Seek multiple sources when diagnosing chronic pain
LAS VEGAS — Chronic pain is not a straightforward disease, and the clinician must gather information from a variety of sources, a presenter said at PAINWeek 2022.
“We don’t get a solid set of training to deal with patients like this,” Michael R. Clark, MD, MPH, MBA, a professor of psychiatry and behavior sciences at George Washington University School of Medicine and Health Sciences, said. “Even though chronic pain is a disease, it’s different than hypertension, cancer and diabetes where we understand a certain cascade of cause and effect. We have to think about what makes these patients so voluminous and difficult. It isn’t a straightforward disease.”
Clark advised first determining if you are treating chronic pain or treating chronic pain from a particular type of disorder with an accompanying pathophysiology and related consequences.
“Talk to patients; elicit from them what they’ve experienced, what they’ve done and benefited from, what hasn’t worked,” he said. “Ask for other sources of information — a family member, another doctor, old records, tests ordered. Use questionnaires. Find out what is driving their pain.”
A functional assessment is important to determine what the patient is able to do or not do and whether or not it is because of the pain or something else.
Find out how much the patient is suffering through a psychological assessment, Clark said.
“A lot of medicines get prescribed in this field, so it’s important to know what people have taken, who prescribed it and for how long,” he said. “This population tends to take things over-the-counter and pursue all other kinds of treatments. You must be aware of what they’re doing. You’re more than likely not going to get them off of every substance they take.”
Remember the HAMSTER pneumonic to help build a treatment plan: history, assessment, mechanism (of pain), social (and psychological factors), treatment, education and reassessment, he said.
Previous tools for patients to rate pain are not useful, Clark said.
“It’s impossible to ask someone to rate their pain,” he said. “These tools were an early attempt to legitimize and objectify pain.”
The psychological questions are important to determine what your patient’s problems are, what supports they have and how they cope.
“Talk to them about what they’re experiencing,” Clark said. “You’re just trying to walk in their shoes.”
“Catastrophizing” can be minimized with a good patient-provider relationship,” he noted.
Patients who avoid doing things that might hurt them are experiencing kinesiophobia.
“Getting people through avoidance behavior is like dealing with a phobia,” Clark said. “You do it little by little. It’s all about anxiety management and reduction and a sense of mastery. People who are distressed and disabled and aren’t doing well with their chronic pain feel incompetent. Our biggest fear is that they develop a substance use disorder.”
There is no single diagnostic test for pain, Clark said. The use of imaging, neurophysiologic testing and lab studies can confirm or exclude underlying causes such as rheumatoid arthritis, diabetic neuropathy, spinal disorders, HIV, hepatitis C, herpesviruses, vitamin deficiencies, autoimmune disorders and malignancies.
The initial treatment should be individualized; may be stepwise; involve a multidisciplinary team; include behavioral, nonpharmacologic and pharmacologic modalities; and involve analgesics along with other complementary agents, he added.
He noted that multiple tests may not be helpful and can produce false positives.
“The best source of data is old records from previous practitioners,” Clark said.
“Come up with a plan of care based on your best formulation and what you think is the etiology of pain, and be ready for patients not to listen to you.”