frustrating events in my correctional medicine world used to be when a new chronic pain patient would arrive in my clinic. A typical patient would be a “Ralph,” a middle-aged man who has had chronic back pain for many years. Ralph has had a couple of back surgeries, steroid injections and more than one kind of stimulator, none of which has been effective. He arrived at the jail taking a long list of sedating medications such as muscle relaxers, gabapentin, and sleeping aids plus, of course, big opioids. In addition, Ralph has alcohol abuse issues. The reason he is in jail is a felony DUI charge. Now he is in my medical clinic, looking expectantly at me. How am I going to fix his pain problem?
The answer, of course, is that I am not. I am not that smart. He has already seen lots of doctors, including pain specialists and surgeons, who have tried almost everything that can be tried and they have not fixed his chronic pain problem. I’m not going to be able to, either. In my opinion, the most common and serious mistake made in the treatment of chronic pain in corrections is when we imply that we can eliminate chronic pain.
It is an easy trap to fall into; it works like this. Ralph will say, “I have chronic pain. You are now my doctor. What are you going to do about my pain?” And I would reply something like “Well let’s try X.” “X” could be NSAIDS, gabapentin, duloxetine—anything really. What Ralph understands, though, is that whatever I have prescribed should reduce or eliminate his pain. Why else would a doctor have prescribed it?
But, of course it does not eliminate Ralph’s pain. How often has one of your chronic pain patients come back to you and said “Ya did it doc! After years of chronic pain, that meloxicam prescription finally did the trick!” None of mine have ever said that, either.
No, inevitably, Ralph will say “I’m still having pain.” “Well, let’s try ‘Y’ then,” I’ll say. Of course, “Y” won’t work to eliminate his pain, either. Repeat this pattern a couple more times and a severely dysfunctional dynamic has been firmly established. Since nothing I prescribe works, Ralph suspects I am not competent. A better doctor would have figured this out! Eventually, Ralph and other chronic pain patients become frustrated, angry and distrustful. The clinical encounters become adversarial and unpleasant. We doctors dread seeing these patients.
But it does not have to be this way! The root problem here is that, without meaning to, I have set the wrong treatment goal for my patient Ralph; a treatment goal that I cannot achieve. I cannot eliminate Ralph’s chronic pain. I should not imply that I can.
According to a great article published last year in the Journal of the American Medical Association (JAMA), entitled Primary Care of Patients with Chronic Pain, I need to have a long conversation with Ralph in which I make clear that elimination of his pain is not likely to happen. Instead, he and I need to focus on his lifestyle and keeping him active.
JAMA says “The primary goal of caring for the patient with chronic pain is not the elimination of pain but the improvement of function.”
This simple sentence has totally transformed my approach to chronic pain patients. The result has been that we get much more accomplished, I don’t dread seeing them and they are happier. My chronic pain patients and I are no longer adversaries.
Now, when I see chronic pain patients like Ralph, the first thing I do is come right out and say “I am not going to be able to cure your chronic pain. No one can cure most cases of chronic pain. If I could cure chronic pain, I wouldn’t be here—I’d be spending my millions of dollars on some beach in the Caribbean (that usually gets a laugh). To some degree, you’re going to have to learn to live with your chronic pain. I will help you with this.”
We will then discuss Ralph’s level of activity. If he is the Most Valuable Player in the prison basketball league, I probably have little to offer him (Don’t laugh; this was an actual chronic pain patient). More likely, we will set a goal of improving his activity level. If he is in a wheelchair, I want him using a walker. If he uses a walker, I want him to progress to a cane and so on. For most of my chronic pain patients, I mainly want him not to vegetate in his cell. I want him walking in his dorm and in rec. I‘ll ask Ralph to track how much he walks and report back to me. I want him to increase his range of flexibility, as well.
What I have asked Ralph to do is hard work and he will need help. One of my jobs is to get him this help by asking my colleagues for their expertise. The formal term for this is a “multidisciplinary approach to chronic pain.” For example, many (if not most) chronic pain patients have a mood disorder, usually depression, because dealing with chronic pain can weigh one down. I’ll arrange for Ralph to see a mental health professional. Ralph and most other chronic pain patients should also see a physical therapist and so I’ll arrange that, as well. Cognitive Behavioral Therapy (CBT) can be thought of as formal instruction on techniques for dealing with incessant chronic pain. CBT has been shown to improve function in chronic pain patients and is well worth the effort to set up at your institution.
I’ll also use medications, but medications must be tied to increasing function. If I prescribe gabapentin, say, it will be tied to a specific objective goal, such as walking with a walker instead of using a wheelchair or flexibility that I can easily measure in my clinic. If the objective goal is not met, the medication has failed and will be stopped.
One great advantage of this approach is that I can objectively measure how well Ralph is doing. By using function as a goal, I can verify whether Ralph has reached his goals. Notice also that I am no longer responsible for Ralph’s pain. Instead, I am giving him resources to help him manage his own problem. The shift in responsibility here is huge! I can tell you that this shift in approach to chronic pain has made me a much more effective physician to my chronic pain patients.
“The primary goal of caring for the patient with chronic pain is not the elimination of pain but the improvement of function.” Primary Care of Patients with Chronic Pain, JAMA June 20, 2017
As always, what I have written here is my opinion based on my training, research and experience. I could be wrong! Feel free to disagree, but please say why in comments . . .
This article was first published in CorrectCare, Winter 2019