The following case illustrations highlight major issues related to chronic pain management.
CASE ILLUSTRATION 1
CHRONIC HEADACHE PAIN
Lisa is a 39-year-old woman who sought care for her long-standing headaches. These headaches first appeared at the age of 18 years, at which time they were characterized by severe left orbital and temporal pain associated with nausea, nasal stuffiness, and photophobia. They were often preceded by a scintillating scotoma in the right temporal/visual field. Her workup included a normal lumbar puncture, several normal EEGs, computerized tomography (CT) scans, and blood chemistries. She was virtually headache-free for 1 year following a pregnancy in her early 20s. Headaches gradually recurred but remitted again for a year after a hysterectomy for endometriosis in her early 30s. She now reports that the headaches have increased in frequency, duration, and severity over the past 2 years with more photophobia, nausea, and vomiting.
Treatment modalities have included analgesia (aspirin, acetaminophen, NSAIDs, opioids), abortive agents (sumatriptan and topiramate), prophylactic medications (amitriptyline, cyproheptadine, phenytoin, valproic acid, propranolol), and vitamins, all of which have had only transient benefit. Dietary and activity prescriptions have also been of minimal success. Her main source or relief over the past year has been repeated emergency room visits for intravenous opioids. She has seen multiple internists, neurologists, anesthesiologists for trigger point injections and nerve blocks, allergists and emergency room physicians.
Long-standing, recurrent, incapacitating, nonmalignant pain creates a number of challenges in management:
Seeking assistance from a series of caregivers without resolution.
A clear fluctuation in the frequency and intensity of the headache seemingly due to physiologic changes, but without an exploration of the possible behavioral or social changes associated with these fluctuations.
Failure to explore the impact the headache has had in the patient’s life.
A pain history revealed that Lisa’s headaches in early adulthood were infrequent (several per year) and were managed conservatively. Her single severe attack resulted in a hospitalization that was a source of embarrassment to her and her husband. During the early years of her marriage she continued to have infrequent but more severe headaches. During a period of 6 months of treatment with oral contraceptives her headaches became more frequent and severe. As her daughter grew older and her job responsibilities increased, the frequency and severity of the headaches grew. She further reported that she was best able to control her pain by being alone in a quiet room, reading, or listening to quiet music.
The patient is now identifying what may be a clear relationship between marital or social stress and her headache complaint. The headache can provide “time-out” from the conflicts at hand, and she can ease the pain by listening to music or reading. She further indicates that the headaches did not have a significant impact in her early life.
The headache pattern remained unchanged until 1½ years ago. At that time Lisa and her husband relocated as a result of her husband’s work and they moved into a home that required major remodeling, the responsibility of which was largely the patient’s. She had difficulty replacing her former employment and considered a new career. Although she reported enthusiasm for the remodeling and the relocation, Lisa also reported a marked increase in the frequency of the headaches. She was unable to work around the house remodeling or participate in family discussions when she had the headache, but was otherwise able to prepare meals, do housework, and drive as far as 30 miles one way for social and medical visits. She reported that when she retreats to her room with a headache her husband and children attend to her until she starts to improve. She also indicated that her husband returned home early from work during times of a severe headache. She has seen a cascade of physicians in various specialties with a variety of unremarkable diagnostic tests and specialty workups. Her average length of treatment with any one physician was five visits. She reported with embarrassment that she had been unable to keep up with her diet and exercise program and was increasingly overweight. Otherwise, she was in good health with no other medical problems.
Although the headache event is likely to have muscle contraction, endocrine, and vascular components, there appear to be a number of clear situations or conditions that accompany its onset and severity. Moreover, it is clear that as life stress has increased, Lisa’s headaches have also increased in severity and frequency. There seem to be behavioral factors that reinforce the headache complaint: (1) avoidance of stress and (2) increased attention from others.
The following treatment course of action was undertaken:
The physician explained to the patient that she wanted to work with her to ease her headaches. She reassured Lisa that she thought that by working together and taking a broad view they could ease the frequency and severity of headaches and improve her quality of life overall.
It was agreed that the best course of treatment was to use as little opioid medication as possible. Even though opioids were found to be useful by the patient, she recognized that ultimately they were not changing the overall pattern of her headaches and decided to use them only for severe headaches that did not resolve with other measures. Patient and physician medication management responsibilities were outlined in the medication agreement, which specified the number and frequency of opioid medications.
