EXPERT ANALYSIS FROM PAIN CARE FOR PRIMARY CARE

LAKE BUENA VISTA, FLA. (FRONTLINE MEDICAL NEWS) – Discomfort treating chronic pain, inadequate empathy for pain complaints, and failure to set appropriate boundaries for scheduled pain medications are among the key obstacles to effective chronic pain management by primary care physicians, according to two experts.

For those with doubts about their abilities or the validity of pain complaints, “how you feel about treating chronic pain is going to be perceived by the patient,” cautioned Louis Kuritzky, MD, clinical assistant professor, University of Florida, Gainesville. “The mindset of the clinician is important.”

When clinicians consider chronic pain patients difficult or burdensome, patients can develop a sense of stigmatization without anything explicit being expressed by the treating physician, Dr. Kuritzky said. This can be self-defeating. The clinician-patient relationship and the chance of successful therapy are in trouble before either gets started.

Primary care physicians – not chronic pain specialists – provide most of the care for chronic pain, according to several experts at the meeting, held by the American Pain Society and Global Medical Academy. Yet, chronic pain management receives limited attention in family medicine or internal medicine training. According to one survey cited at the meeting, the majority of primary care physicians report that they are uncomfortable treating these complaints.

“What are the two things that primary care specialists struggle with most? Pain and psychiatric disorders,” said Robert M. McCarron, DO, DFAPA, director of pain psychiatry in the division of pain medicine at the University of California, Davis, in Sacramento. Like Dr. Kuritzky, he believes the physician-patient relationship often sours when patients sense their clinician’s discomfort.

“They feel the angst from us, and it becomes a countertransference,” Dr. McCarron said.

The first steps, Dr. Kuritzky and Dr. McCarron said, are to develop a genuine empathy for the burden of the pain and the confidence that effective options exist – even when pain includes a psychiatric component.

Although both Dr. Kuritzky and Dr. McCarron conceded that treating chronic pain is challenging, they also agreed that effective pain control is built upon a systematic approach starting with a structured assessment. While recognizing that both physical complaints and psychiatric comorbidity may be involved, each expert counseled that the immediate goal is not typically complete pain control. Rather, it is some reasonable degree of improvement.

“Identify functional improvements that the patient considers to be important and set realistic goals,” Dr. Kuritzky said. An incremental reduction in the burden of pain, whether the level of discomfort or the restoration of an activity that pain had prevented, can be the first step for a patient trying to escape from the vicious cycle of that sustains pain-related disability.

Not least of the reasons that many primary physicians are reluctant to treat chronic pain is their fear that a prescription of analgesics will lead to dependence or abuse, Dr. Kuritzky and Dr. McCarron said. They noted that patients often insist on pain medications even when clinicians are not convinced that these are in their best interest. The defense, according to Dr. Kuritzky, is for physicians to exercise their fiduciary duty.

“In our fiduciary capacity, we have been entrusted to act on behalf of the best interests of our patients,” Dr. Kuritzky explained. He urged clinicians to explain to patients when they feel a scheduled medication such as an opioid poses a greater potential for harm than benefit. This explanation, when offered with confidence, is persuasive for many patients, he said.

Dr. McCarron said it is important not to ignore the mind-body connection. Pain often has an emotional component even when a physical basis is present. He suggested that primary care physicians often are uncomfortable with the psychosomatic aspect common to chronic pain. But this discomfort prove counterproductive.

“Authentic suffering and distress from the symptom or symptoms should be the diagnostic and treatment focus” independent of etiology, Dr. McCarron maintained. He suggested that clinicians who can develop empathy for the very real symptoms of pain are better prepared to pursue the steps needed to bring chronic pain under control.

Dr. Kuritzky and Dr. McCarron reported no conflicts of interest. Global Academy and this organization are owned by the same company.

fpnews@frontlinemedcom.com

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