ASRA Pain Medicine Update

Pain is the subjective interpretation of nociceptive input: an objective, noxious stimulus that is processed through the lenses of a patient's particular affect and circumstances to generate both a perception and a behavioral response. The extrasomatic filters that make each patient unique can also generate some of our greatest therapeutic challenges. But, when does a patient transition from being a challenge, where he or she can still be rewarding to treat, to being outright difficult to work with? This article will address what may make a patient encounter difficult, identify factors attributed to the patient and the practitioner that interplay in such a situation, and suggest strategies that can mitigate most instances so that the encounter can have some positive influence in patient management.

Webster's New World Dictionary defines difficult as (1) hard to do, make, change, manage, understand, etc.; (2) involving trouble or requiring extra effort, skill, or thought; or (3) hard to satisfy, persuade, please, etc.^[1] This is clearly a broad term open to interpretation, yet certain patterns emerge that many of us routinely encounter. Have you dealt with any of the following patients?

• The patient with multiple (convenient) allergies to many pain medications except meperidine or a drug of their apparent choice
• The patient with the superior mesenteric artery restricted-byligament compression who has high opioid requirements and lots of family “support”
• The patient with an opioid-only agenda (“I've done all you asked and it hasn't worked, so give me that prescription for an opioid.”)
• The patient who vents at you for all the abuse he or she has suffered in the health care system and tells you the entire story
• The yeller whose volume and ferocity only increase as you decline repeated requests for a special test, drug, or disability rating
• The patient who refuses to follow your advice for more investigation (eg, seeing the disability specialist or the pain psychologist
• The patient who perceives disability but does not qualify administratively or legally
• The chronic appointment canceller who is noncompliant and disruptive when he or she does show

Although many patients can be difficult to treat, what is distinctive about patients with chronic pain? Chronic pain lingers, which breeds failed expectations for treatment leading to cure among physicians and patients alike. Frustration agitates the doctor–patient relationship, where discussions leading to evaluation or treatment decisions intensify and judgment and biases become evident. Over time, patients adopt a belief that they are entitled to certain tests, medications, allowances from work, among others. Patients can develop (1) maladaptive changes in their attitudes about ever regaining their health, (2) nonproductive and even obstructive behaviors, (3) self-destructive lifestyles, and (4) physioanatomic changes in the pain-processing and transmission system, termed neuroplasticity, that essentially hardwire the pain response pattern. Chronic opioid use and neuropathic pain independently lower the set point threshold in the central nervous system for a response to nociceptive input, such that patients with longstanding pain or opioid use have an increased likelihood to experience pain from a remarkably low stimulus intensity.

“The bottom line is to err on the side of safety, patient education, and support, despite the patient's ardent passion.”

Pain catastrophizing can pose an added degree of difficulty for patients and practitioners, so it must be identified in order to provide relevant therapy. In the introduction to a special issue of the Journal of Applied Behavioral Research on pain catastrophizing, Gatchel defines this as “an exaggerated negative orientation toward actual or anticipated pain experiences…. Current conceptualizations most often describe it in terms of appraisal or as a set of maladaptive beliefs.”^[2] Pain catastrophizing influences the severity of pain (both acute and chronic), the patient's functional disability and quality of life, the incidence of depression, and the patient's reported pain intensity. Brain imaging studies have shown that this phenomenon has an organic basis, because pain catastrophizing can affect activation of different cortical regions during pain-inducing manipulations.^[2]

In medical school, we have been trained to interview patients to obtain their history; process the history, physical exam, and lab results; collate those data with literature and consultation; and provide feedback to patients about the working diagnosis and differential diagnosis. However, studies have shown that empathy (the appreciation for what the patient is going through) starts to drop when third-year medical students begin to get actual patient contact.^[3] A difficult patient becomes particularly challenging in the setting of waning empathy. What can help is accruing experience listening carefully to patients, sitting down rather than standing at the bedside, not interrupting patients, maintaining eye contact, asking patients how you can specifically help them today, and dealing with patients' emotions—all to establish a resilient doctor–patient relationship that can withstand the future need to deliver controversial or disappointing news.