It was agreed that the patient would not seek additional medical evaluation or treatment without discussing it with her primary care physician first.
The primary care physician agreed that she or her designee would be available within a 12-hour period of being contacted about a headache to discuss the headache and the possible situation surrounding it. It was agreed that these conversations would generally be brief and not longer than 5–10 minutes.
The physician discussed a comprehensive approach to the headaches, including a course of biofeedback training and instruction for neck exercises in physical therapy. Lisa agreed to participate actively in these treatments.
The physician also referred Lisa for CBT.
If this plan did not show significant reduction in headaches within 3 months, referral to a multidisciplinary pain rehabilitation program would be considered.
Finally, the physician would attend to all of Lisa’s medical needs, including preventive care, which had been somewhat neglected due to a singular focus on the headache and the frequent changing of doctors.
In this way, the primary care physician helped Lisa redefine the headache treatment regimen: it does not need immediate or intensive medical care; it does not need further diagnostic evaluation (because a detailed medical evaluation had already been done); and it does not need further multiple/different medication trials (these have also been tried). By creating an effective relationship with the patient, acknowledging the severity of her complaint, setting expectations for how to respond to symptoms, explicitly stating a desire and intent to help, and securing the patient’s commitment to work within this setting, a productive patient–physician partnership was established to address Lisa’s pain complaint.
CASE ILLUSTRATION 2
CHRONIC INTRACTIBLE PAIN: CHRONIC LOW BACK PAIN
Michael is a 45-year-old man with controlled hypertension who presented with low back pain. He reported that while working on a farm 2 years ago he experienced a motor vehicle accident that resulted in a herniated disc in his lumbar spine. A lumbar laminectomy and discectomy followed with some relief of pain for approximately 3 months. Since that time he had 6 weeks of passive physical therapy (hot packs, ultrasound, massage, gentle stretching) and was receiving oral opioids and NSAIDs from his surgeon. He had low back pain and no other complaints. He had not returned to work since the day of the injury and was currently involved in a vocational rehabilitation plan.
On physical examination, the patient was tender to palpation across his low back bilaterally. Passive straight leg raising was normal. Sharp, dull, and light touch sensations were intact throughout, with symmetric reflexes in both the lower extremities. The CT scan of the lumbar and sacral spine revealed old surgical repair of a herniated disc without other abnormalities. Recent nerve conduction studies were unremarkable for nerve slowing. The patient’s surgeon, who had “nothing more to offer,” referred him back to his primary care physician for continued treatment. The primary care physician referred him for a series of three epidural injections. The first injection resulted in partial pain relief for 2 weeks. The last two injections produced no relief of pain.
Chronic low back pain often has the following characteristics:
Subjective complaint of pain with minimal objective findings.
Use of “passive” rather than “active” physical therapy.
Continuous use of opioid medication in escalating dose to manage the pain.
The patient reported that he spends much of the day sitting in his reclining chair, either watching television or reading except for when he attends the vocational training. He moves from the chair two or three times each day, primarily for meals. He frequently naps during the day and reports disrupted sleep at night, averaging 5–6 hours. He feels depressed and hopeless about his recovery and believes that unless his pain is relieved he will be unable to return to work. He acknowledges that his spouse and children are angry with him and his inability to return to work.
On further questioning it was discovered that the social “cost” of the pain is high. Michael’s daily activities are greatly impaired. His self-esteem and affect have plummeted, and he is further emotionally isolated from his family. In a circumstance in which a patient’s chronic pain is associated with the patient belief that pain relief is necessary to return to a degree of normal living, the doctor must accurately establish expectations for recovery and the probable outcomes of treatment. Because the patient is usually still focused on the pain as a continuation of the original precipitating injury, it becomes necessary to identify and deal with the patient’s pain beliefs while focusing on improving function.
Although Michael reported feelings of depression, it is inaccurate to say that the pain is caused by the depression or vice versa, but rather it is comorbid to the pain. It has been shown, however, that the intensity of pain often diminishes with a trial of antidepressant medication, which can improve sleep as well.
