Experts suggest ways for PCPs to identify, manage patients’ pain

Bill McCarberg
Bill McCarberg

With the CDC stating that the opioid epidemic claims 91 lives per day and at least one study suggesting that chronic opioid use can be triggered in as little 3 days, the treatment of pain is under the microscope more than ever.

It is against this backdrop that the 16th Pain Awareness Month is taking place. According to the American Chronic Pain Association, each September various groups step up their efforts to increase public awareness of issues in the area of pain and pain management.

Laws regulating opioid prescriptions vary from state to state, but the CDC has outlined a number of guidelines that primary care physicians can follow regarding these medications, such as prescribing the least amount of opioids possible that will achieve results.

In conjunction with Pain Awareness Month, Healio Family Medicine asked Bill McCarberg, MD, past president of the American Academy of Pain Medicine, and Kimberly Schelling, MD, a primary care physician with Tufts Medical Center, Boston, for suggestions on how primary care physicians can identify the full scope of their patients’ pain and determine the best treatment strategy. – by Janel Miller

Question: How can a PCP help a patient determine the severity of his or her pain?

Kimberly Schelling
Kimberly Schelling

 

Schelling: Doctors should ask the patient to describe how long they have had the pain, the location of it, whether or not the pain moves on to various places in the body, what brings the pain on, what makes it better, and what makes it worse. Doctors with patients who cannot verbalize their pain can use the Smiley-Face Pain Scale, which uses a visual scale from 1 to 10 to help classify the level of pain.

McCarberg: I recommend three things. First, if there was an injury [that led to the pain], it is important to know how significant it was (eg, motor vehicle accident at high speeds and major impact, fall from height and bone fracture). Second, most of our back pain patients have recurrent pain and the new pain episode does not come from any major accident, so asking about prior episodes and what hastened the recovery (physical therapy, chiropractic, medication, etc.) will likely work for the new pain experience. And third, imaging studies can help determine if there has been a major mechanical event.

Q: There have been several studies that suggest some pharmaceutical approaches do not work for pain. How can a doctor best decide the approach his or her patient should take, in light of these findings?

Schelling: A doctor needs to take into account many of the criteria I described earlier, such as where the pain is and how long it has been there. They then need to combine that information with the resources the patient has access to — rides to physical therapy, a gym with a pool, a nearby acupuncturist — as well as what their goals are regarding their pain (eg, “I want to play with my grandkids” or “I want to walk the track near my house”) and decide with the patient what treatment modality will be best suited for them.

Q: What specific questions can a PCP ask to determine if nonpharmaceutical approaches are better than a pill?

McCarberg: Asking what has worked in the past is always helpful. [For example,] a patient with a kidney stone will almost certainly need an opioid since the pain is so severe and will request the medication. If the condition is new and the diagnosis is unknown, finding out what is wrong with the patient through history, physical exam, testing and imaging studies will help determine what will help the patient recover.

Q: Patients may insist on taking a pill to manage their pain, since in many instances these pills work faster than nonpharmaceutical approaches. How difficult is it to discuss such options in pain management with patients?

Schelling: Treatment options like physical therapy can involve copayments, finding a ride, and in some instances taking time off work. [But] in light of the opioid crisis, many patients are concerned about taking pills and will do anything to avoid medications. For these patients, there’s a robust set of nonpharmaceutical approaches that patients can pursue outside of pills, like acupuncture and water therapy. From my perspective, in the age of the opiate crisis, it is more important to talk about nonpharmaceutical approaches to pain rather than pharmaceutical approaches.

References: “A Look at State Legislation Limiting Opioid Prescriptions.” Available at: http://www.astho.org/StatePublicHealth/A-Look-at-State-Legislation-Limiting-Opioid-Prescriptions/2-23-17/. Accessed Sept. 8, 2017.

"September is Pain Awareness Month." Available at: https://theacpa.org/September-is-Pain-Awareness-Month. Accessed Sept. 8. 2017.

