AAPM 2009: Specialists Confront Refractory Chronic Pain

Allison Gandey

February 12, 2009

February 12, 2009 (Honolulu, Hawaii) — The mainstays of chronic pain medicine include disease-modifying interventions and mechanism-specific therapies, but these approaches do not help all patients achieve pain control. Here at the American Academy of Pain Medicine (AAPM) 25th Annual Meeting, specialists discussed the challenges associated with management of patients with chronic refractory pain and how behavioral or psychological approaches may help treat it.

"Pain is not a symptom," panelist Michael Moskowitz, MD, from the University of California, Davis School of Medicine, in Sacramento, told Medscape Neurology & Neurosurgery. "It is a disease, and the brain undergoes important changes during this process. It is our job to figure out how to help change it back."

Dr. Perry Fine

However, there are limits to what can be accomplished with current therapies, said session moderator Perry Fine, MD, from the University of Utah School of Medicine, in Salt Lake City.

"What do we do when interventional and pharmacological therapies do not yield the hoped-for therapeutic outcomes or when we reach the limits of our understanding of pain mechanisms and available clinical science?" he asked. While science informs management, he said, there is an art to the practice of pain medicine. "Art is very personal, and there is a subjective nature to what we do."

"With some patients, we will reach a point when we have exhausted all reasonable treatments and there’s no reason to perform an eighth back surgery," AAPM President Kenneth Follett, MD, from the University of Nebraska Medical Center, in Omaha, said at the meeting. "We have to accept the fact that we need to shift our focus from treating the pain to coping with it."

Dr. Follett pointed out that at his institution there is a cognitive behavioral pain program where he can refer patients.

"People with chronic pain who travel for treatment often come in with very high expectations," panelist Leonardo Kapural, MD, from the Cleveland Clinic Foundation, in Ohio, added. "I explain to them that if they've had this pain for 10 years, it's not going to go away in a snap."

But not everyone agrees with these assessments. Dr. Moskowitz argued at the meeting that every patient in pain can feel better. "I like to raise expectations, not lower them," he told attendees. "I think our brains are malleable enough that all patients can heal. I object to implications that some patients are just never going to get better."

Failed Treatments

Refractory chronic pain patients tend to see many doctors, have experienced multiple failed treatments, and may feel overwhelmed by their condition, the group reported.

"Some of these patients have been picked over by so many surgeons, if you give them water, they leak," Dr. Moskowitz said. "It can be a very discouraging and frustrating experience, and some patients come to me just needing to tell their story and be heard."

I object to implications that some patients are just never going to get better.

Dr. Fine said he likes to ask patients with refractory chronic pain to name the best thing that happened to them in the past week. "This tells me whether patients have the capacity to feel better — even if only for a minute. If I can see that spark of joy or pleasure arise when they talk about something else, then I know we have a good chance for success."

Dr. Follett said he tries to gauge whether patients are willing to participate in getting better. "Patients who are willing to assume control of their own treatment have a much better chance of healing than those who aren't," he said.

"I often can't tell who is going to get better," panelist Norman Doidge, MD, from the University of Toronto, in Ontario, said at the meeting. "People surprise me all the time."

Dr. Doidge is a psychiatrist and also gave the meeting's keynote address on neuroplasticity and chronic pain. "It strikes me that the anguish pain patients experience is similar to what patients with intense anxiety disorders go through."

Taking an informal poll at the meeting, Dr. Doidge asked meeting attendees to raise their hands if they have found that their chronic-pain patients have experienced early childhood trauma. He estimates that about 60% of pain specialists in the room raised their hand.

A Multifaceted Approach

Some patients develop chronic pain immediately after an accident, Dr. Doidge pointed out, but for others the pain comes later with the onset of posttraumatic stress disorder, and, in many cases, depression develops as well.

"Pain patients are often diagnosed with personality disorders, but it's hard to know to what extent it's the pain," Dr. Doidge said. "I know that when I'm in pain, I feel pretty rotten, and someone could say I have a personality disorder, but really I just feel bad."

Dr. Doidge told attendees to think of snow on a mountain and to imagine someone skiing down it. "This is kind of what the brain is like and after a while, things have been firing so long that they become engraved in — like the ruts of ski tracks down the side of that mountain. And if it's engraved in, no one is going to get better," he said.

While there are many paths the skier could take down the mountain, it becomes habitual to stick with the tracks. "In the case of the chronic-pain patient, we need to set up a roadblock so that the patient can't keep skiing down the hill in exactly the same way."

He suggests the brain is a changeable organ that can alter its own structure and function. "We have to find ways to get in and help change the body map." Dr. Doidge pointed, for example, to some early work suggesting eye-movement desensitization and reprocessing (EMDR) may be useful.

EMDR for Chronic Pain?

EMDR is a form of psychotherapy that was developed to resolve symptoms resulting from disturbing and unresolved life experiences.

The approach was developed by Francine Shapiro, PhD, executive director of the EMDR Institute, in Watsonville, California, to resolve the development of trauma-related disorders such as recovering after rape. The theory underlying EMDR treatment is that it works by helping the sufferer process distressing memories more fully to reduce the distress.

Dr. Doidge wonders whether EMDR may also help patients in chronic pain. The panelists concluded that a multifaceted approach to pain management is optimal, and many patients will benefit from behavioral or psychological approaches.

Dr. Kapural reports that he has received funding from Baylis Medical Company.

American Academy of Pain Medicine 25th Annual Meeting: Plenary session 108. Presented January 30, 2009.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.