The goals of treatment for chronic low back pain are primarily focused on improving the patient’s activity level; diminishing their reliance on medications because, as in this case, they have not improved functioning despite escalating doses; and reducing pain behaviors (e.g., changing the focus of treatment from decreasing pain to increasing activity level for meaningful tasks). In this way, the doctor assists in “managing” the pain behavior.
At the same time the doctor should challenge the commonly held belief that increased opioid medication is necessary for increased activity. Whereas this is often the case for acute pain conditions, the same is not necessarily true for chronic noncancer pain conditions, and in some cases increasing opioid dose is associated with worse overall functioning. The doctor also should help the patient recognize that increases in pain with activity do not mean that an underlying condition is getting worse. The doctor should also reinforce the use of nonpharmacological methods of pain control while the patient is increasing his functional activity levels.
After a careful explanation by the doctor of the anatomy, physiology, and possible/probable causes of Michael’s low back pain, a collaborative discussion followed, leading to an agreement on the following treatment plan:
A course of physical therapy using primarily active exercises (e.g., aerobic exercise, walking, strengthening, and stretching). In addition, the patient agreed to take progressively longer walks each day. It was expected that with increased activity there would be an initial increase in pain. For that reason it was agreed that the patient could continue to use his opioid medication at the same dose during this period.
Although there was no evidence of addiction or abuse of opioids, it was also clear that increasing opioid doses and prn use had not improved the patient’s pain or function. The physician realized that the sole reliance on opioids for management was not working. On the other hand, given prolonged use of opioids, discontinuation was also not a realistic option. Oral opioid medication was managed with a long-acting preparation with no short-acting or “breakthrough” dosing. This approach avoided linking the patient’s pain with the timing and amount of dosing. The physician wrote monthly prescriptions. It was agreed that any request for change in his medication regimen would be directed only to the primary care physician and not to emergency rooms or other physicians. This was outlined and signed in a patient medication agreement.
The patient would be seen once a month by the doctor. A primary focus of future visits would be discussion about daily activities or return-to-work goals, if appropriate, rather than pain interferences with life.
Progress toward increased functional activities and reduced reliance on medications was monitored monthly through a brief activity-oriented questionnaire filled out at each doctor’s visit.
The patient and the physician agreed that reducing opioid use was a goal and would be done gradually over time as tolerated. The physician reassured the patient that he would continue opioids if necessary but expected that a more comprehensive approach would lead to improvement that would obviate the need for opioids.
The doctor has now, in collaboration with the patient, established the parameters of treatment, clarified the expected outcomes in terms of function, developed a more rational plan for the use of opioids, and progressed toward meaningful employment goals if appropriate, all in the context of reassuring the patient that the physician was invested in helping him and would work with him. This approach is a far cry from the previous message of “there is nothing more to do” and provides hope to the patient. These steps define the treatment effort to reducing pain perception and pain behaviors and changing beliefs about pain impact. Patients who respond favorably to this treatment of chronic pain usually report either that the pain is significantly reduced or that it does not bother them as much as it used to. When pain behavior is more entrenched (the patient is unresponsive to treatment due in part to beliefs about pain impact or secondary gain or both), referral to a multidisciplinary pain rehabilitation facility is recommended.
Cognitive-behavioral therapy and other behavioral approaches (Table 35-6) are often useful therapies independent of the multidisciplinary pain rehabilitation programs and would be reasonable adjuncts for this patient.
CASE ILLUSTRATION 3
Kim is a 46-year-old woman with a known history of gastroesophageal reflux disease (GERD), who presented with total body pain. She reported that while lifting some baked goods in her kitchen 20 years ago she felt an acute snap coming from her right shoulder. She was later diagnosed with thoracic outlet syndrome and underwent removal of her first rib. She experienced pain relief for approximately 8 months with a recurrence of symptoms followed by an additional supraclavicular surgery. She continued to report having neck and shoulder pain. She was then diagnosed with cervical spondylosis and underwent a cervical laminectomy 5 years later with good benefit. Thereafter, she was tapered from her pain medications and returned to normal life, including work as a baker. For approximately 10 years following her surgery she reported essentially no recurring symptoms. She then had an onset of “achiness” in her shoulders and upper extremities bilaterally.