Bill McCarberg
Bill McCarberg

With the CDC stating that the opioid epidemic claims 91 lives per day and at least one study suggesting that chronic opioid use can be triggered in as little 3 days, the treatment of pain is under the microscope more than ever.

It is against this backdrop that the 16th Pain Awareness Month is taking place. According to the American Chronic Pain Association, each September various groups step up their efforts to increase public awareness of issues in the area of pain and pain management.

Laws regulating opioid prescriptions vary from state to state, but the CDC has outlined a number of guidelines that primary care physicians can follow regarding these medications, such as prescribing the least amount of opioids possible that will achieve results.

In conjunction with Pain Awareness Month, Healio Family Medicine asked Bill McCarberg, MD, past president of the American Academy of Pain Medicine, and Kimberly Schelling, MD, a primary care physician with Tufts Medical Center, Boston, for suggestions on how primary care physicians can identify the full scope of their patients’ pain and determine the best treatment strategy. – by Janel Miller

Question: How can a PCP help a patient determine the severity of his or her pain?

Kimberly Schelling
Kimberly Schelling

 

Schelling: Doctors should ask the patient to describe how long they have had the pain, the location of it, whether or not the pain moves on to various places in the body, what brings the pain on, what makes it better, and what makes it worse. Doctors with patients who cannot verbalize their pain can use the Smiley-Face Pain Scale, which uses a visual scale from 1 to 10 to help classify the level of pain.

McCarberg: I recommend three things. First, if there was an injury [that led to the pain], it is important to know how significant it was (eg, motor vehicle accident at high speeds and major impact, fall from height and bone fracture). Second, most of our back pain patients have recurrent pain and the new pain episode does not come from any major accident, so asking about prior episodes and what hastened the recovery (physical therapy, chiropractic, medication, etc.) will likely work for the new pain experience. And third, imaging studies can help determine if there has been a major mechanical event.

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Q: There have been several studies that suggest some pharmaceutical approaches do not work for pain. How can a doctor best decide the approach his or her patient should take, in light of these findings?

Schelling: A doctor needs to take into account many of the criteria I described earlier, such as where the pain is and how long it has been there. They then need to combine that information with the resources the patient has access to — rides to physical therapy, a gym with a pool, a nearby acupuncturist — as well as what their goals are regarding their pain (eg, “I want to play with my grandkids” or “I want to walk the track near my house”) and decide with the patient what treatment modality will be best suited for them.

Q: What specific questions can a PCP ask to determine if nonpharmaceutical approaches are better than a pill?

McCarberg: Asking what has worked in the past is always helpful. [For example,] a patient with a kidney stone will almost certainly need an opioid since the pain is so severe and will request the medication. If the condition is new and the diagnosis is unknown, finding out what is wrong with the patient through history, physical exam, testing and imaging studies will help determine what will help the patient recover.

Q: Patients may insist on taking a pill to manage their pain, since in many instances these pills work faster than nonpharmaceutical approaches. How difficult is it to discuss such options in pain management with patients?

Schelling: Treatment options like physical therapy can involve copayments, finding a ride, and in some instances taking time off work. [But] in light of the opioid crisis, many patients are concerned about taking pills and will do anything to avoid medications. For these patients, there’s a robust set of nonpharmaceutical approaches that patients can pursue outside of pills, like acupuncture and water therapy. From my perspective, in the age of the opiate crisis, it is more important to talk about nonpharmaceutical approaches to pain rather than pharmaceutical approaches.

References: “A Look at State Legislation Limiting Opioid Prescriptions.” Available at: http://www.astho.org/StatePublicHealth/A-Look-at-State-Legislation-Limiting-Opioid-Prescriptions/2-23-17/. Accessed Sept. 8, 2017.

"September is Pain Awareness Month." Available at: https://theacpa.org/September-is-Pain-Awareness-Month. Accessed Sept. 8. 2017.

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