Manage Patients’ Expectations in Pain Management

Acute and chronic pain can have numerous long-lasting effects. Moderate to severe pain associated with surgery or trauma can slow recovery.^1,2 Globally, approximately 20% of individuals report chronic pain so severe it impedes their everyday activities and negatively affects their mental health.^3,4 In addition, the health care and loss in productivity costs are steep; in the United States, economists estimate those costs are a staggering $560 billion to $635 billion annually.⁵

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Patients who experience pain often have one thought: “Make it go away!” Although the sentiment is understandable, in many cases analgesics will only resolve the pain completely if patients take high doses. And it is unclear which patients take a pill at the first sign of distress as opposed to those who tough it out. Neither option is ideal.

This is where managing expectations becomes useful. Pharmacists can use several tools (Table 1^6,7) to help patients decide whether they need to take an analgesic or manage their pain differently.

Patient Perception of Pain

When discussing patient perception of pain, many researchers talk about the patient’s level of pain self-efficacy, which means they measure the patient’s confidence to perform activities and achieve established goals despite the presence of pain. In patients who seek treatment for musculoskeletal pain (MSP) in the shoulder, for instance, nearly 1 in 3 report no significant improvement after education, exercise, surgery, or oral or injectable medication. Researchers found that patients with higher levels of pain self-efficacy are more likely to experience less pain and disability. They asked patients starting various therapies to describe their expectations in terms of how much the intervention will help. Patients with higher expectations tended to experience more pain relief than those with low expectations.⁸

Patient expectation has been linked to both the placebo and the nocebo effects in a study that enrolled 1112 patients experiencing MSP.⁹ Those expectations may be heavily influenced by previous positive or negative experiences, which indicates clinicians should always ask about the patient’s previous experiences. The study also found that patients who wanted or expected a certain type of treatment responded better to treatment.⁹

Adherence to All Treatment: The SMART Approach

When discussing treatment adherence, pharmacists typically think about adherence to medication. In the case of pain, it is essential to think about adherence to the entire treatment plan, both pharmacologic and nonpharmacologic.¹⁰ Increasingly, experts understand that biopsychosocial solutions must address physical health, mental or behavioral health, and social functioning and its context. Unfortunately, multimodal approaches remain underutilized.¹⁰

Pharmacists counseling patients who have prescriptions for analgesics and are experiencing either acute or chronic pain can start a conversation about the medications, how the pain is affecting the patient, and their expectations in terms of pain relief and ability to engage in activities of daily living. Utilizing this approach and underscoring the necessity of a multimodal approach can help patients manage expectations.

For example, patients may say that they prefer not to exercise because it’s painful. It is critical to point out that patients need to expect some pain when they exercise. Questions such as, “What did your physical therapist tell you to do to reduce the pain?” can help patients remember to take a nonsteroidal anti-inflammatory medication or apply heat or cold before exercising. Other discussion points include the following:

• Do not wait until the pain is unbearable to take an analgesic.
• Schedule doses if the pain is chronic and unremitting.
• Identify a specific pain level on a scale of 1 to 10 at which it is time to take an as-needed dose.

Working together, the pharmacist and the patient can create a SMART (specific, measurable, achievable, realistic, timely) plan. They can decide when the patient will take the least potent but effective analgesic (eg, take acetaminophen before taking an opioid), how the patient will measure pain, at what point the patient will take an additional dose, and how far apart to spread those doses.

Divergent Beliefs

It is no surprise that patients and providers sometimes have divergent beliefs about pain management. In fact, many health care providers have beliefs that diverge from established pain management guidelines. Low back pain (LBP) can provide an example. In a study that enrolled 428 individuals with LBP, researchers found that a high proportion of individuals associated LBP with inevitable chronic back pain, chronic back weakness, worsening pain, and the need to have imaging and rest.¹¹ However, the data, as seen in Table 2^12-17, indicate that these beliefs are incorrect. The evidence has been available to providers and patients for more than 20 years, yet individuals with LBP continue to have beliefs that diverge with science.

Ninety percent of individuals have at least 1 episode of LBP during their lifetime,¹¹ and pharmacists are likely to have contact with patients experiencing pain that can be excruciating with no apparent cause. It is critical that pharmacists use their skills of persuasion to help patients understand the actual evidence. Again, emphasizing that treatment of LBP and all pain must be multimodal and include movement and exercise is important.

