American Society of Regional Anesthesia and Pain Medicine May 2018 - 25

the treatment course, it is imperative to establish mutually agreed
upon, realistic goals and expectations of pain management as an
index on which to base conclusions about success of management.
From the physician's perspective, the goals of chronic pain
management should be to decrease the frequency and/or the
intensity of pain over time, while increasing patients' ability
to function physically, emotionally, and cognitively. If needed,
contemporary medications should be used, but the therapeutic
approach must be broadened beyond just pharmacologic
management, given the disease concept of neuropathic pain. We
should help patients cope with residual pain and pain-related
issues (eg, worker's compensation, disability determinations, legal
matters).
Most patients will see even a slight decrease in their primary pain
once a treatment program is started. This is a crucial achievement
because it demonstrates that something can indeed be done about
the pain that has previously only been worsening. This element of
progress, no matter how small, must be constantly presented to
patients to engage their continued participation in the program.
Realistically, it can be very exasperating to confront only a negative
reaction to this good news in difficult patients.
The bottom line is that many patient-specific and circumstantial
challenges are inherent in treating patients with chronic or
neuropathic pain. Major differences in the agenda between
physicians and patients must be actively dealt with at every visit
to align the expectations of management. Repetitive education
that frequently involves explaining what you are doing and why is
necessary for patients that may have low health care literacy.
Even with good therapeutic alliance and patient education, we need
to increasingly understand complex intricacies of polypharmacy
in the face of patient-specific pharmacogenomics. It is difficult
enough at the present time to get a genuine drug trial that
generates solid, objective data in medically complex patients,
because they change their compliance with the recommendations.
Our approach may be one drug or one dose change at a time, yet
patients make independent decisions about efficacy, based on
too-short trials, so time is wasted in modifying the treatment plan.

Understanding all of these challenges in the concurrent setting
of your hospital's or practice's systems arrangements can add a
further layer of complexity (eg, the availability of a particular drug
or specific therapy, a primary care provider who will not write for
a drug in the patient's home area, a patient who is denied formal
rehabilitation).
In the end, it is important to remember that just because
something is difficult to do does not mean it is not worth doing.
Pain physicians can manage difficult patients when they have
established policies about refill prescriptions, acceptable behavior
in the office, no-show events, and late-to-appointment episodes.
Difficult patients should have specific times to call and visit the
office to stabilize the contact rules of engagement. Patients and
their family members deserve direct, honest dialogue in language
they understand and need help in sorting through the myriad
sources of medical information available in the today's media
world. Perhaps the most assured technique to assess what patients
actually understand from your visit is to ask that they repeat back
to you what you have discovered/discussed/agreed upon.
We are obligated to share our expertise with all patients, even
those designated as "difficult." Using a systematic, straightforward
approach, even these patients can be served.
REFERENCES
1.

Webster's New World Dictionary. New York, NY: Simon and Schuster, Inc.; 1988.

2.

Gatchel RJ. Introduction to the "Special issue on pain catastrophizing". J Appl
Behav Res. 2017;22:e12088.

3.

Hojat M, Vergare MJ, Maxwell K, et al. The devil is in the third year: a
longitudinal study of empathy in medical school. Acad Med. 2009;84(9):1182-
1191.

4.

Mariano AJ. Practical advice for real-world practice: facilitating selfmanagement in challenging patients. Presented at: American Academy of Pain
Medicine 33rd Annual Meeting; March 16-19, 2017; Orlando, FL.

5.

Mandelbaum BR. Five principles for the future of healthcare. May 3, 2017.
Available at: http://www.medscape.com/viewarticle/879203. Accessed March
5, 2017.

6.

Association of American Physicians and Surgeons, Inc. Physician oaths.
Available at: http://www.aapsonline.org/ethics/oaths.htm. Accessed March 5,
2017.

7.

Messelink EJ. The pelvic pain centre. World J Urol. 2001;19:208-212.

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2018

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http://www.medscape.com/viewarticle/879203 http://www.aapsonline.org/ethics/oaths.htm

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