How Primary Care Can Better Treat Chronic Pain

Jill Schneiderhan, MD, remembers only receiving one or two lectures on basic pain physiology during medical school.

photo of Jill Schneiderhan
Jill Schneiderhan, MD

That time was not enough, Schneiderhan said, who is now a primary care physician and codirector of Integrative Family Medicine at Michigan Medicine in Ann Arbor, Michigan. Medical schools in the United States spend an average of 11 hours on pain management training.

“I think that the understanding of different types of pain and the nervous system is improving,” Schneiderhan said. “But how we as primary care providers can sit with patients with complicated pain experiences, and integrate various treatments into the primary care setting, is where the system falls apart.”

Despite 1 in 5 Americans experiencing chronic pain, a gap exists in the pain management training of primary care providers (PCPs). Pain specialists are calling for the empowerment of their first-line-of-defense counterparts with the knowledge and tools necessary to navigate the intricate challenges posed by chronic pain.

Treatment beyond medication is the primary challenge — particularly with pressures and time constraints inherent in family medicine.

“It’s so difficult to teach a PCP how to treat pain because pain management is an entire fellowship,” said Shravani Durbhakula MD, MPH, MBA, from Vanderbilt University in Nashville, Tennessee, who is on the Board of Directors for the American Academy of Pain Medicine Foundation. But “we encourage a multidisciplinary approach: This includes physical therapy, medication, injections, and other methods. Those different elements coming together typically give some relief.”

Categories of Chronic Pain

Experts sort pain into three broad categories: Nociceptive (from tissue injury), neuropathic (from a nerve injury), and nociplastic (from a sensitized nervous system).

Tissue injury is the most common cause of pain and is characterized by aching and throbbing, while nerve injury causes more burning and shooting sensations.

Nociplastic pain, which arises from abnormal processing of pain signals without clear evidence of tissue damage, is often hardest to understand and trickier to treat. These types of conditions include fibromyalgia, irritable bowel syndrome, and nonspecific back pain, according to Durbhakula.

“One of the really big challenges is that it’s an invisible condition — you don’t have a cast on or crutches,” Durbhakula said. “We don’t have great objective measures for pain, and sometimes pain patients feel stigmatized and like their pain is dismissed.”

Primary care specialists should consider six steps to guide their pain assessments, including properly assessing the pain, identifying the pain generator, discussing sensible medications, considering appropriate procedures, recommending appropriate behavioral techniques, and focusing on multidisciplinary management, according to Durbhakula.

Persistent pain is often too complex to treat with singular methods. For instance, studies have shown pain can lead to structural changes in the brain, such as a decrease in gray matter and differences in neural areas that modulate pain. These neurologic changes illustrate the complicated nature of chronic pain and the need for a multipronged treatment plan.

Don’t Discount the ‘Fluffy Stuff’

One of the biggest challenges in managing chronic pain is the dearth of effective remedies, said Michael Kaplan, MD, a rheumatologist at Mount Sinai Health System in New York City.

While other debilitating conditions have seen breakthroughs — insulin for diabetes, penicillin for pneumonia — pain remains without a cure.

“In the world of centralized pains, we’re lagging behind,” Kaplan said. “Opioids didn’t work, and here we are in the aftermath of an opioid epidemic.”

Patients can make significant headway with non-pharmacologic management, or what some consider to be the “fluffy stuff,” including yoga, meditation, acupuncture, dry needling, massage therapy, and acupuncture, according to Kaplan.

But these approaches are often financially unfeasible for patients because insurance companies sporadically cover them. However, free apps can help patients practice things like better sleep and meditation.

“These things actually work, and there is very low risk in trying them,” Kaplan said. To be sure, medication has an important place in pain management. Neuropathic pain medications or nonsteroidal anti-inflammatory drugs can be effective options for some patients, said Christopher Gilligan, MD, Chief of the Division of Pain Medicine at Brigham and Women’s Hospital in Boston, Massachusetts.

Drugs that target nerve pain include gabapentin and pregabalin, certain antidepressants, and anticonvulsants, which can help dull pain signals in the nerves.

“When a patient has not responded to a first- or second-line medication in those categories, that can be a time when referral to a pain medicine physician can be helpful,” Gilligan said.

Procedural options that are less invasive than surgery may also be appropriate, Gilligan said. These include nerve ablation and restorative neurostimulators for people with lower back pain and ganglion stimulation for patients experiencing neuropathic pain.

“The efficacy of interventions for specific pain conditions has gotten better over the years,” he said.

Learn to Listen

The two most important activities to recommend when treating chronic pain patients also can be the most difficult: Sleeping and exercise. For people experiencing unrelenting discomfort, both can feel impossible, according to Dan Clauw, MD, professor of anesthesiology at the University of Michigan in Ann Arbor, Michigan.

“If you stop moving, your pain is going to get worse and worse and worse,” Clauw said. “But you have to be careful about how you talk about it. For example, don’t use the word ‘exercise’ when you’re talking to a chronic pain patient, use the word ‘activity’.”

As people become more active, they begin sleeping better, he said.

Most importantly, Clauw said, clinicians must demonstrate empathy and listening skills. Patients with chronic pain often are used to being dismissed and have become isolated in their personal lives.

“There is a lack of properly trained providers who can listen rather than do procedures,” Clauw said. “What happens is people just constrict their lives over the course of having pain, and they fall into this shell of themselves. They need their doctors to hear them.”

For primary care doctors seeking more information on pain management, online resources can be helpful, said Robert L. Rich Jr, former chair of the American Academy of Family Physicians Commission on Health of the Public and Science.

“One suggestion I’d begin with is to look at pain guidelines, not just from the CDC and AAFP but also from local medical boards,” Rich said, adding that California and Washington State have done extensive work on chronic pain. “I am seeing more of a movement again toward teaching the management of chronic pain, but we still need more training.”

Lindsay Kalter is a freelance journalist living in Michigan.

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