Kim now presents with pain in all four quadrants of her body and was positive for increased sensitivity for 16 of 18 tender points when applying 9 lbs of pressure. Kim also reports having an increased sensitivity to pain especially in her neck and shoulder.
Fibromyalgia is a clinical syndrome or cluster of symptoms for which there is little agreement as to cause or etiology. Complaints of total body achiness in all four quadrants of the body plus tenderness in 11–18 tender points when applying 9 lbs of pressure are sufficient to make a diagnosis. Report of symptoms of fibromyalgia can occur with no known traumatic event or illness.
On physical examination, sensation was intact throughout with symmetric reflexes without evidence of clubbing, cyanosis, or edema. She had full range of motion in the bilateral upper and lower extremities with no motor deficits identified. An MRI of the cervical spine showed old cervical repair with no abnormalities. Kim was then referred to a pain relief specialist (anesthesiologist) at a multidisciplinary pain procedure program.
A detailed history taken at the multidisciplinary pain procedure program documented pain symptoms, together with chronic fatigue, sleep disturbance, intermittent headaches, loss of weight, subjective feelings of weakness, intermittent report of irritable bowel, and anxiety. The multidisciplinary evaluation included a psychological evaluation, which diagnosed comorbid depression and anxiety with an above-normal arousal response to stress.
The multidisciplinary evaluation identified a number of other symptoms that are commonly seen with fibromyalgia, including fatigue, sleep disturbance, intermittent headaches, weight loss or weight gain, complaints of weakness, irritable bowel, and anxiety and depression. Not uncommon with fibromyalgia is an abnormal startle response as well as decreased coping in the presence of increased stress or stimulation.
Kim reports that she is a single mother of three teenage daughters, two of whom are living at home. She reports her ex-husband to be estranged from her and her children. He has not provided child support, requiring that Kim work full time as the sole support of the family. As her daughters grew to their mid-teen years, an increasing number of conflicts occurred between them. Kim reports that she is most worried about her eldest, 17-year-old daughter, who has recently dropped out of school and is living with a boy. Kim fears that she is using recreational drug. Kim reports having missed several days of work due to her pain and has been warned by her employer on two occasions that further absences might lead to disciplinary action. Finally, she reports that she is involved romantically with a man who seems to like her daughters and has been responsive to her needs for support as her pain problems seem to worsen.
While it is unknown if stress is one of the triggers of fibromyalgia, it is not uncommon to find comorbid environmental or personal situations that promote symptoms of anxiety and depression.
Treatment initiated at the multidisciplinary pain procedure clinic included SSRI antidepressant medication, gabapentin, a trial of muscle relaxant medication, and a series of myofascial trigger point injections. She was also seen for a course of CBT designed to improve problem-solving capabilities and teach stress management techniques. She also engaged in passive physical therapy modalities (such as ultrasound, massage, and gentle stretching). Kim reported improved mood and greater relaxation in response to the passive physical therapy techniques and muscle relaxant medications. There was no benefit from the trigger point injections. Finally, it was reported by the psychologist that her decision making about her 17-year-old daughter was improving, with evidence of better coping skills. She also had scheduled relaxation into her daily routine. She has begun a course of oral, short-acting opioid medications; and Kim decided to take a leave of absence from her employer on short-term disability.
In the absence of a true etiology, the tendency is to treat the symptoms of pain. The symptoms are often vague and transient and do not respond well to an acute pain treatment approach. Though Kim does benefit from treatments that are designed to reduce arousal and improve coping skills, she continues to report the symptoms of pain leading to increased disability.
Kim discharged from the multidisciplinary pain procedure program and returned to the care of her primary care physician. In collaboration with her doctor, Kim agreed to continue with her use of the antidepressant medication and to gradually reduce and discontinue her use of muscle relaxant and opioid medications. Consideration was given to use of low-dose NSAIDs. She continued physical therapy that now included walking in the swimming pool three times a week for 1 month, followed by light aerobic exercises three times a week, and, finally, active physical therapy for muscle fitness. It was agreed that she would use hot packs and massage for temporary relief in lieu of the opioid or muscle relaxant medication. She was to continue her relaxation practice throughout the day and agreed to continue CBT to assist with coping.
The doctor agreed to meet with Kim once a month to review progress. Kim agreed to keep records of her daily exercises and her medication use. Kim also agreed in her medication contract that any flare-ups or changes in her medication would be managed by her primary care physician, who agreed to be responsive to her within 24 hours of initial contact between monthly visits.
