Jill Schneiderhan, MD, remembers only receiving one or two lectures on basic pain physiology during medical school.
That time was not enough, Dr. Schneiderhan said, who is now a primary care physician and codirector of Integrative Family Medicine at Michigan Medicine in Ann Arbor, Michigan. Medical schools in the United States spend an average of 11 hours on pain management training.
Despite one in five Americans experiencing chronic pain, a gap exists in the pain management training of primary care providers (PCPs). Pain specialists are calling for the empowerment of their first-line-of-defense counterparts with the knowledge and tools necessary to navigate the intricate challenges posed by chronic pain.
Treatment beyond medication is the primary challenge — particularly with pressures and time constraints inherent in family medicine.
“It’s so difficult to teach a PCP how to treat pain because pain management is an entire fellowship,” said Shravani Durbhakula, MD, MPH, MBA, who is on the Board of Directors for the American Academy of Pain Medicine Foundation. But “we encourage a multidisciplinary approach: This includes physical therapy, medication, injections, and other methods. Those different elements coming together typically give some relief.”
Categories of Chronic Pain
Experts sort pain into three broad categories: Nociceptive (from tissue injury), neuropathic (from a nerve injury), and nociplastic (from a sensitized nervous system).
Tissue injury is the most common cause of pain and is characterized by aching and throbbing, while nerve injury causes more burning and shooting sensations.
Nociplastic pain, which arises from abnormal processing of pain signals without clear evidence of tissue damage, is often hardest to understand and trickier to treat. These types of conditions include fibromyalgia, irritable bowel syndrome, and nonspecific back pain, according to Dr. Durbhakula.
“One of the really big challenges is that it’s an invisible condition — you don’t have a cast on or crutches,” Dr. Durbhakula said. “We don’t have great objective measures for pain, and sometimes pain patients feel stigmatized and like their pain is dismissed.”
Primary care specialists should consider six steps to guide their pain assessments, including properly assessing the pain, identifying the pain generator, discussing sensible medications, considering appropriate procedures, recommending appropriate behavioral techniques, and focusing on multidisciplinary management, according to Dr. Durbhakula.
Persistent pain is often too complex to treat with singular methods. For instance, studies have shown pain can lead to structural changes in the brain, such as a decrease in gray matter and differences in neural areas that modulate pain. These neurologic changes illustrate the complicated nature of chronic pain and the need for a multipronged treatment plan.
Don’t Discount the ‘Fluffy Stuff’
One of the biggest challenges in managing chronic pain is the dearth of effective remedies, said Michael Kaplan, MD, a rheumatologist at Mount Sinai Health System in New York City.
While other debilitating conditions have seen breakthroughs — insulin for diabetes, penicillin for pneumonia — pain remains without a cure.
“In the world of centralized pains, we’re lagging behind,” Dr. Kaplan said. “Opioids didn’t work, and here we are in the aftermath of an opioid epidemic.”
Patients can make significant headway with nonpharmacologic management, or what some consider to be the “fluffy stuff,” including yoga, meditation, acupuncture, dry needling, massage therapy, and acupuncture, according to Dr. Kaplan.
But these approaches are often financially unfeasible for patients because insurance companies sporadically cover them. However, free apps can help patients practice things like better sleep and meditation.
“These things actually work, and there is very low risk in trying them,” Dr. Kaplan said. To be sure, medication has an important place in pain management. Neuropathic pain medications or nonsteroidal anti-inflammatory drugs can be effective options for some patients, said Christopher Gilligan, MD, Chief of the Division of Pain Medicine at Brigham and Women’s Hospital in Boston, Massachusetts.
Drugs that target nerve pain include gabapentin and pregabalin, certain antidepressants, and anticonvulsants, which can help dull pain signals in the nerves.
“When a patient has not responded to a first- or second-line medication in those categories, that can be a time when referral to a pain medicine physician can be helpful,” Dr. Gilligan said.
Procedural options that are less invasive than surgery may also be appropriate, Dr. Gilligan said. These include nerve ablation and restorative neurostimulators for people with lower back pain and ganglion stimulation for patients experiencing neuropathic pain.
“The efficacy of interventions for specific pain conditions has gotten better over the years,” he said.