Hope for Preventing Transition from Acute Pain to Chronic Pain Lies in New Risk Profiles

The standard definition of chronic pain includes a pain severity score above 6 out of 10, duration of pain for longer than three months, and impairments in function and quality of life associated with pain severity and duration. But in his presentation at PAINWeek 2013, Michael R. Clark, MD, MPH, MBA, director of the Chronic Pain Treatment Program at Johns Hopkins Medicine, noted that description doesn’t inform physicians about how chronic pain develops, or why one patient who experiences acute pain crosses into chronic territory while another patient doesn’t.

Instead of rewriting the definition of chronic pain in his “When Does Acute Pain Become Chronic?” session, Clark outlined the vulnerabilities that put patients with acute pain at risk of transitioning into new chronic pain, and then discussed how rational treatment approaches addressing those patient-centered risk factors can prevent that transformation.

Noting that the typical risk factors of demographic variables, pain characteristics, psychological factors, and contextual details provide “no recipe for, ‘Okay, what do you do about these things?’ ” Clark offered a new chronic pain cases formulation that includes four profiles of risk, which are:

• Diseases: Search for all possible broken parts causing pathology and select treatments that will minimize new damage and subsequent pathology
• Dimensions: Recognize how much of each individual trait a patient possesses, and then match the strengths of each trait with specific tasks to optimize the patient’s capabilities
• Behaviors: Point out problematic behaviors every time they occur, but also emphasize and reinforce productive behaviors whenever possible
• Life Stories: Expand medical history to include every aspect of the patient’s life and help the patient find an answer to the question, “What good does life, hold for me?”

Within each of those four perspectives, Clark highlighted significant risk factors — along with their appropriate targeted treatments — that may specifically cause the transition from acute pain to chronic pain. For example, one study found depressive disorders at baseline doubled a patient’s risk for new onset back pain 13 years later, so Clark said a patient who presents that disease should be prescribed antidepressants. Similarly, patients with substance use behaviors should take part in group-based behavioral psychotherapy, while those with a life story of pain catastrophizing — defined as the exaggeration of distress over an anticipated or actual painful experience — should join support groups and receive insight-oriented psychotherapy.

To help the physicians in the audience understand the effectiveness of his strategies, Clark presented a case study of a 45-year-old Korean woman whose foot was crushed by heavy equipment. After six months of poorly complying with physical therapy, experiencing high levels of acute pain, and taking short-acting opioids and acetaminophen with multiple agents for insomnia and anxiety, the patient decided to have her leg below the knee amputated by an orthopedic surgeon against Clark’s pleas not to amputate.

After the patient reluctantly agreed to see Clark throughout her post-operation period, she was prescribed 300-milligram sertraline for her major depressive disorder and 500-milligram BID valproate for her post-amputation pain. Additionally, the patient joined support groups to overcome fear and avoidance, received prosthetics and physical therapy to restore her pre-amputation physical state, and underwent occupational therapy to return to full-time work and become financially independent enough to divorce her cheating husband.

Although Clark said “not many people would think amputation in this case is a good idea,” he noted that his case study provides “hope for preventing chronic pain, since some might say she lost her leg and gained her life, and some might argue it was almost necessary for her to go through the leg amputation to get to this endpoint.”

Clark concluded that hope for preventing chronic pain across the entire acute pain patient population lies in recognizing the four profiles of risk, preventing the transition from acute to chronic pain, treating specific causes of new chronic pain, and addressing the nature of barriers to restoring health.

To learn more about chronic pain patients, watch this YouTube clip of Clark.