After 6 months of treatment Kim was able to improve her function and daily activity sufficiently to return to work on a full-time basis. She was able to plan for her future wedding with her now fiancé and reported that her total body pain had reduced substantially, but “waxed and waned” intermittently.
CASE ILLUSTRATION 4POSTHERPETIC NEURALGIA
Lynn is a 63-year-old woman with well-controlled hypertension and elevated cholesterol. Lynn works as a social worker and also volunteers with social service agencies. Twelve years ago, she developed a vesicular rash on her left frontal scalp and forehead. The area was severely painful. She presented to her general medicine physician 4 days after the rash appeared, having thought it was a reaction to a new shampoo.
She was diagnosed with varicella zoster virus infection (shingles). A careful evaluation was conducted to make sure she did not have any ocular involvement. Despite the delay in her presentation, she was treated with acyclovir and a 10-day course of prednisone.
For her acute pain, she was treated with hydrocodone/acetaminophen and ibuprofen. She received moderate control of her pain but felt somewhat dizzy with the hydrocodone/acetaminophen medication and experienced gastrointestinal upset with the NSAID.
Five weeks after onset and after complete resolution of the lesions, Lynn returned to her primary care physician with the complaint of continued pain on her scalp and forehead. The pain was described as “burning” and “searing.” The patient was most aware of the pain at night, in bed before sleep and it sometimes kept her awake. When she was more active, she reported that she had less pain. However, sometimes the pain was so severe it was difficult for her to go about her usual activities. Lynn was diagnosed with PHN.
Post herpetic neuralgia is an unfortunate complication of varicella zoster infection that is more likely to develop in patients older than 60 years. It can last for months or years or be permanent. The actual cause of the PHN is not known and, therefore, treatment is directed at managing the pain symptoms. People with PHN benefit from an honest explanation of the disorder, the typical course of the condition, and a multidisciplinary approach to management.
Lynn tried gabapentin but experienced little benefit. Moreover, she was burdened by severe sedation at a dose of 900 mg three times daily. Pregabalin was ineffective. She refused a trial of the lidocaine transdermal patch due to cosmetic concerns. Capsaicin cream was difficult to use on her scalp. Nortriptyline up to 150 mg nightly had only a modest effect. Other TCAs, SSRI, and SNRI medications were tried. Duloxetine proved most helpful among these. She continued to use hydrocodone/acetaminophen when the pain was incapacitating; however, she did not like the idea of using an opioid medication regularly and also reported some dizziness even at low doses. Pain relief was only partial at best. The mainstay of her pharmacological treatment was ibuprofen 400 mg two to three times daily. She added a proton pump inhibitor to help with stomach upset.
The side effects of analgesic medications often require management with other medications. Even patients who wish to limit their use of medications may soon find that their pharmacological regimen has become complex and burdensome. Moreover, as in this case, medications alone may not adequately treat the pain and behavioral medicine approaches should be considered.
Lynn tried acupuncture without success as well as a mindfulness-based stress reduction practice, with some benefit. She noted that her Mindfulness exercises were especially useful to her at night when she was going to sleep. She was referred to physical therapy, where modalities including contrast heat/cold treatments were used, followed by a trial of the transcutaneous nerve stimulator (TENS), all with only temporary benefit. She was referred for CBT where she learned to accept her pain, be mindful of her life with pain, and to live a normal life despite the pain.
In cases such as these, where pain is refractory to multiple medications, the focus is on chronic pain management. Chronic pain typically has no cure and is poorly managed by medications alone. Combining CBT techniques with physical rehabilitation and medications has shown the best outcomes in the treatment of neuropathic chronic pain.
After 6 months of managing her symptoms, Lynn settled into a regular medication regimen of ibuprofen, omeprazole, and duloxetine, and needed hydrocodone/acetaminophen only rarely. She recognized that being as active as possible at work and at home greatly improved her quality of life, including the management of her pain. After 12 weeks of CBT and 6 weeks of physical therapy, she now a has an active life despite the pain, a number of self-management approaches that she employs as needed, and an acceptable pharmaceutical regime with few side effects—all of which enhance her well-being and resilience.