Saturday, October 2, 2010

Why Do Patients Dislike Pain Care Providers?

Chronic pain is a common complaint among patients seeking treatment from primary care providers. Yet, as confirmed by a recent investigation, patients report low levels of satisfaction with their pain care providers, the care they receive, and the outcomes. Unfortunately, these perspectives come as no surprise and there are a number of reasons for them.

Researchers at the University of Massachusetts, Boston, MA, conducted focused interviews involving 17 groups of patients (3-7 participants/group; 11 in English, 6 in Spanish) to assess their perspectives on pain care [Upshur et al. 2010]. A total of 72 adult patients participated (68% female, 44% Latino, mean age = 48.1 years) from 4 primary care practices in Central Massachusetts. Across all groups, and all gender, ethnicity, and age groups, most patients reported suboptimal interactions with their healthcare providers when seeking care for chronic pain.

In general, patients acknowledged feeling disrespected and distrusted by their healthcare providers, suspected of drug-seeking, and having their self-reported symptoms dismissed as trivial and/or not warranting medical attention. The participants reported greater satisfaction when they felt the provider listened to them, trusted them, was accessible to address pain concerns between visits, and used patient-centered approaches to establish goals and treatment plans. The study authors concluded that implementing more patient-centered approaches and managing chronic pain as would be appropriate for dealing with any chronic disease might improve both patient and provider satisfaction. However, this seems easier said than done.

COMMENT: Despite major strides during the past couple of decades toward recognizing pain as a vital sign of physical and/or mental distress requiring immediate and appropriate therapy, the pendulum may be swinging in the wrong direction. Patients appear to be increasingly less satisfied with the pain care they are receiving, especially for chronic pain conditions.

We have discussed these issues and some reasons in prior UPDATES postings [here], [here], and [here]. Concerns of practitioners center largely on insufficient training in pain management, apprehension about being deceived by patients, and consequent fears of legal or regulatory chastisement. It also is important to review the many comments by patients to those UPDATES blogposts, as they express exasperation and some desperation about being mistreated by approaches to pain care that are not focused on compassionate, evidence-based best practices. Rather, their care seems driven by adherence to questionable guidelines, oftentimes vague regulatory restrictions, and limitations imposed by healthcare insurance.

Furthermore, it was surprising and somewhat disheartening to see an editorial recently in the Archives of Internal Medicine by a physician describing how he “lost his faith” in long-term opioid treatment for chronic noncancer pain [Katz 2010]. He expresses alarm at “frighteningly high” opioid doses being prescribed for some patients, even though there is technically no ceiling level of analgesic effect for most opioids and minimal danger of harm if patients are opioid tolerant and compliant with properly-prescribed therapy. The underlying tone of the article expresses a fundamental mistrust of patients with pain needing (or requesting) strong analgesics, as if all patients requiring long-term opioids for chronic pain are automatically worthy of suspicion.

The author is well-meaning — in his own way. He seems to recognize that the solution does not always rest with referring patients to pain specialists, who may be in short supply in many parts of country and also could “undermine the relationship between patients and their primary care physicians.” He realistically acknowledges that “pain clinics might not be an option for uninsured low-income patients,” while not commenting on the societal inequalities of this circumstance.

Most concerning, however, the editorialist suggests that guidelines should establish a maximum dose of opioids in the long-term treatment of noncancer pain. This is not because doses above a certain level do not help patients or are inherently hazardous for all persons; rather, because it would “decrease the unhealthy patient-physician negotiation that often occurs when patients seek higher doses. We would simply tell patients that they are already receiving the highest recommended dose.” This might be dismissed as a deceptive, unscientific, and almost inhumane proposal were it not for the fact that exactly such a plan to establish opioid dosing limits is occurring in Washington State and could spread elsewhere [discussed here].

Finally, the author recommends that pain-treatment guidelines “should explicitly acknowledge that not all chronic pain can be eliminated.” However, we might ask, will such guidelines also define the limits of how much pain and associated suffering are acceptable; or, is that up to the discretion of the practitioner? While we would agree with the author’s statement that learning to cope with pain to an extent can be empowering, rather than merely “trying to find a pill to completely eliminate it,” we would still like to have all therapeutic options available, including strong analgesics, without arbitrary limitations or restrictions of those agents based on unscientific preconceptions and personal biases of how much pain relief is enough. What do you think? Comment below.

> Katz MH. Long-term Opioid Treatment of Nonmalignant Pain: A Believer Loses His Faith. Arch Int Med. 2010;170(16):1422-1423 [
extract here].
> Upshur CC, Bacigalupe G, Luckmann R. “They Don't Want Anything to Do with You”: Patient Views of Primary Care Management of Chronic Pain. Pain Med. 2010(Oct 1). Online ahead of print [
abstract here].