Pain Begets Pain: Presented at PAIN
By Kristina R. Anderson
LAS VEGAS, NV -- September 7, 2007 -- All people in pain have one thing in common and that is that none will perceive pain in the same way, according to James Giordano, PhD, Associate Professor of Palliative Medicine, Department of Medicine, Georgetown University Medical Center, and Director, Center for Brain, Mind and Health Research, the Samueli Institute, Alexandria, Virginia.
"Each individual has a different valance," said Dr. Giordano, who spoke here on September 6 at PAIN Week 2007, "and the only thing we have in common is our differences -- genomically and phenotypically."
Dr. Giordano made it clear that individuals with different genotypes have particular predispositions as to how they experience their pain and that in some patients, their endorphin system has been over-fatigued, thus making them resistant to pain-treatment protocols.
"Pain begets illness and illness begets pain -- it's critical to interrupt that cycle early on," said Dr. Giordano. Those with a greater predisposition may have an increased insensitivity to opioids and that patient populations may need their initial levels of pain medications to begin at a higher dosage. "Each individual's modulating system is different," said Dr. Giordano.
Treating pain, he said, is an experiment with a patient number of one. "Very often, treatment can be hit or miss and you have to establish a level of dialog with the patient," Dr. Giordano said. "Pain is not a disorder that can be objectified."
He said it was an ethical mistake to "blow off patient responses" if the patient said their pain was a "12 on a scale of one to 10."
"Your job is to try to figure out what the patient is feeling. Each patient with pain is unique," he said.
He warned that physician barriers could go up if they think the patient is overreacting to their pain, but he reminded the audience that it is physicians' job to take the critical step with the patient and teach them what it is they were feeling and why they feel such levels of pain.
"Patients expect a magic bullet because of the society in which we live," Dr. Giordano said. He stressed that some physicians fear the regulatory environment. Forty percent of the attendees indicated through electronic voting that the "fellows in yellow jackets showing up," referring to federal drug agents, had an impact on their practice when it came time to reach for their prescription pads. "There is also a fear of patient addiction no matter what is prescribed," he said.
So what is the physician to do when a patient experiences high levels of chronic pain? Dr. Giordano said there is no singular approach to pain, that protocols need to be dictated by the person in pain, and that the patient must be aware of the fact that there is not going to be a cure-all for their chronic pain. "Pain care is not cookie cutter; our role is to work with the patient in an on-going dialog."
Dr. Giordano said he recommends that physicians, after conducting a thorough history, ask their patients for a written narrative from which they can extract features of the patient's expectations, goals and values. He said the physician should not hesitate to let the patient know that their pain may be intractable.
"It's not a question of 'what I'm going to be able to do for the patient'; rather, it's 'how can I work with the patient to help them achieve their meaningful goals'," said Dr. Giordano.
Three major goals exist for the treating physician, he said:
1. To reduce or eliminate pain as best possible.
2. Enhance the patient's ability to cope with pain that persists.
3. Restore a functional level of control in the patient's life
After attempting to reduce the pain using this protocol, he said, it may be time to call in some other troops, such as physical therapists, psychologists or whatever the patient requires. "There is no formula for the patient with pain."
When asked about the possibility of malingering, Dr. Giordano was quick to say that only a very small percentage of chronic pain sufferers were the quintessential pain malingerers. "Not to say it doesn't occur," he said, adding that even if the patient's pain was psychological, that didn't mean that the patient wasn't feeling high levels of anxiety and depression.
He said that more common than malingering is the patient that overstates their pain when given the stage to explain what is going on in their lives. "Some patients need to convince their clinician that their pain is real and to make sure they are not being dismissed or abandoned. Oftentimes, the pain patient tends to exaggerate their pain to convince their doctor that their pain is real and to authenticate the relationship," said Dr. Giordano.
In the dance of pain, he said, it's a good thing to allow the patient to initially lead the dance and then to gently assume the lead. He noted that frequently patients have been dismissed and that they have a need to make the doctor understand what they're feeling in the 20-minute visit.
"Here is when you communicate with the patient and let them know you understand," said Dr. Giordano.