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OB/GYN Editorial NOVEMBER 2004
The Challenge of Managing Chronic Pain in Primary Care: What Critical Historical Clues Are We Missing?
Jeff Unger, MD
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Mrs Feldman showed up again for her weekly appointment. I have been caring for this 54-year-old chronic pain patient for over 2 years. Nothing seems to help her, yet she keeps coming back to see me. She never misses any of her appointments, although sometimes I wish she would! Most of the time, she leaves in tears while I endeavor to prescribe another futile round of medications, injections, nerve blocks, or physical therapy programs. She won't consider seeing a pain specialist. I am "doctor number 14," and she seems to have a great deal of faith that someday I might be able to come up with a miracle treatment for the unrelenting total body pain she has been living with for over 30 years. She has been previously diagnosed by other physicians as having fibromyalgia, chronic fatigue syndrome, depression, arthritis, stress, somatic disorder, lupus, chronic migraine, hypothyroidism, narcotic addiction, anorexia, myofascial disease, temporomandibular joint disease, sleep apnea, and has even been labeled a malingerer. Over the past 20 years, she has had just about every bone scan, X-ray, muscle biopsy, blood test, MRI, body fluid analysis, and endoscopic evaluation one could imagine. In fact, for 1 year, she participated in an open-label clinical trial for an investigational antidepressant medication that did not provide her with any relief. Mrs Feldman has been on nearly every chronic pain drug marketed over the past 20 years and has used all of the different drug delivery systems—patches, pills, liquids, suppositories, placebos, injections, nose sprays, and medicated ointments. Still, nothing has helped her chronic pain. Through the years, her physical examination has remained entirely normal, as documented in her six-volume medical record that dates back to 1999.
By some estimates, acute pain affects at least one of every three Americans at some point in his or her life. Fifteen percent of Americans suffer from chronic pain that, by definition, lasts for longer than 6 months. Seventy percent of Americans have seen at least three physicians for pain management. Their daily pain prevents them from having a good quality of life, productive employment, and enjoying the pleasures of family life and society.
While acute pain mechanisms are easily identified and treated, the exact source or reason behind chronic pain can be a mystery. Chronic pain often disrupts sleep and interferes with normal living. Most of the chronic pain patients who consult me do so for two reasons: (1) to determine the exact cause of their life-long suffering; and (2) to receive a prescription "cure" for their problem. Unfortunately, most chronic pain patients are shocked to learn that I often can do neither of these things. However, after spending time with each patient discussing the nature of their illness, the pathophysiology of their chronic pain, their own responsibilities in managing their pain, medications which should but may not be useful in pain management, and our goals for pain management, they rarely wander off to other specialists.
Many chronic pain patients have a family history of chronic pain. Therefore, susceptibility to chronic pain appears to be genetic and may be initiated when one's sensitive nervous system first suffers an acute pain insult from which recovery is slow. For example, migraine often develops and becomes daily and persistent after a patient has sustained a whiplash injury. Although such a patient may never have suffered from headaches before, her parents may suffer from "sick headaches." Traumatic injuries "turn on" neurological sensitivity in genetically susceptible individuals.
I recently attended a CME-sponsored pain conference and learned that in 1993, a group of orthopedic surgeons published a retrospective chart review which evaluated refractory pain to the history of childhood psychological trauma in 89 consecutive back patients. Patients were asked about their personal history regarding physical abuse, sexual abuse, emotional neglect or abuse, abandonment, chemical dependency, and whether their parents were separated or together. A positive response to any question was considered a "risk factor" for poor outcome in chronic back pain. Nearly 85% of the patients with chronic back pain had three or more risk factors present.1
The neurological interconnections that modulate pain mechanisms within the brain are very complex. For instance, we know that migraineurs have a high incidence of comorbid depression and anxiety. If these psychological components are present, active treatment of these comorbid conditions improves the outcome of migraine therapy.2 Psychologists who manage chronic pain speak of the limbic system connections that these patients experience on a daily basis: anger, frustration, depression, worry, worthlessness, and hopelessness. How often do treating physicians place themselves in their patients' situations when attempting to manage chronic pain? Our patients have not volunteered to assume this painful state; they have been dealt this extremely unpleasant sensory and emotional experience which often lasts a lifetime. As primary care physicians, we must not give up on these unfortunate individuals. Although they present challenging and frustrating problems that can be time-consuming and seemingly bleak, we must never take hope and encouragement away from our patients. Even if we improve their pain and function by 20%, we have given them hope.
As I walked into the exam room to see Mrs Feldman, I was filled with an unusual amount of excitement. I told her I was going to ask her some "tough questions" that I believe have never been addressed by any of her treating physicians in the past. I also explained that after asking the questions, I would tell her why the answers would be so important to her care. Over the next 2 minutes, Mrs Feldman admitted that her parents divorced when she was 3 years-old, and that she had never known her father. She further explained that the aunt and uncle who raised her and her younger sister repeatedly molested them. Mrs Feldman said she was physically abused up until age 10 years, at which time she was placed in foster care by state authorities.
She recalled experiencing her first migraine at age 12 years, and said she has had headaches almost daily since that time—nearly 42 years. After hearing her answers, which were very forthcoming, Mrs Feldman cried and said that for years she had been trying to forget her "vicious past." She admitted that no one had ever asked her these questions before. For the first time in our 2-year relationship, I felt as though I could actually help this patient with her chronic pain. I spent 30 minutes explaining to her the link between the limbic system and higher cortical centers of the brain where pain is processed. I explained that in order to help her, we would need to combine behavioral and pharmacologic therapy with life-style modification. Targeting improvement in function rather than pain would also be warranted.
Mrs Feldman left the office, not in tears, but with a new hope for the future. She told me that she never wanted to move on to "doctor number 15" and prayed that eventually I would be able to provide insight into the reason for her chronic suffering. Although this process took nearly 2 years, I feel that I have done a very good deed. I have eased someone's chronic suffering by taking the time to learn about her devastating past.
Jeff Unger, MD
Associate Advisory Board Member
Director, Chino Medical Group
Headache Intervention Center
References
- Schofferman J, Anderson D, Hines R, Smith G, Keane G. Childhood psychological trauma and chronic refractory low-back pain. Clin J Pain. 1993; 9(4): 260-265.
- Unger J, Cady RK, Farmer-Cady K. Migraine headaches, part 2: treatment options. The Female Patient. 2003; 6(28)22-29.
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