Dawn A. Marcus - Chronic Pain

School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA

Dawn A. Marcus

URL: www.dawnmarcusmd.com

During her annual examination, Ms. Malone, a 53-year-old nurse, reports increased interference from her chronic back pain. She developed low back pain while lifting equipment at work 2 years earlier. Ms. Malone was initially work disabled for 6 months, but successfully returned to modified nursing duties after completing physical therapy. I'm still having problems with my back. I'm limited at work. I have trouble keeping my house in order, I'm missing my grandkids' performances in school, and don't even ask about my sleep. Is there anything else we can do? After glancing at his watch, and realizing that the appointment has already extended 15 minutes beyond schedule, her doctor suggests they schedule a follow-up appointment to address her ongoing pain complaints. Ms. Malone begins to sob, You don't believe I have pain! My family doesn't believe I'm in pain! And my boss is positive that I'm making it all up just to get out of work! I've been trying to just pretend everything's fine, but it's not and I need help! Why can't I find a doctor who is willing to help me?

Chronic pain is a frequent patient complaint, with 70% of patients with persistent pain being managed by their primary care physician and only 2% seeing a pain management specialist.).

As seen in Ms. Malone's case, chronic pain negatively affects sleep, mood, and productivity (Table About 60% of employed patients with low back pain missed at least one work day during the preceding 3 months, with an average loss of 33 out of 60 possible work days. These data suggest that healthcare providers should minimize concerns about treatment costs to actively address pain complaints with a view to reducing disability and avoiding the substantially greater costs of pain-related disability.

Healthcare providers are often perceived by their patients as having a negative attitude about treating chronic pain. One in three people with chronic pain is not currently receiving treatment. This is often due to patient perceptions that their healthcare providers cannot help, that they should just live with their pain, or treatments will not be effective (Box Primary care physicians are also uncomfortable with the expanded need to prescribe opioids to patients with chronic pain; 41% of doctors waited for patients to initiate a request for pain medication.

The evaluation of pain begins with identifying pain location. This is most conveniently done by asking patients to complete a simple pain drawing (Fig. ). This drawing effectively identifies all potentially important pain areas, rather than focusing only on a particular area of immediate concern to the patient.

Although the majority of patients will report more than one active pain area,.

Some patients find it easier to describe pain complaints using a drawing rather than describing them verbally. A study evaluating headache complaints in 226 children showed the diagnostic sensitivity of a pain drawing for evaluating pain in patients with migraine was 93%, with a specificity of 83%, and a positive predictive value of 87%. For example, aura was not identified in 46% who were later discovered to have an aura; vomiting was not confirmed by 50%, nausea by 31%, unilateral location by 38%, throbbing quality by 29%, photophobia by 11%, or phonophobia by 11%.