How 'whole-person' integrative care can best address chronic pain

As a family physician for more than 40 years, I have had countless patients come to me desperately hoping to alleviate their chronic pain.

It is rarely their first time searching for relief, with many having already turned to opioids or alcohol — with devastating results. They are struggling, and they want answers from their doctors and care providers. My experience and research show that we can best help them by adopting a whole-person approach as the way to better understand our patients, their struggles and their needs, empowering them to take control of their own path toward healing.

As physicians trying to relieve suffering, we are too often failing. We are focusing on pills and procedures that are not really working, rather than addressing the fundamental question of whether these treatments help stop chronic disease. In my practice, I have shifted to creating a personalized treatment plan that works for each individual patient’s lifestyle, resources and life goals. I have changed my conversations with patients from asking “What’s the matter with you?” to asking, “What really matters to you?”

According to a 2021 survey, more than half of Americans experience chronic pain, with nearly three in four saying they are in pain every day. Among young adults, nearly two-thirds reported suffering chronic pain, with more than half of them saying they are in daily pain. Among those in chronic pain, 83% say their quality of life would improve if they were able to better manage it, and 62% do not even know what type of health care provider might best be able to help them. Many of these patients are at risk of becoming casualties in the ongoing epidemic of opioid abuse.

Our patients urgently need our help. We already know that chronic pain is multifactorial and multidimensional, so there is no “magic bullet” cure. Chronic pain is not just a body thing. It is a mind-body thing, so we must treat it as such. Psychosocial stressors severely undermine the person’s ability to recover, while also increasing the risk that pain will persist even after an injury heals. This means that prescribing opioids for chronic pain cannot get to the root of the problem, and only creates addiction with a death toll of more than 100,000 each year.

Most of our health is actually determined by factors outside the office, including behavior and lifestyle factors — smoking, alcohol, stress, nutrition, movement and sleep — as well as larger social and environmental determinants of health in our society. In fact, the ACP recommends that physicians initially try using non-drug therapies for chronic pain, such as exercise, physical therapy, acupuncture, mindfulness-based stress reduction, tai chi, yoga, spinal manipulation and cognitive behavioral therapy.

It is exciting to see the guidelines change over time, even if we were not trained in them during medical school. We need to continue our training throughout our careers to best support our patients. And there are resources to help us learn.

Recently, the Samueli Foundation partnered with Tufts University to offer a free CME course on ways to deliver effective pain management. Over four modules, providers can learn how to move from conflict to collaboration with patients, explore expanded options for treating chronic pain and discover ways to motivate and energize patients to take control of their own care and decrease opioid use.

We also can learn how to make small changes to our practice that reap large rewards. We were all trained in medical school how to write a SOAP note (Subjective, Objective, Assessment, Plan) to chart a patient’s condition and planned treatment. However, research shows that only about 20% of health and healing comes from this type of medical treatment itself — with the other 80% resulting from factors such as emotional and mental health, behavioral and lifestyle practices and the social and economic environment in which a person lives.

In my practice, I have crafted a HOPE note (Healing-Oriented Practices and Environments) to supplement the limitations of the SOAP note. The HOPE process addresses the social, behavioral, environmental and spiritual components of healing required for chronic disease management. Walking our patients through these questions helps us make shared decisions, placing them at the center of their own care.

When I use these visits, I find that patients are usually open to these methods. This anecdotal evidence is backed up by the same 2021 survey’s findings that show that 80% of patients are interested in managing their pain by eating healthier, 71% by exercising, 68% by trying massage therapy, 62% by physical therapy and 61% by mindfulness-based stress reduction or meditation.

This should be a wake-up call to us as physicians. Our patients are clear about what they want and need: more information and guidance on how they can manage their chronic pain. We have more evidence-based tools than ever to help them find relief, and we must do just that. By focusing on whole-person health instead of symptoms only, we can address the root of the pain and engage patients on their personal path to healing.

Participate in Pain Management activities at Healio CME

References:

Chronic pain survey results. https://drwaynejonas.com/wp-content/uploads/2021/10/Samueli_Chronic-Pain-Report_Final.pdf. Published September 2021. Accessed Oct. 25, 2022.

Dr. Wayne Jonas. https://drwaynejonas.com/. Accessed Oct. 25, 2022.

Integrative approaches to chronic pain management course. https://drwaynejonas.com/cme/. Accessed Oct. 25, 2022.

Issue brief: Nation’s drug-related overdose and death epidemic continues to worsen. https://www.ama-assn.org/system/files/issue-brief-increases-in-opioid-related-overdose.pdf. Published Sept. 7, 2022. Accessed Oct. 25, 2022.

Olson DP, et al. Health Aff. 2019;doi:10.1377/forefront.20190311.823116.

The HOPE note. https://drwaynejonas.com/resources/hope-note/hope-visit/. Accessed Oct. 25, 2022.