Conclusion

When patients have pain, it is critical to manage their expectations. When patients have realistic expectations, they are more likely to adhere to their treatment plans and progress. A goal of complete absence of pain is often unrealistic. Using evidence-based interventions can help establish realistic goals and perhaps lead to that pain-free state. Addressing pain from a SMART perspective is also a way to empower patients toward self-efficacy.

References

1. Edgley C, Hogg M, De Silva A, Braat S, Bucknill A, Leslie K. Severe acute pain and persistent post-surgical pain in orthopaedic trauma patients: a cohort study. Br J Anaesth. 2019;123(3):350-359. doi:10.1016/j.bja.2019.05.030

2. Meissner W, Huygen F, Neugebauer EAM, et al. Management of acute pain in the postoperative setting: the importance of quality indicators. Curr Med Res Opin. 2018;34(1):187-196. doi:10.1080/03007995.2017.1391081

3. Dueñas M, Ojeda B, Salazar A, Mico JA, Failde I. A review of chronic pain impact on patients, their social environment and the health care system. J Pain Res. 2016;9:457-467. doi:10.2147/JPR.S105892

4. Hayhurst CJ, Jackson JC, Archer KR, Thompson JL, Chandrasekhar R, Hughes CG. Pain and its long-term interference of daily life after critical illness. Anesth Analg. 2018;127(3):690-697. doi:10.1213/ANE.0000000000003358

5. Smith TJ, Hillner BE. The cost of pain. JAMA Netw Open. 2019;2(4):e191532. doi:10.1001/jamanetworkopen.2019.1532

6. Bérubé M, Verret M, Bourque L, et al. Educational needs and preferences of adult patients with acute pain: a mixed-methods systematic review. Pain. Published online June 18, 2024. doi:10.1097/j.pain.0000000000003288

7. Brox JI, Gjengedal E, Uppheim G, et al. Arthroscopic surgery versus supervised exercises in patients with rotator cuff disease (stage II impingement syndrome): a prospective, randomized, controlled study in 125 patients with a 2 1/2-year follow-up. J Shoulder Elbow Surg. 1999;8(2):102-111. doi:10.1016/s1058-2746(99)90001-0

8. Chester R, Khondoker M, Shepstone L, Lewis JS, Jerosch-Herold C. Self-efficacy and risk of persistent shoulder pain: results of a classification and regression tree (CART) analysis. Br J Sports Med. 2019;53(13):825-834. doi:10.1136/bjsports-2018-099450

9. Moretti A, Snichelotto F, Liguori S, et al. The challenge of pharmacotherapy for musculoskeletal pain: an overview of unmet needs. Ther Adv Musculoskelet Dis. 2024;16:1759720X241253656. doi:10.1177/1759720X241253656

10. Kress HG, Aldington D, Alon E, et al. A holistic approach to chronic pain management that involves all stakeholders: change is needed. Curr Med Res Opin. 2015;31(9):1743-1754. doi:10.1185/03007995.2015.1072088

11. Hall A, Coombs D, Richmond H, et al. What do the general public believe about the causes, prognosis and best management strategies for low back pain? a cross-sectional study. BMC Public Health. 2021;21(1):682. doi:10.1186/s12889-021-10664-5

12. Waddell G. 1987 Volvo award in clinical sciences: a new clinical model for the treatment of low-back pain. Spine. 1987 ;12(7):632–644. doi:10.1097/00007632-198709000-00002

13. Williams CM, Maher CG, Latimer J, et al. Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial. Lancet. 2014;384(9954):1586–1596. doi:10.1016/S0140-6736(14)60805-9

14. Shaheed CA, Maher CG, Williams KA,McLachlan AJ. Interventions available over the counter and advice for acute low back pain: systematic review and meta-analysis. J Pain. 2014;15(1):2–15. doi:10.1016/j.jpain.2013.09.016

15. Koes B. Moderate quality evidence that compared to advice to rest in bed, advice to remain active provides small improvements in pain and functional status in people with acute low back pain. BMJ Evid-Based Med. 2010;15(6):171–172. doi:10.1136/ebm1132

16. Lemmers GPG, van Lankveld W, Westert GP, van der Wees PJ, Staal JB. Imaging versus no imaging for low back pain: a systematic review, measuring costs, healthcare utilization and absence from work. Eur Spine J. 2019;28(5):937–950. doi:10.1007/s00586-019-05918-1

17. Oliveira CB, Maher CG, Pinto RZ, et al. Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview. Eur Spine J. 2018;27(11):2791–2803. doi:10.1007/s00586-018-5673-2