When Is a Person with Chronic Pain a Patient

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                                                             APS Bulletin • Volume 15, Number 2, Spring 2005
                                  Education                  President’s Message
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                                                             When Is a Person with Chronic Pain a Patient?
                           The Journal of Pain
                                                             Dennis C. Turk, PhD
                  Principles of Analgesic Use
                                                                                     Quick, what thoughts come to mind when I ask you to think about a “typical”
                       APS Bulletin Archives
                                                                                     chronic pain patient? Check your list against characteristics cited in the
                                  APS E-News                                         literature for patients who seek treatment by pain specialists. Compared to
                                                                                     community samples of people with chronic pain, pain clinic samples are more
                  Clinical Practice Guidelines
                                                                                     likely to report constant pain, high levels of emotional distress, functional
                                Annual Reports                                       impairments, opioid medication consumption, work-related injuries, frequent
                                                                                     use of the healthcare system, and prior surgeries (Crook, Tunks, Rideout, &
               Guides for Persons with Pain
                                                                                     Browne, 1986). Patients are individuals who are awaiting or are already under
                                   Online Store                                      medical care and treatment. According to Webster’s Tenth Collegiate
                                                                                     Dictionary (1996), they are people who are “acted upon.” Thus, diabetics are
                                   Advocacy                                          “patients” when in the clinic, but outside the clinic setting are they “diabetic
                                                                                     patients” or rather “persons who have diabetes”? Webster’s defines person as
                                  Resources                  “a human individual.” A patient is also a human individual, both in a healthcare provider’s office and
                                                             when not being treated directly. Patient is therefore a subset within the broader category of human
                             Support APS                     individuals. Yet many people with chronic pain identify themselves as chronic pain patients. So when
                                                             is a person with chronic pain a patient, and should we help shift their perception of themselves as
                                                             people rather than patients? We should consider how healthcare providers contribute to the patient
                                                             versus person perspective.

                                                             It is estimated that 75–150 million people in the United States have a chronic pain disorder (Elliott,
                                                             Smith, Penny, Smith, & Chambers, 1999; Harstall, 2003). According to MarketData Enterprises (1995),
                                                             2.9 million (2.5%–5%) people seek treatment by pain specialists. What do we know about the other
                                                             72–147 million people with chronic pain who do not seek treatment by pain specialists? An unknown
                                                             proportion of those have learned ways to adapt despite the presence of persistent pain.

                                                             Many rehabilitation programs focus on helping patients adapt to becoming people with persistent pain,
                                                             not patients, when there is no cure. Although there have been efforts to identify predictors of
                                                             successful outcomes (e.g., Jensen, Roman, Turner, Good, & Wald, 1999; Kerns & Rosenberg, 2000),
                                                             we do not have sufficient evidence to draw conclusions with confidence. Moreover, we have little
                                                             information about how patients treated by pain specialists compare to community samples with pain
                                                             that are not actively seeking treatment, at least not by pain specialists.

                                                             To date, there are only a few small-scale, qualitative epidemiological studies that include in-depth
                                                             interviews and first-person accounts about community samples of people with experiences of pain
                                                             (e.g., Price, 1994). Some research has begun to focus on acceptance and moving on with life despite
                                                             pain (e.g., McCracken & Eccleston, 2003). We need to know more about how this comes about. To
                                                             date, this research has focused on clinic samples, although exceptions are beginning to appear (e.g.,
                                                             Viane, Crombez, Eccleston, Devulder, & DeCorte, 2004). Although a number of studies have
                                                             examined coping and adaptation by community samples of people with pain (e.g., Affleck et al.,
                                                             1999), few make direct comparisons with clinic samples (e.g., Bradley et al., 1994). Often the
                                                             measures used are sufficiently discrepant to prevent firm conclusions (e.g., Nicassio, Schoenfeld,
                                                             Radojevic, & Schuman, 1995; White, Speechley, Harth, & Ostbye, 1999).



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When Is a Person with Chronic Pain a Patient? | American Pain Society


                                                             So how do people with significant levels of pain adjust despite physical impairments and aversive
                                                             sensations that we might all agree are significant? Financial resources, religious faith, and spirituality
                                                             have all been postulated as important mediators of adaptation. There has been some research on the
                                                             role of social support (e.g., Romano, Turner, & Jensen, 1997), although once again, this research has
                                                             focused more on clinic samples. Although we might conjecture that coping with pain and disability is
                                                             easier without financial worries, little is known about the contribution of financial resources to
                                                             adaptation to chronic pain. The role of religious faith and spirituality is also virgin territory. Although a
                                                             significant majority of the U.S. population purports to be religious, systematic studies of the
                                                             importance of faith and prayer for people with chronic pain and even pain patients are largely
                                                             nonexistent.

