Managing Patients With Chronic Pain in a Post-opioid World

Neha Pathak, MD; Daniel Clauw, MD


August 23, 2023

This transcript has been edited for clarity.

Neha Pathak, MD: I'm Dr Neha Pathak. Welcome to our four-part interview with Dr Daniel Clauw about the state of the art in the management of patients with chronic pain in a post-opioid world.

Dr Clauw is a professor at the University of Michigan in Ann Arbor, where he's running the largest clinical trial to date in people with chronic back pain. Our series will look at best practices for pain-management referrals, how opioids fit into the treatment armamentarium, ways to optimize patient communication and expectation management when it comes to pain control, and approaches to multidisciplinary care.

We're talking today about best practices for pain-management referrals in a post-opioid world. As a primary care doctor, one of the things that I really want to ensure is that I have a good relationship with the folks that I consult with. I'd like to start right there with the referral process.

Could you share with me your guidance on the best way to optimize a referral to a pain specialist so that both the patient and the primary care provider get the most out of that consult?

Daniel Clauw, MD: There are a couple different types of referrals you might make. One would be that you have some uncertainty about the diagnosis that the person might have. You might, in that kind of scenario, send someone, for example, to a rheumatologist to make sure they don't have an autoimmune disease before you can see that they have something like fibromyalgia.

Another referral would be that you've actually tried to manage the person on your own and you weren't able to manage that individual. Then, the referral would really be more to a pain-management center for specific treatments.

That latter type of referral is not that simple in the United States because most of the providers that have been trained in the US and credentialed in pain medicine are primarily trained to do procedures, and they want to do procedures. They don't want to see patients with conditions like fibromyalgia or low back pain if it's nonoperative, nonprocedural, low-back pain.

We really have a problem, and we don't really have a set of providers who want to see these large masses of individuals with chronic pain that doesn't need a surgical procedure or spinal intervention. Because of that, we have to do a better job of supporting primary care physicians and other types of providers in their management of these chronic pain patients because there are far too many of them for any subspecialty to be primarily responsible.

Pathak: What would you suggest in terms of our histories and our physicals in primary care? Are there things that you see that we're missing or that would really help optimize our care and our management of patients with chronic low back pain, for example?

Clauw: I think one of the first things you can do is try to figure out if the pain is coming from the back or coming more so from the brain. These conditions like fibromyalgia, irritable bowel, and headache have taught us about this third mechanism of pain, which is being called nociplastic pain and used to be called central sensitization, where the pain is really coming from the central nervous system rather than from the region of the body in which the person is experiencing pain.

We have a pretty good idea of how to differentiate someone whose pain is coming from the central nervous system rather than the periphery. Their pain is going to be a lot more widespread. If you're not using a body map in clinical practice, I think any time you see a chronic pain patient, give them a body map, just a single point in time to try to see if the pain is widespread or if the pain is in just one or two locations.

If the pain is in one or two locations, it's likely to be a problem in those one or two areas of the body. Those subspecialists or those individuals that subspecialize in those areas of the body, if you as the primary care physician are not comfortable taking care of that, might be very able to help those individuals.

When the pain is widespread, again, these are individuals that we don't really have a great care pathway or a care model for because then they have these sort of chronic overlapping pain conditions, this nociplastic pain or central sensitization, and there are not many providers that feel quite comfortable managing those individuals.

Pathak: In terms of really optimizing our own understanding of where the chronic pain is coming from — specifically, we're thinking about back pain — before we're even thinking about referral, understanding the constraints of our United States healthcare system and what a referral would mean for that patient, we're really trying to identify where the pain is coming from, and ensuring that we've asked the right questions in our history and done an appropriate physical so that we can then travel down this management route.

That's where I'd like to move next. When thinking about management and multimodal pain control, there are many primary care physicians who struggle with how to optimize what to give the individual patient in front of us. Some will go for a shotgun approach and prescribe many different things, from NSAIDs to potentially steroids to topicals. Some will really go in a very stepwise approach.

How do you advise primary care providers to think about management?

Clauw: We know almost nothing right now about what's going to work in which patients. That's what the BEST trial that's underway now that I'm helping lead will help tell us. It's, for the first time, really rigidly applying a precision-medicine approach to a single pain condition. We do know a fair amount about — especially after you try to do this differentiation — is this pain more widespread? Has the person had many other chronic overlapping pain conditions? That's one path that you are going to go down vs the person who has very localized, very regional pain.

In addition to figuring out widespread vs not widespread, look for psychological comorbidities and especially a history of a large amount of trauma. Those are individuals, I think, for whom specific types of cognitive-behavioral therapy have been developed — for people with really strong trauma histories who have CNS-driven pain, but who actually might need a specific type of treatment rather than the nonspecific treatments. This includes getting people sleeping better, getting them more active, and managing their stress the way we do with general nociplastic pain where there's not much trauma in the background.

Pathak: Thank you so much again to Dr Clauw for joining us and being our pain consultant, and helping us think about managing back pain in the post-opioid world.

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