It has been well established that pain is the most commonly reported symptom in primary care and a leading cause of disability. Primary care providers (PCPs) face numerous challenges in caring for patients with chronic pain. Pain is subjective, and there are no objective tests that confirm the level of pain people experience. One patient might rate pain as a 4 on a 1-to-10 pain scale while another might label the same degree of pain as a 6 or 7. The successful treatment of chronic pain is challenging, especially in cases for which no sure cause of the pain can be identified. Alleviating pain can be elusive, which becomes frustrating to both patients and PCPs. It can also put a strain on the patient-provider relationship, which can ultimately impact the well-being of both parties.
Elucidating the Provider’s Perspective
Many studies have looked at the treatment of chronic pain from the patient’s perspective, but there has been little research on those who provide care for these patients. In a study published in the November 2010 issue of Pain Medicine, my colleagues and I surveyed 20 PCPs with open-ended questions to elicit their perspectives on experiences in caring for patients with chronic pain.
A central theme from our investigation was that chronic pain takes a real toll on PCPs and their patients. Three other broad themes also emerged from our analysis. First, providers emphasized the importance of the patient-provider relationship, asserting that productive relationships with patients are essential for good pain care. Second, providers detailed the difficulties they encountered when caring for patients with chronic pain. These included:
– Feeling pressured to treat chronic pain with opioids.
– Believability of patients’ reports of pain.
– Worries about secondary gain or diversion of opioids.
– “Abusive” or “difficult” patients.
Third, providers described the emotional toll they sometimes felt with chronic pain care. Oftentimes, PCPs reported feeling frustrated, ungratified, and guilty. Many criticized themselves because they felt unable to treat chronic pain effectively, others internalized their negative feelings.
Negative feelings were also compounded by hostile interactions with some patients. Suspicion and distrust were prevalent, especially in cases in which it was perceived that individuals were seeking pain medications for uses other than pain control. PCPs dreaded seeing these individuals’ names on their clinic schedule, because they knew the interaction would likely be unsuccessful at best and difficult or hostile at worst. These challenges added to feelings of providing ineffective and unsuccessful care for chronic pain patients.
Important Clinical Implications
Based on our findings, there are two important clinical implications to consider for PCPs. First, we cannot ignore the needs of PCPs in the context of pain care. PCPs need instrumental and emotional support throughout their care for patients with chronic pain. New strategies are needed to ease frustrations and defuse potential hostility in clinical interactions. Second, improving patient-centered communication skills for PCPs is promising for alleviating some of the strain and burden that has been reported. This includes demonstrating empathy and encouraging shared decision making with patients. We must remember that potential solutions to difficulties in chronic pain care extend beyond the individual provider. By finding new strategies that address challenges for clinicians and patients alike, we may ultimately improve patient care.
Matthias MS, Parpart AL, Nyland KA, et al. The patient-provider relationship in chronic pain care: providers’ perspectives. Pain Med. 2010;11:1688-1697. Available at:http://onlinelibrary.wiley.com/doi/10.1111/j.1526-4637.2010.00980.x/abstract.
Matthias MS, Bair MJ. The patient-provider relationship in chronic pain management: where do we go from here? Pain Med. 2010;11:1747-1749.
Bair MJ, Matthias MS, Nyland KA, et al. Barriers and facilitators to chronic pain self-management: a qualitative study of primary care patients with comorbid musculoskeletal pain and depression. Pain Med. 2009;10:1280-1290.
Teh CF, Karp JF, Kleinman A, Reynolds CF, Weiner DK, Cleary PD. Older people’s experiences of patient-centered treatment for chronic pain: a qualitative study. Pain Med. 2009;10:521-530.