Who manages chronic pain?

Who Manages Chronic Pain

Chronic pain is optimally managed by an interdisciplinary team consisting of primary care providers, nurses, physical and occupational therapists, psychologists, psychiatrists, and case managers, with pain specialists available for consultation when needed. 1, 2

Primary Management Structure

Core Team Composition

The most clinically effective and cost-effective approach relies on a multidisciplinary team that addresses biological, behavioral, and social factors to achieve functional restoration rather than simply eliminating pain 1. The essential team members include:

• Primary care providers who coordinate overall care and can manage baseline therapy including breathing techniques, low-dose tricyclic antidepressants, and SNRIs 1
• Physical and occupational therapists who provide rehabilitation and functional restoration 1, 2
• Psychologists who deliver cognitive behavioral therapy and other evidence-based behavioral interventions 1
• Psychiatrists who manage significant psychiatric comorbidities present in up to 90% of chronic pain patients 1
• Nurses who provide counseling, follow-up support, and patient education 1, 2
• Case managers who coordinate care across disciplines 1, 2

Distribution of Chronic Pain Patients Across Providers

In real-world practice, primary care physicians treat approximately 52% of chronic pain patients, chiropractors treat 40%, pain physicians treat only 2%, and acupuncturists treat 7% 3. However, this distribution does not reflect optimal care delivery, as primary care physicians report the least confidence in managing musculoskeletal and neuropathic pain and are least likely to favor mandatory pain education 3.

Role-Specific Responsibilities

Primary Care Provider Role

Primary care providers serve as the foundation of chronic pain management and should 1, 2:

• Conduct comprehensive pain assessments using multidimensional instruments like the Brief Pain Inventory (BPI) or the 3-item PEG tool (Pain intensity, Enjoyment of life, General activity) 1, 2
• Perform physical examination, psychosocial evaluation, and diagnostic workup to determine pain etiology 1
• Prescribe first-line pharmacotherapy including acetaminophen up to 3g/day, NSAIDs with appropriate precautions, and gabapentin for neuropathic components 2
• Monitor treatment with periodic assessment of functional goals, pain intensity, quality of life, and adverse events 1, 2
• Build therapeutic partnerships through empathy, reflective listening, and believing the patient's pain expression 1, 2

Critical caveat: When new pain develops in patients with existing chronic pain, this requires thorough reevaluation rather than simply increasing current medications 1, 2.

When to Involve Pain Specialists

Pain specialists should be consulted for 1, 2:

• Complex chronic pain cases, especially with co-occurring substance use or psychiatric disorders
• Patients requiring interventional procedures such as diagnostic nerve blocks, intraarticular facet joint injections, or spinal cord stimulation
• Cases where conservative management has failed and ablative techniques are being considered
• Patients on methadone or buprenorphine requiring dose adjustments for pain control

Mental Health Professional Role

Psychologists with experience in chronic pain management are essential team members, not optional consultants 1. They should:

• Deliver cognitive behavioral therapy, which has strong evidence (moderate quality) for chronic pain management 1, 2
• Provide hypnotherapy for patients with visceral hypersensitivity or somatic symptoms (contraindicated in severe PTSD) 1
• Screen for and treat comorbid depression, anxiety, personality disorders, and PTSD present in 90% of chronic pain sufferers 1
• Address catastrophizing, poor coping styles, and pain-related emotions 1

Nonpsychologists should yield to mental health professionals on modality choice 1.

Disease-Specific Management Considerations

Cancer Survivors

The question of who manages pain in cancer survivors may be dictated by available community resources 1. Oncology teams providing ongoing care are optimal because they routinely manage complex cancer therapy regimens and related symptoms 1. When other professionals manage pain, clear, early, and ongoing communication should delineate each team's roles and responsibilities 1.

HIV Patients

HIV medical providers should develop and participate in interdisciplinary teams, particularly for patients with co-occurring substance use or psychiatric disorders 1. As patients age and develop HIV-related comorbidities, frequent communication with the patient and support system becomes critical 1. Consultation with palliative care specialists is recommended for advanced illness 1.

Inflammatory Bowel Disease

The gastroenterologist ideally manages chronic abdominal pain in IBD patients, supported by a psychologist experienced in pain management 1. The provider and patient must collaborate to understand personal, biological, psychological, and social factors facilitating chronic pain 1. Virtual programs are available to identify psychologists with expertise in brain-gut disorders for providers not in integrated multidisciplinary programs 1.

Common Pitfalls in Care Delivery

• Fragmented care: Lack of communication between providers managing different aspects of pain leads to suboptimal outcomes 1
• Delayed psychological intervention: Psychological therapy is often employed too late in the treatment course 4
• Underutilization of allied health professionals: Nurses', pharmacists', and physiotherapists' skills are not fully utilized in many settings 4
• Inadequate training: Many patients believe healthcare professionals lack relevant knowledge, and consultations are rushed 4
• Regulatory concerns: 29% of primary care physicians and 16% of pain physicians prescribe opioids less often than deemed appropriate due to regulatory oversight concerns 3

Practical Implementation

The interdisciplinary team should meet regularly to discuss complex cases and coordinate treatment plans 1, 2. Communication should occur at a health literacy level appropriate for the patient and support system, potentially requiring longer appointment times 1. The team addresses not just pain elimination but functional restoration, pain-coping resources, pain-related disability reduction, and emotional stress management 1.

For patients whose chronic pain is controlled, any new pain report requires careful investigation and may necessitate added treatments or dose adjustments while the new problem is evaluated 1. Providers must clearly document new symptoms and consult with experienced pain management providers or specialists when possible 1.