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Clinician Interview: Working With Chronic Pain Patients

“Spiritual teachings of all traditions enjoin us to see the divine in each other. Namaste, the Sanskrit holy greeting, means, ‘The divine in me salutes the divine in you.’ The divine? It’s so hard for us even to see the human. What have I to offer this young Native woman whose three decades of life bear the compressed torment of generations? An antidepressant capsule every morning, to be dispensed with her methadone, and half an hour of my time once or twice a month.”  Gabor Maté, In the Realm of Hungry Ghosts

The story above highlights a stark reality for millions of chronic pain patients across the globe whose complex medical needs may not be met by a prescription for opioids or NSAIDs. A 2005 study suggests that in routine medical practice, treatment for primary pain fails to achieve adequate relief in at least 40% of patients, even though effective treatments are currently available.1 Furthermore, studies suggest that despite the multiplicity of available pain treatments, there is a subgroup of intractable pain patients who have not responded.2 A 2014 survey found that of 40 patients, collectively, they had consulted 461 physicians, 172 pain specialists, 104 psychologists or psychiatrists, and 23 university centers without finding sustained pain relief.2 (The 40 patients in this study were referred to the study’s author due to failure of standard treatment, including potent opioids).2

In the video below, Functional Medicine clinician Henri Roca, MD, discusses his Functional Medicine approach to chronic pain. Dr. Roca works with chronic pain patients and was a speaker at IFM’s 2019 Annual International Conference.

Chronic pain has been increasingly recognized as a biopsychosocial condition, and many clinicians find that comprehensive interdisciplinary management is preferred over medication only.3 Recent studies strongly support a biopsychosocial basis to all pain, even pediatric chronic pain; the subjective experience of chronic pain is believed to result from interactions between multiple contributors, including nociceptive, affective, sociocultural, behavioral, and cognitive.4 The development and persistence of chronic pain involves long-term changes in multiple integrated peripheral, spinal, and brain regions interacting in a complex way to shape the individual’s experience.4 It is not a purely physical or psychological phenomenon.4

While there is support for the application of biopsychosocial perspectives in the treatment of chronic pain cases, such perspectives are often overlooked due to either inadequate training or attitudes favoring a biomedical approach.5 In one survey, both established general practitioners and medical students were shown to account for some psychosocial factors when making clinical judgments regarding chronic pain cases; however, they reported not being likely to apply these in real-world, clinical settings due to numerous factors, including available time with patients.5

Yet spending time with a pain patient during the “interview” period has been called the cornerstone of the physical examination, diagnosis, plan of care, prognosis, and overall efficacy of the therapeutic experience.6 Pain researchers suggest that a patient interview is far more than just collecting information.6 That initial meeting is a critical component to establishing an alliance with a patient.6

Functional Medicine clinician Henri Roca, MD, understands that health behaviors are born within family, community, and social systems. “Everything that has ever happened to you, every choice you have ever made brings you to the health you have today,” Dr. Roca tells his patients.

Each choice you make today creates the foundation upon which you can build the health you desire.

Dr. Roca is skilled at interpreting interconnecting webs of cause and effect to get to underlying root causes of chronic pain, and his unique way of connecting with patients has helped him form myriad effective therapeutic relationships.

“I practice integrative Functional Medicine. That’s the only way I can do medicine,” says Dr. Roca. “So I have to see the whole person. I have to get to the root cause. I have to honor their life story, and I have to use everything that works to help bring the person to their best place of health.”

Currently, Dr. Roca is doing this with the Veterans Administration in Arkansas, as the program director for the Integrative Medicine Program for Pain. He offers an individualized approach to health and disease, recognizing the interaction and importance of every aspect of a person’s life—mind, body, spirit, and emotion.


References

  1. Whitten CE, Donovan M, Cristobal K. Treating chronic pain: new knowledge, more choices. Perm J. 2005;9(4):9-18.
  2. Tennant F. Intractable pain patients who have been unresponsive to standard treatments. J Pain. 2014;15(4):S92. doi:1016/j.jpain.2014.01.378.
  3. Ramond-Roquin A, Bouton C, Bègue C, Petit A, Roquelaure Y, Huez JF. Psychosocial risk factors, interventions, and comorbidity in patients with non-specific low back pain in primary care: need for comprehensive and patient-centered care. Front Med. 2015;2:73. doi:3389/fmed.2015.00073.
  4. Liossi C, Howard RF. Pediatric chronic pain: biopsychosocial assessment and formulation. Pediatrics. 2016;138(5):e20160331. doi:1542/peds.2016-0331.
  5. Dwyer CP, McKenna-Plumley PE, Durand H, et al. Factors influencing the application of a biopsychosocial perspective in clinical judgement of chronic pain: interactive management with medical students. Pain Physician. 2017;20(6):E951-E960.
  6. Diener I, Kargela M, Louw A. Listening is therapy: patient interviewing from a pain science perspective. Physiother Theory Pract. 2016;32(5):356-367. doi:10.1080/09593985.2016.1194648.

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