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
As we said where I come from: “You hit it right in the nail.”
Excellent post, like always. Thanks for sharing your knowledge.
I work at a prison and your blog has been such a resource for our unique niche of medicine. There’s nothing like practicing “behind the walls”!
Since starting over 5 years ago, the method was as you described. Change around the NSAIDs and get them out of your office, because really what else could we do? Recently I’ve been incorporating more conversations about functionality and short-term/long-term goals and visits are mostly positive. However, there are the difficult patients that insist on being completely pain free, or wanting to bargain-“well if you’re not going to do anything, can I have an extra mat?” Or “Can I have a bottom floor restriction?” “Transfer me then!” “Give me insoles.” …and other requests like this. How do you recommend I come to an agreement with these patients that are difficult to have conversations with? Or how to address those who have descriptions of pain or loss of functionality that do not match with the exam? If by the end of the appointment we do not come to some sort of agreement, they end up right back in sick call with the same complaint. Then the cycle repeats.
Thanks for the comment! I need to add “Bargaining” to my list of manipulative behaviors! In order to effectively respond to this kind of bargaining, you cannot be the sole Decider. The Decider is the person who can make a judgement and grant requests without having to refer to anyone else. You have to stop being the sole Decider. It is kind of like buying a used car and making an offer to the salesperson and having them say, “I’ll have to check with my manager.” In a correctional setting, the Decider you should have to check with will be not usually a single person but a Committee. For example, you can solve all of the bargaining you mentioned like this: Schedule a meeting of say, a nurse, a practitioner, a medical administrator and a representative of security. (you can include more if you want). Then hash out how everyone at the facility is going to handle comfort item requests like an extra mat or shoes or insoles. Then when a patient says, “just approve me for an extra mat,” instead of saying “No,” you say “I can’t. They (the committee) won’t let me.”
Great article with practical tips which i fully intend to steal!
We have a joke in the Minnesota Correctional system- The only thing that “cures” pain is when an inmate becomes eligible for boot camp (6 month semi-military style boot camp that can reduce sentences by up to 5 years). Suddenly- all of these patients who needed restrictions and medications (that they cannot have at boot camp) no longer need these items. Still- I have yet to see one patient leave boot camp in more pain than he arrived. Even difficult, complicated or geriatric (yes)- patients improve both function and pain going thru boot camp. 99% of inmate patients hurt because they move too little rather than too much. This topic will exist forever but Dr. Keller is spot on in terms of the discussions. Professional honesty about condition- including conditions of confinement (Prison mattress, inactivity, mental health stresses, etc) all contribute to increase pain. I share outside articles on frequency and difficulty managing chronic pain in society. Many of these patients used narcotics (legal or illegal)- and thus produced an unrealistic amount of pain relief on the streets. I am a big fan of any topicals for pain- we have Capsaisin and Salonpas. Both are attractive for many reasons- cheap, safe, effective and some placebo benefit. No one is ever solving this problem- managing it without losing your mind is the goal.
A case of unintended consequences – the ‘Fifth’ vital sign.
There are so many articles on pain assessment and management that it is nearly impossible to guild the lily.
At some risk though, here is a suggestion –
1. Ask (at some point) what the level of pain is (0-5 or 0-10)
2. Follow that by asking what was the worst pain ever [here comes the catch]
3. Review the answer to the worst pain – confirm that as a 10 (or 8, 9)
4. Now repeat question #1 –
My experience is that the current level drops 2 – 3 points.
Another consideration is what the worst pain was – Grade 1 sprain or fractured femur / shoulder dislocation.
If all above is well documented – and you anchor the pain scale to a tangible event – any type of prescribing review should be satisfied
That is excellent, Al! I’m going to try it out.