Providers should focus on pain interference, not intensity, in chronic pain management

Key takeaways:

• Chronic pain and mental illness can be “mutually exacerbating,” according to a presenter at the Psychiatry for Non-psychiatrists Conference.
• Rather than focusing on pain intensity, providers should focus on the level of pain that is interfering with a patient’s quality of life, the presenter said.
• “Fear avoidance” — when patients are afraid of activities that might elicit pain — can drive the transition from acute or intermittent pain to chronic or disabling.

When caring for older adults with non-cancer chronic pain, primary care providers should consider psychological factors like depression and fear avoidance, according to a presentation.

At the Psychiatry for Non-psychiatrists Conference, Debra K. Weiner, MD, a geriatrician, professor of medicine, psychiatry, anesthesiology and clinical and translational science at the University of Pittsburgh School of Medicine and associate director for research at the VA Pittsburgh Health Care System’s Geriatric Research, Education and Clinical Center, discussed the role of primary care physicians in chronic pain care for older adults.

“A conference designed to optimize care outcomes for patients with mental illness should not occur without a presentation on pain because these two groups of conditions are mutually exacerbating,” Weiner said. “So, optimizing pain management will optimize your capacity to care for your patients with mental illness, particularly anxiety and depression, and vice versa.”

Pain interference

Weiner said that it is important to identify key psychosocial treatment targets in older adults with chronic non-cancer pain like anxiety and depression, as they can significantly contribute to pain interference, which she called “the key vital sign in patients with chronic pain.”

“What we need to teach [patients] is that, currently, they may be feeling overwhelmed by pain and that pain is controlling every aspect of their lives,” she said. “Over the ensuing months of treatment, what you're going to enable them to do is feel in control of their pain.”

She added that there is “only a very modest overlap” between pain intensity and severity of disability. What providers should focus on, she said, is pain interference. In other words, to what extent is pain interfering with a patient’s quality of life?

Improving pain interference may not even mean reducing pain, Weiner said. Sometimes, treating a patient’s depression or anxiety can reduce pain interference.

Fear avoidance

“Central to maladaptive coping in the pain world is something called fear avoidance,” Weiner said. “A reasonable screen for the presence of fear avoidance ... is to say to the patient, do you agree or disagree with the following statement: it is not really safe for a person with my pain problem to be physically active. If they agree, then you say ‘perhaps fear avoidance is playing a significant role.’”

The fear avoidance model has previously been shown to drive the transition from acute or intermittent pain into a chronic, disabling pain, Weiner said.

“It is a very, very important concept when treating people with chronic pain,” she added.

Fear avoidance is rooted in the concept of pain catastrophizing — when patients are afraid of anything that might elicit pain and then hyperfocus on the pain, avoid activity and become disabled, Weiner said. But there are several treatment options, depending on resources available and patient preferences.

“Physical therapists who are very experienced in treating chronic pain patients can significantly reduce fear avoidance beliefs by effectively desensitizing them,” she said. “If you have access to a paid psychologist, when the patient is interested in that they can undergo pain cognitive behavioral therapy. I have found that patients with depression or anxiety — very often, successful treatment of that depression and or anxiety can effectively reduce fear avoidance beliefs.”

Self-efficacy

Weiner said that physicians can also screen for self-efficacy — one’s belief in their ability to accomplish a task in the face of other challenges — which is another concept that is not prominent in general medical literature.

A two-item question will suffice: how confident are you that you can do some form of work despite the pain and how confident are you that you can live a normal lifestyle despite the pain? Each item is scored from zero to six, and a total score of five or less indicates that the patient needs help with self-efficacy.

In closing, Weiner said that “psychosocial dysfunction treatment holds an important key to minimizing pain interference, which is the key track treatment outcome in people with chronic pain.”