Diversity of Patients

Diversity of Patients

by Kenneth L. Kirsh, PhD

& Steven D. Passik, PhD

Expert authors received compensation from Janssen Pharmaceuticals, Inc. for their contributions to PrescribeResponsibly.com

Pain management is a complex endeavor even for patients with few comorbidities. Developing algorithms or "cookie cutter" approaches to pain management remains ineffective in even the uncomplicated cases due to variable responses in metabolism, neuroreceptor profiles, and variations in side effect profiles and tolerability. Many patients, however, have significant issues that affect their lives, which create a more complex scenario.

Patients roughly fall into 3 camps of complexity: low, moderate, and high. Where they fall on this spectrum depends on the involvement of issues such as abuse, addiction, medical comorbidities, psychiatric issues, past functional history, and the number of pain complaints. This section provides a series of brief examples that are commonly seen when caring for patients with pain.

Special Populations: Catastrophizing

The term "pain catastrophizing" refers to a patient's core belief that his or her pain is awful, unbearable, and horrible.40 One of the most robust findings in recent psychological pain research is the role of pain catastrophizing in exacerbating the experience of pain. Medical literature defines pain catastrophizing in many different ways, but usually includes a tendency for the patient to ruminate about the pain condition, magnify or exaggerate the meaning of the pain for daily functioning, and feel helpless to manage the pain.41

Empirical studies demonstrate that higher levels of pain catastrophizing are associated with increased pain sensitivity and emotional distress, and this impact is present and significant even when controlling for other variables such as pain severity, depression, anxiety, and fear of pain.40,42 There is no doubt that living in such an emotionally charged state would have a definite impact on the overall functioning of patients with pain; however, it is not always evident which patients are most likely to fall into this category. For this reason, having a screening tool available to give an indication of whether a patient is engaged in catastrophizing can be extremely helpful for healthcare professionals.

While several scales have been created to measure catastrophizing, the Pain Catastrophizing Scale has received the most attention and has proven to have stable test-retest reliability.41 Once pain catastrophizing has been identified, it is usually best to seek consultation to help the patient engage in cognitive restructuring to reduce disability and pain severity and improve mood.

Chemical Coping

There is a vast middle ground between generally compliant drug-taking behavior and frequent or severe aberrant behaviors that are likely to be associated with addiction. A large group of patients in the middle fall between these two ends of the spectrum — those who display aberrant behaviors periodically and may have a mixed response to opioid therapy. While most research focuses on the prediction, assessment, and treatment of substance use disorders, little attention has been paid to this group of patients.43 Some of these patients may be termed "chemical copers."

Palliative care specialist, Eduardo Bruera, MD, and colleagues coined the term "chemical coping" to describe a pattern of maladaptive coping through drug use that they observed in patients struggling with the stress of end-stage cancer.43 Building on this notion, Kenneth Kirsh, PhD, and colleagues adapted the notion to patients with pain, in general, and ultimately developed a scale to detect chemical coping. It is important, however, to understand the current definition of this phenomenon.43

Simply put, chemical copers occasionally use their medications in nonprescribed ways to deal with stress. For these patients, medication use becomes central to life, while other interests become less important. As a result, chemical copers in treatment often fail to move forward toward stated psychosocial goals. They are typically uninterested in treating pain or coping with pain nonpharmacologically and do not take advantage of other treatment options provided (eg, fail to follow up on recommendations to see psychologists or physical therapists). As a manifestation of chemical coping, these patients remain on the fringe of appropriate use of their medication. They occasionally self-escalate their medication dosage in times of stress and sometimes need to have prescriptions refilled early.43

Chemical coping can complicate opioid therapy, but many chemical copers are able to comply with their physician's opioid agreement enough to avoid being removed from treatment.43

Best Practice Suggestions With the Chemical Coper:43
  • Whenever possible, simplify drug regimens (ie, prescribe longer-acting medications to reduce overall number of pills available to a patient at any one time).
  • Decentralize opioid use in these patients (ie, always reinforce that opioids are part of the full regimen and not the sole focus).
  • Encourage or require psychotherapy and other adjunctive modalities to be part of the treatment approach.
  • Focus on teaching coping strategies as alternate choices to reaching for a pill bottle in times of stress or emotional upset.
Comorbidity Issues: Depression

The notions of pain catastrophizing or chemical coping are important, but neither truly rises to the level of a unique comorbid condition when discussing patients with pain. On that front, the most frequent comorbid condition seen with pain is major depression.31 Whether depression is premorbid or manifested as a result of the pain condition, the burdens of coexisting pain and depression should not be ignored. Although there is more work to be done, there has been enormous progress in understanding, assessing, evaluating, and treating these patients.

The overlap of pain and depression is seen in 30 to 60 percent of patients.44 Research has also shown that the more severe, frequent, and enduring the painful condition, the more severe any corresponding depression will be.45 Further, patients with more severe levels of depression have a tendency toward establishing less realistic goals and less acceptance of their condition, thus creating a cycle of hopelessness that exacerbates their pain condition.44 Finally, some research proposes two facets that may mediate the effects of pain and depression: a patient's perspective on the role of pain in his or her life and the ability to maintain control over the pain and life, in general.46 Thus, the more perceived control a patient believes he or she has in life, and the smaller role that pain is allowed to play, the less likely the patient will become depressed.47

References Used in the Section:

  • 31 Dersh J, Polatin PB, Gatchel RJ. Chronic pain and psychopathology: research findings and theoretical considerations. Psychosomatic Medicine. 2002; 64(5):773-786.
  • 40 Kunz M, Chatelle C, Lautenbacher S, et al. The relation between catastrophizing and facial responsiveness to pain. Pain. 2008; 140(1):127-134.
  • 41 Nelson PJ, Tucker S. Developing an intervention to alter catastrophizing in persons with fibromyalgia. Orthopaedic Nursing. 2006; 25(3):205-214.
  • 42 Geisser ME, Robinson ME, Keefe FJ. Catastrophizing, depression and the sensory, affective and evaluative aspects of chronic pain. Pain. 1994; 59(1):79-83.
  • 43 Kirsh KL, Jass C, Bennett DS, et al. Initial development of a survey tool to detect issues of chemical coping in chronic pain patients. Palliative and Supportive Care. 2007; 5:1-8.
  • 44 Bair MJ, Robinson RL, Katon W, et al. Depression and Pain Comorbidity: A Literature Review. Arch Intern Med. 2003; 163(20):2433-2445.
  • 45 Fishbain DA, Cutler R, Rosomoff HL, et al. Chronic pain-associated depression: antecedent or consequence of chronic pain? A review. The Clinical Journal. 1997; 13(2):116-137.
  • 46 Turk DC, Okifuji A, Scharff L. Chronic pain and depression: role of perceived impact and perceived control in different age cohorts. Pain. 1995; 61(1):93-101.
  • 47 Rudy TE, Kerns RD, Turk DC. Chronic pain and depression: toward a cognitive-behavioral mediation model. Pain.1988; 35(2):129-140.