Taking A Closer Look At Helping Patients Manage Chronic Pain

Recent years’ events have increased our awareness of the dangers of opioid dependence and we lessen this burden with judicious and responsible opioid prescribing. We all realize the benefits of utilizing a multimodal pain management protocol, and we probably implement these tools for our patients when appropriate. There are, however, few tools available to help guide therapy in patients who have chronic pain, are having trouble controlling pain, or are already opioid-dependent. I intend to focus in this column on maximizing pain control outcomes in this complex patient cohort. In my experience, this population requires a more robust and dynamic pain management treatment plan than one might initially anticipate.

Strategies For Managing Challenging Pain Scenarios

The default I observe for many surgeons is resorting to an opioid contract. The framework of such agreements revolves around a medicolegal concept that I feel puts the doctor before the patient. Most patients, I find, are not fond of these. Moreover, while these contracts are probably a good idea for chart hygiene when a patient requires a higher-than-anticipated level of pain management, they also carry an inherent problem. Pulling out the document does not magically lessen pain, and when invoked, it does not relieve the treating surgeon or physician from the obligation to treat the patient’s pain. While I do still suggest preemptively obtaining such documentation, it is even more critical to preemptively discuss your algorithm for treating mild, moderate, and breakthrough pain with patients, especially those for whom you anticipate challenges. It is also imperative to match patient and provider expectations during initial and subsequent visits. In my opinion, these discussions by far have a greater impact on clinical decision-making and management optimization than any other component a clinician may render.

I also highly support incorporating a pain management specialist into the care team. While some patients come with one already on board for chronic pain issues, others can develop pain that ultimately requires the input of qualified pain management service providers. In my observation, I’ve noticed profound variation among these providers in the degree of involvement and communication, non-opioid methodology, or even willingness to consider non-pharmacologic treatments, such as the incorporation of transcutaneous electrical nerve stimulation (TENS), and other modalities when appropriate. I find that the most critical aspect of maximizing the benefit of these services is ensuring the patient is at the center of the conversation. In this example, if a TENS unit is an option, patient-driven advocacy seems to yield the highest degree of implementation.

It is important to note that, although variable, patients who are not opioid-naïve exhibit a shorter time to tolerance than those who are opioid-naive. This means that some patients may require medication escalation during the initial phase of treatment. This emphasizes the importance of a multimodal pain management plan. In addition, patients can experience increased rebound pain when weaning from their medications, which can be clinically difficult to differentiate from other causes of pain. The only clinical clue that I find lies in the timing of opioid reduction. To avoid rebound pain and other complications, in my experience it is imperative to wean opioid-sensitized patients slowly and assure them that rebound pain is transient.

Another helpful caveat comes into play when treating patients that present with opioid medications already on board. A common mistake I see with many of my second opinion referrals is that some doctors assume that because a patient is already on an opioid, their baseline medication(s) and dose(s) will cover a new acute trauma or surgery/ procedure. I content that this is rarely the case, and all patients under this umbrella should have some component of pain coverage available to address the new needs.

In Summary

I will contend that a simple but overlooked aspect of caring for patients with difficulty controlling pain is the offer of compassion. In my experience, adjusting medications frequently as needed, adjusting expectations while navigating the journey of recovery, and decreasing patient anxiety all go a long way in the face of pain. Overall, I realize that difficult-to-manage pain and chronic pain scenarios can present many challenges along the continuum of treatment. That being said, early implementation of a multimodal pain algorithm for each patient and following a few additional general steps has the potential to improve outcomes. 

Dr. Elmarsafi is a fellowship-trained foot and ankle surgeon with Vascular Surgery Associates, LLC in Maryland.

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