Filling in the Gaps in Chronic Pain Management

One of the biggest challenges in managing chronic pain stems from gaps that exist in between visits to various members of the care team. And it’s these “holes in the Swiss cheese of managing pain” that can make it all the more difficult for both the chronic pain patient and the provider to establish a course of treatment for the condition and chart its progress, according to Kevin L. Zacharoff, MD.

In a presentation delivered at the PAINWeek 2011 conference in Las Vegas, Nevada, from September 7-10, Zacharoff discussed the key aspects of chronic disease management, the role of self-management in treating chronic pain, and how an effective medical home can help fill in some of the gaps.

According to Zacharoff, approximately 116 million US adults are burdened by chronic pain, which is more than diabetes, heart disease, and cancer combined. Yet despite these staggering statistics, chronic pain is still largely misunderstood. Part of the problem is the fact that primary care providers, who are often the first line of care for patients experiencing persistent pain, have an average of just 7 minutes to make an assessment. What compounds the issue is the fact that training support is often inadequate, and in many areas of the country, there are few options for specialist referrals.

Another barrier—perhaps the most significant barrier—is that pain can be difficult to diagnose, even for those with expertise, because of its very nature. Pain, according to Zacharoff, is both a sensory and an emotional experience, and as a result, can present in different ways among different individuals.

“The challenge is that pain is subjective,” he noted, adding that although pain scales can help establish a baseline, they can’t be the sole marker utilized, as pain can affect individuals differently in terms of severity, duration, and impact on daily activities.

For these reasons, Zacharoff believes it is critical that providers play an integral role in developing a treatment plan and establishing goals that are tailored to meet their needs. Unlike the management of conditions like diabetes and hypertension—where specific methods are used to determine whether treatment is effective—in chronic pain, patient input is pivotal in deciding the next steps.

Therefore, it is critical that providers help patients understand the key role they play in managing their chronic pain. Some of the steps providers can take are:

• Listen to the patient, validate symptoms, establish eye contact, and address persistent problems in the context of daily living;
• Have available trusted education to give to patients (such as recommending reliable websites);
• Clarify statements to make sure patients understand them.

It is also critical to educate patients about the importance of adhering to medication and therapeutic regimens and tracking and communicating their progress to their care provider. Many chronic pain patients, however, deal with a number of providers, which can make it difficult—for both the patient and providers—to determine whether a treatment is working.

This, said Zacharoff, is where the medical home comes into play. “The medical home is an important foundation of effective care,” he added, noting that having one provider that can coordinate the patient’s care and ensure that providers are communicating to each other and accessing the same data can be extremely beneficial, particularly for elderly patients.

The medical home, he said, helps fill in the gaps for providers by facilitating better communication about the patient’s progress. Patients, on the other hand, often turn to the Internet to help piece together the puzzle.

According to Emil Chiauzzi, PhD, another speaker at the session, a growing number of patients are relying on websites to gain the information they need to more successfully manage their condition. The problem with this is that not only is there too much information—according to Chiauzzi, the term “pain education” produces 408 hits on Google—but much of it is presented in an encyclopedia-like format that requires little if any interaction from patients. The majority of sites, he says, lack evidence-based interventions or suggestions for self-management.

To that end, Chiauzzi, Zacharoff and others have developed a website—www.painACTION.com—that creates tailored pages for patients where they can learn self-management skills, access recommendations for different types of pain, track their progress using a calendar, read stories about other patients, and access practical advice on issues like how to handle challenges at work.

The site is meant to “pick up where the office visit leaves off,” said Chiauzzi, and help chronic pain patients more effectively manage their condition. “We need resources that health care providers can use to help guide patients instead of just going to Google.”