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Chronic Pain:
Treatment Barriers and Strategies for Clinical Practice

Journal of the American Board of Family Practice

Myra Glajchen, DSW, Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, New York

Journal of the American Board of Family Practice 14(3):178-183, 2001.   © 2001 American Board of Family Practice

Abstract

Background: Chronic pain is a clinical challenge for the practicing physician. Lack of knowledge about opioids, negative attitudes toward prescribing opioids, and inadequate pain-assessment skills combine to create major barriers to pain relief. Patient-related barriers, such as lack of communication and unwarranted fears of addiction, further complicate pain assessment and treatment. The health care system itself can hinder pain relief through practical constraints in the community and fear of regulatory scrutiny by the physician. Methods: Information was gathered by doing a literature search, collating clinical information from practice and additional research findings from national meetings, and reviewing the Bulletin of the American Pain Society. Key search terms included "pain," "chronic pain," "pain management," "pain assessment," "pain treatment," and "barriers to pain management." Results and Conclusions: Concrete steps for the clinician engaged in the treatment of chronic pain include selection and administration of an effective opioid, dose titration, short-vs long-acting opioids, opioid rotation, ongoing assessment, and consideration of patient preferences. In addition, communication, coping behaviors, and pain education play important roles in the pain equation. [J Am Board Fam Pract 14(3):178-183, 2001. © 2001 American Board of Family Practice]

Introduction

The prevalence of chronic pain among adults in the United States has been estimated to range from 2% to 40% of the general population[1-3] and from 45% to 80% among nursing home patients,[4] and it has been found in up to 75% of patients with advanced cancer.[5] Because more than 40% to 50% of patients in routine practice settings fail to achieve adequate relief, chronic pain is now considered to be a public health problem of major proportions.[6] Chronic pain can dramatically affect quality of life, a multidimensional concept that includes physical, psychological, spiritual, and social domains.[7] Un-remitting pain is associated with anxiety, depression, loss of independence, and interference with work and relationships. The annual cost of chronic pain, including medical expenses, lost income, and lost productivity, is an estimated $100 billion.[3,8]

For all these reasons, it is essential that primary care physicians become knowledgeable in the area of pain management. Because pain is such a subjective experience, influenced by a host of no medical factors, including age, sex, culture, communication style, and fear of addiction, these demographic and behavioral barriers must be considered in assessment and treatment.[9,10] This article presents an overview of the major barriers to chronic pain management, with strategies for over-coming them in clinical practice.

Address reprint requests to: Myra Glajchen, DSW, Institute for Education and Research in Pain and Palliative Care, Beth Israel Medical Center, Department of Pain Medicine and Palliative Care, First Avenue at 16th Street, New York, NY 10003