A Focus On: The Complex Chronic Pain Patient
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Most patients with chronic pain are relatively straightforward to treat. However some patients present with an overwhelming symptom complex that is hard to diagnose, harder to treat, and requires a multidisciplinary treatment team. These patients are completely disabled by their pain and commonly have a long history of psychological dysfunction.1 Despite a substantial workup and multiple specialist visits, little pathology is found, and what is discovered does not seem to explain the pain.2
Both patients with chronic pain and chronic pain syndrome have no characteristic diagnosis and are usually still functioning, just sometimes at a reduced level. They exhibit occasional pain behaviors, have received limited care, report improvement in function with analgesics, find a physical exam straight forward, exhibit reactive depression, and are compliant with treatment recommendations. Both interventional therapies and surgery have successful outcomes.
On the other hand, patients with chronic pain syndrome are totally incapacitated by their condition or disabled by the pain alone. They frequently exhibit pain behaviors, especially with exertion of any kind. They have seen an unusual number of providers, analgesics do not improve function, and substance misuse is common. Even a physical exam results in severe exacerbation lasting days and exam findings are non-physiologic. Common psychological diagnoses are personality disorders. Compliance with treatment recommendations is poor, and psychological dysfunction and negative outcomes for procedures and surgery are very common.
No single therapy will work with the chronic pain syndrome patients.3 Substantial relief of pain is not an achievable goal; treatment should be directed towards restoration of function.4 Treatment requires a simultaneous three-prong approach:
• Management of nociception
• Management of psychological issues directly related to their pain
This approach requires a significant commitment from the patient, family and the pain center’s professional staff. Real change can be difficult to achieve but with a highly functioning treatment team along with patient and family buy-in success is reachable.5,6
Edgar L. Ross, MD is Director of the Pain Management Center and Assistant Professor of Anesthesiology and Pain Management, Harvard Medical School, Brigham & Women’s Hospital, Boston, Massachusetts, USA.
1. McQuay, H., Management of Chronic Pain: Help and hope at the bottom of the pile. BMJ, 2008. 336(7650): p. 954-5.
2. McBeth, J., et al., Risk factors for persistent chronic widespread pain: a community-based study. Rheumatology (Oxford), 2001. 40(1): p. 95-101.
3. Kalso, E., et al., Opioids in chronic non-cancer pain: systematic review of efficacy and safety. Pain, 2004. 112(3): p. 372-80.
4. Seers, K., Review: intensive multidisciplinary biopsychosocial rehabilitation reduces pain and improves function in chronic low back pain. Evid Based Nurs, 2002. 5(4): p. 116.
5. Scott-Dempster, C., et al., Physiotherapists' experiences of activity pacing with people with chronic musculoskeletal pain: an interpretative phenomenological analysis. Physiother Theory Pract, 2014. 30(5): p. 319-28.
6. Toye, F., et al., Patients' experiences of chronic non-malignant musculoskeletal pain: a qualitative systematic review. Br J Gen Pract, 2013. 63(617): p. e829-41.
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