It's a pain to take care of pain

December 16, 2010, Indiana University School of Medicine

While many studies have looked at the treatment of chronic pain from the patient's perspective, there has been little research on those who provide care for chronic pain.

In a study in the November 2010 issue of the journal , researchers from the Regenstrief Institute, the Indiana University School of Medicine, the IU School of Liberal Arts and the Roudebush VA Medical Center report that takes a toll on primary care providers as well as their patients. They conclude that providers' needs should not be ignored if pain care is to be improved.

Most chronic pain is treated by primary care providers and necessitates frequent interactions with the patient. In this study the researchers surveyed 20 primary care providers (15 physicians, four and one pharmacist) with varying clinical experience in the Roudebush VA Medical Center in Indianapolis. All 10 men and 10 women were asked open-ended questions designed to elicit their experiences with chronic pain management.

"Many providers criticized themselves because they felt unable to treat chronic pain effectively. Many internalized their lack of success with pain treatment, felt stress, and had guilty feelings. These were compounded by hostile interactions with some patients, suspicions and distrust of some patients, especially those they suspected might be seeking pain medications for uses other than pain control, or to sell," said study first author Marianne Matthias, Ph.D., a Regenstrief Institute investigator, adjunct assistant professor of communication studies in the IU School of Liberal Arts and a research scientist at the Roudebush VA Medical Center.

Unlike other symptoms, such as elevated blood pressure or cholesterol readings, pain is subjective without any objective tests to confirm. One individual might rate pain a four on a one to 10 pain scale; another might label the same degree of pain a six or a seven. While and cholesterol often can be lowered with medication; successful treatment of chronic pain -- especially pain for which there is no known cause -- can be elusive, which is frustrating to both patients and care providers and can put a strain on their relationship, which can ultimately impact both patients' and providers' well-being.

"The providers often described dread when seeing a patient's name on their clinic schedule, knowing the interaction was going to be unsuccessful at best, difficult or hostile at worst. They described feeling ineffective and unsuccessful in their ability to treat many of their patients with pain. Interestingly, reports of frustration and negative experiences were present throughout the sample. Even those who were generally positive about their relationships with their patients reported difficulties, distrust and other relational issues at times," said Dr. Matthias, who is a health services researcher.

One provider interviewed said, "I beat myself up with it…You want to be liked by your patients. You want to be respected by your peers. You don't want to personally feel like you are being Cruella Deville by denying taking them out of pain. Of course, you want to relieve their pain, so I beat myself up. I feel guilty when these people end up yelling at me, and they do."

The study authors conclude that strategies to ease frustrations and defuse potential hostility in clinical interactions will ultimately improve pain management from the perspectives of both patients and providers. However they also note that potential solutions to difficulties in chronic pain care extend beyond the individual provider. The culture of the organizations -- for example if there is pressure to prescribe or not to prescribe opioids for chronic pain -- in which providers practice play an important role in providers' experiences, potentially making a difference in relationships with chronic pain patients.

"As an internist who frequently treats patients with chronic pain, I know how debilitating and disheartening chronic pain can be for patients. Clinicians need to work with their patients to give them hope that effective treatment of pain is possible," said the paper's senior author, Matthew Bair, M.D., a Regenstrief Institute investigator, assistant professor of medicine at the IU School of Medicine and a research scientist at the Roudebush VA Medical Center.

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