In the year 2000, Congress declared a “Decade of Pain Control and Research” in response to rising instances of chronic pain among Americans. More than a decade later, though new treatments and drugs continue to proliferate, chronic pain still plagues the American population and the problem of prescription medication abuse has escalated. Part of the problem is that many chronic pain solutions are misguided, aiming for quick fixes that do not do justice to a problem as complex as chronic pain. Though the statistics are often lumped together for effect, there is a significant difference between having a chronically painful body part and a lifestyle disrupted by a chronic pain complaint.
Even with recent advances, uncontrolled pain and lifestyle dysfunction are on the rise; and evaluating chronic pain is an increasingly necessary skill among physicians and medical professionals. To properly identify and treat chronic pain, it is important to understand that pain is not a “vital sign” like blood pressure or temperature, but rather a complex biopsychosocial condition. An injured worker may transition from experiencing acute injury-related pain to chronic pain following a seemingly ordinary physiological trauma. Understanding the biological and psychosocial factors that cause or promote suffering in chronic pain is vital to providing effective treatment.
Three Interconnected Elements
Even as treatment options increase, uncontrolled or poorly controlled chronic pain cases remain on the rise because the condition is not treated in an integrated manner. During the progression from acute to chronic pain, biological, psychological and social components intertwine to create a unique, individual experience.
1. Biological: Biological pain responses may be the best understood component in chronic pain management, yet they’re still quite complex and difficult to treat. Physiological disturbances can stimulate pain receptors incorrectly, as in the cases of nociceptive and neuropathic pain. The nervous system can become sensitized and its ability to modulate pain adequately can fail. Pain may also occur due to old, poorly maintained injuries or to degeneration of the body with increasing age combined with lack of adequate physical fitness.
Finding and managing the biological basis for the pain is important, yet biological management alone won’t end a patient’s chronic pain. There is danger in overemphasizing the biomedical model (i.e. searching for a “pain generator” and extinguishing it). This approach often results in escalation of multiple medications and other interventions of questionable effectiveness. Medications that should work theoretically based on biology or laboratory results, or in carefully selected patients, often do not succeed when used in the masses or as a quick fix.
2. Psychological: Psychology can both affect pain and be affected by pain. One’s psychological state can impact one’s perception of pain, understanding of its meaning, behavior, and precision of reporting. Emotional components like catastrophic thinking and symptom magnification can make it difficult for a physician to properly diagnose and treat a disease, while pain-related anxiety, dependence, and addiction can be results of living with long-term pain. Many who experience pain deal with concurrent anxiety, depression, and substance abuse, among other conditions.
Clinicians who do not actively take into account these aspects of pain may incorrectly ascribe all of a patient’s distress to the pain and treat only the symptoms with little functional gain. The most effective treatments in managing chronic pain–therapeutic exercise, physical adaptation, independent self-care and healthy coping–take long-term motivation that is often difficult for many people to muster. This often requires a cognitive behavioral approach which reframes the pain dilemma and promotes a better sense of self-care and effectiveness (self-efficacy).
3. Social: Culture, lifestyle, and personal demographics can also contribute to chronic pain problems. The cultural milieu in which the patient moves can positively or negatively impact recovery, and lead to workplace problems and possible litigation. These social variables can both exacerbate chronic pain and create trouble during recovery, or, conversely, encourage a person with chronic pain to seek help and support. Though we have all heard of “secondary gains,” such as not having to work and financial rewards, as motivations to stay in the sick role, injured workers often experience “secondary losses,” such as loss of work identity and placing one’s life on hold, as well. The injured worker is often not conscious of either.
If the treating physician does not recognize each of the biopsychosocial components in his or her patient, instead choosing to focus on medical remedies only, the injured worker is unlikely to achieve the best outcome. Thus, many cases of chronic pain persist despite new medical innovations. We invite you to read our whitepaper titled “Addressing Chronic Pain Cases” to learn more about distinguishing chronic pain and the characteristics of a multidisciplinary treatment plan.