Unclear and Conflicting Pain Guidelines Lead to Significant Differences in How Pain is Treated

A study in BMC Medical Education suggests that earlier education, better understanding of pain guidelines, and better agreement among those guidelines are needed to prevent significant disparities in how certain types of pain are treated.

Chronic pain treatment guidelines, while long-established in many cases, are “unclear and conflicting,” according to the study authors, “which contributes to inconsistent pain care. In order to improve pain care, it is important to understand the various factors that providers rely on to make treatment decisions. The purpose of this study was to examine factors that reportedly influence providers’ chronic pain treatment decisions. A secondary aim was to examine differences across participant training level.”

As part of the study, 85 participants (35 medical students, 50 physicians) made treatment decisions for 16 computer-simulated patients with chronic pain. Participants then selected from provided lists the information they used and the information they would have used (had it been available) to make their chronic pain treatment decisions for the patient vignettes.

Frequency analyses indicated that most participants reported using patients’ pain histories (97.6 %) and pain description (95.3 %) when making treatment decisions, and they would have used information about patients’ previous treatments (97.6 %) and average and current pain ratings (96.5 %) had this information been available. Compared to physicians, medical students endorsed more frequently that they would have used patients’ employment and/or disability status (p&thinsp;<&thinsp;0.05).

A greater proportion of medical students wanted information on patients’ use of illicit drugs and alcohol to make treatment decisions, while a greater proportion of physicians reported using personal experience to inform their decisions. “These results highlight the complexity of chronic pain care and suggest a need for more chronic pain education aimed at medical students and practicing providers,” the study authors noted.

One concern echoed here and in other studies is the paucity of training for chronic pain management in medical school and residency programs. According to the researchers, this may be partly attributable to the mixed evidence base, as as well as the challenges of curriculum reform and a lack of educational resources. Whatever the reasons, this lack of training leads to a lack of confidence in treating chronic pain, and may in many cases lead to sub-optimal care.

Another was the use by more than half of the providers of patients’ demographic characteristics in chronic pain treatment decisions. “While patients’ age and sex can sometimes be relevant to chronic pain care — for example, to predict risk of medication misuse and/or adverse effects – there is limited evidence beyond these items to support using patients’ sex, race, or age when making chronic pain treatment decisions,” the researchers observe.

Clearer guidelines and deeper instruction, while a clear need, won’t be easy to implement, the researchers caution. But the potential benefit to providers and patients alike would be substantial.