About the Author
Jeannette Y. Wick, RPh, MBA, FASCP, is the director of the Office of Pharmacy Professional Development at the University of Connecticut at Storrs.
Setting realistic goals can improve patients’ medication adherence and self-efficacy.
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 16,7) 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
Jeannette Y. Wick, RPh, MBA, FASCP, is the director of the Office of Pharmacy Professional Development at the University of Connecticut at Storrs.
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:
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 212-17, 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.