The psychologist A.J. Mariano^[4] provided advice in 2017 for dealing with difficult patients. His primary focus was answering whether pain physicians should reinstate opioid prescriptions in patients who had been successfully weaned off the medications, but the principles have broader application. Mariano noted that learning self-management strategies is difficult for patients and most patients have an opinion about what physician-active treatment is needed next. Yet, treatment must always be safe, logical, and sustainable.^[4]

In making treatment decisions, patients must be advised to consider their other life problems even while we are trying to treat their pain—all that's wrong in their life isn't only their pain.^[4] Our responsibility is to get patients the help they need as opposed to what they think they want (eg, getting more tests, seeing other specialists, having their medication dose increased). Mariano^[4] recommended not responding to their accusations; the reality is, we are making recommendations, but it is a patient's responsibility to make choices. If a patient starts making threats, the best course is to document and explain our rationale for seeking advice from other colleagues or services. If you are very truly uncertain what action to take, then seek consultation for yourself at the time when you believe it is the right action, even if the patient disagrees. The bottom line is to err on the side of safety, patient education, and support, despite the patient's ardent passion.^[4]

Beware of patients who perceive that you promised medications, particularly an opioid, only if they will try other modalities first. Those patients may attempt to “wait you out” and often offer (plausible, at least to them) reasons why they could not comply with the alternate options. We must appreciate, too, that patients will interpret clinical responses differently. A patient whose pain has not improved after three opioid dose escalations will continue to voice that the “right” dose simply has not been reached yet, whereas we see that as a pain that is not opioid responsive.

Looking toward the future of health care, Mandelbaum^[5] emphasized that it would behoove us to remember five important principles. Per the Hippocratic oath, “I will prescribe a regimen for the good of my patients according to my ability and my judgment and never do harm to anyone.”^[6] The goal of health care is to keep healthy people healthy and take care of those who are not. Adapting his ideas to pain management, we should empower patients with a single source of information (grounded in our pain practices from which consistent information is generously provided to patients and families), expand access to care (recommending necessary consultations to expand the database upon which treatment decisions will be made and referring patients to centers for specialized procedures), centralize care in centers of excellence (using pain specialists, even if across state lines), and optimize technology (in the evaluation and the treatment phases of care). Finally, Mandelbaum adds that “politics should not determine how we care for people in need.”^[5] We are well aware of how unsettled the current health care climate is, where patients worry about insurance coverage for needed therapy and access to necessary care mandates. Mandelbaum is correct in saying that “patients need to be served” and pondering whether the Affordable Care Act is patient or even physician centered.

In the end, we truly need to manage neuropathic pain, as we do for diseases such as diabetes and asthma, because curing chronic pain is exceedingly difficult. Neuropathic pain exists at the intersection of physical and psychological pathology, which compounds the task of management. We need patients who are active in the evaluation process, management planning, prescription phases of care, and provision of physician feedback. Engaged, insightful patients can be helped more than those who demonstrate learned helplessness or passively wait for the doctor to fix all of their problems. Placing the burden for improvement entirely on the physician is naïve and nonproductive, but this demeanor can be induced by pain-related anxiety and depression. Thus, ongoing patient education and re-evaluation are major, ever-present responsibilities of the pain management practice. Establishing a clear and correct diagnosis is uniformly paramount, because it is essential to treat the underlying cause of the pain rather than addressing only the symptoms.

Factors that lay a solid foundation for success in the doctor– patient relationship include taking time to understand and address concerns from the patient's perspective.^[7] With this mind-set, the goals of chronic pain treatment plans should include ensuring that patients perceive that their needs are taken seriously, feel educated about their pain syndrome and about available treatments, understand their diagnosis and the rationale for the treatment or action plan, endorse that treatment is lessening their pain symptoms over time, and establish that they are able to live with residual pain. Ultimately, patients should feel that the negative impact of pain on their ability to function in life is lessening. Early in the treatment course, it is imperative to establish mutually agreed upon, realistic goals and expectations of pain management as an index on which to base conclusions about success of management.

From the physician's perspective, the goals of chronic pain management should be to decrease the frequency and/or the intensity of pain over time, while increasing patients' ability to function physically, emotionally, and cognitively. If needed, contemporary medications should be used, but the therapeutic approach must be broadened beyond just pharmacologic management, given the disease concept of neuropathic pain. We should help patients cope with residual pain and pain-related issues (eg, worker's compensation, disability determinations, legal matters). Most patients will see even a slight decrease in their primary pain once a treatment program is started. This is a crucial achievement because it demonstrates that something can indeed be done about the pain that has previously only been worsening. This element of progress, no matter how small, must be constantly presented to patients to engage their continued participation in the program. Realistically, it can be very exasperating to confront only a negative reaction to this good news in difficult patients.

The bottom line is that many patient-specific and circumstantial challenges are inherent in treating patients with chronic or neuropathic pain. Major differences in the agenda between physicians and patients must be actively dealt with at every visit to align the expectations of management. Repetitive education that frequently involves explaining what you are doing and why is necessary for patients that may have low health care literacy.

Even with good therapeutic alliance and patient education, we need to increasingly understand complex intricacies of polypharmacy in the face of patient-specific pharmacogenomics. It is difficult enough at the present time to get a genuine drug trial that generates solid, objective data in medically complex patients, because they change their compliance with the recommendations. Our approach may be one drug or one dose change at a time, yet patients make independent decisions about efficacy, based on too-short trials, so time is wasted in modifying the treatment plan. Understanding all of these challenges in the concurrent setting of your hospital's or practice's systems arrangements can add a further layer of complexity (eg, the availability of a particular drug or specific therapy, a primary care provider who will not write for a drug in the patient's home area, a patient who is denied formal rehabilitation).

In the end, it is important to remember that just because something is difficult to do does not mean it is not worth doing. Pain physicians can manage difficult patients when they have established policies about refill prescriptions, acceptable behavior in the office, no-show events, and late-to-appointment episodes. Difficult patients should have specific times to call and visit the office to stabilize the contact rules of engagement. Patients and their family members deserve direct, honest dialogue in language they understand and need help in sorting through the myriad sources of medical information available in the today's media world. Perhaps the most assured technique to assess what patients actually understand from your visit is to ask that they repeat back to you what you have discovered/discussed/agreed upon.

We are obligated to share our expertise with all patients, even those designated as “difficult.” Using a systematic, straightforward approach, even these patients can be served.

References

1. Webster's New World Dictionary. New York, NY: Simon and Schuster, Inc.; 1988.
2. Gatchel RJ. Introduction to the “Special issue on pain catastrophizing”. J Appl Behav Res. 2017;22:e12088.
3. Hojat M, Vergare MJ, Maxwell K, et al. The devil is in the third year: a longitudinal study of empathy in medical school. Acad Med. 2009;84(9):1182– 1191.
4. Mariano AJ. Practical advice for real-world practice: facilitating selfmanagement in challenging patients. Presented at: American Academy of Pain Medicine 33rd Annual Meeting; March 16–19, 2017; Orlando, FL.
5. Mandelbaum BR. Five principles for the future of healthcare. May 3, 2017. Available at: http://www.medscape.com/viewarticle/879203. Accessed March 5, 2017.
6. Association of American Physicians and Surgeons, Inc. Physician oaths. Available at: http://www.aapsonline.org/ethics/oaths.htm. Accessed March 5, 2017.
7. Messelink EJ. The pelvic pain centre. World J Urol. 2001;19:208–212.