                                                             Because research has not provided us with all the answers we need to treat chronic pain patients
                                                             effectively, it is worthwhile to ask targeted questions. What differentiates pain patients from the
                                                             persons with pain? What factors contribute to pain patients’ ability to live effectively despite pain?
                                                             What can we learn from studying those who have been able to transcend their experiences to help in
                                                             the design of interventions? How do provider-patient interactions affect how patients live with pain?

                                                             Focusing solely on pain clinic samples provides a biased view and tells us little about how the
                                                             majority of people cope with and adapt to their pain experience. Studies to address these questions
                                                             are timely and potentially of great value. In the years to come I hope that APS members will take the
                                                             lead in investigating the questions that I have posed and that the information obtained will guide the
                                                             development of a new way of thinking about the patients we see in our clinics, those who do not seek
                                                             care by pain specialists, and more broadly the people with pain who exist and spend the majority of
                                                             their lives outside the clinical contexts in which we most often see them.

                                                             References
                                                             Affleck, G., Tennen, H., Keefe, F. J., Lefebvre, J. C., Kashikar-Zuck, S., Wright, K., et al. (1999). Everyday life with
                                                             osteoarthritis or rheumatoid arthritis: Independent effects of disease and gender on daily pain, mood, and coping. Pain,
                                                             83, 601–609.

                                                             Bradley, L. A., Alarcon, G. S., Alexander, R. W., Triana, M., Aaron, L. A., & Stewart, K. E. (1994). Pain threshold,
                                                             symptom severity, coping strategies, and pain beliefs as predictor of health care seeking in fibromyalgia patients. In G. F.
                                                             Gebhart, D. L. Hammond, & T. S. Jensen (Eds.), Proceedings of the 7th World Congress of Pain (pp. 167–176). Seattle,
                                                             WA: IASP Press.

                                                             Crook, J., Tunks, E., Rideout, E., & Browne, G. (1986). Epidemiologic comparison of persistent pain sufferers in a
                                                             specialty pain clinic and in the community. Archives of Physical Medicine and Rehabilitation, 67, 451–455.

                                                             Elliott, A. M., Smith, B. H., Penny, K., Smith, W. L., & Chambers, W. A. (1999). The epidemiology of chronic pain in the
                                                             community. Lancet, 354, 1248–1252.

                                                             Harstall, C. (2003). How prevalent is chronic pain? Pain: Clinical Updates, XI, 1–4.

                                                             Jensen, M. P., Romano, J. M., Turner, J. A., Good, A. B., & Wald, L. H. (1999). Patient beliefs predict patient functioning:
                                                             Further support for a cognitive-behavioral model of chronic pain. Pain, 81, 94–104.

                                                             Kerns, R. D., & Rosenberg, R. (2000). Predicting responses to self-management treatments for chronic pain: Application
                                                             of the pain stages of change model. Pain, 84, 49–55.

                                                             Marketdata Enterprises (1995). Chronic pain management programs: A market analysis. Valley Stream, NY:

                                                             McCracken, L. M., & Eccleston, C. (2003). Coping or acceptance: What to do about chronic pain. Pain, 105, 197–204.

                                                             Nicassio, P. M., Schoenfeld-Smith, K., Radojevic,V., & Schuman, C. (1995). Pain coping mechanisms in fibromyalgia:
                                                             Relationship to pain and functional outcomes. Journal of Rheumatolgy, 22, 1552–1558.

                                                             Price, R. A. (1994). A whole new life: An illness and a healing. New York: Atheneum.

                                                             Romano, J. M., Turner, J. A., & Jensen, M. P. (1997). The family environment in chronic pain patients: Comparison to
                                                             controls and relationship to patient functioning. Journal of Clinical Psychology in Medical Settings, 4, 383–395.

                                                             Viane, I., Crombez, G., Eccleston, C., Devulder, J., & De Corte, W. (2004). Acceptance of the unpleasant reality of
                                                             chronic pain: Effects upon attention to pain and engagement with daily activities. Pain, 112, 282–288.

                                                             Webster’ s Tenth New Collegiate Dictonary. (1996). Springfield, MA: Merriam-Webster.

                                                             White, K. P., Speechley, M., Harth, M., & Ostbye, T. (1999). Comparing self-reported function and work disability in 100
                                                             community cases of fibromyalgia versus control in London, Ontario. The London Fibromyalgia Epidemiology Study.
                                                             Arthritis & Rheumatism, 42, 76–83.




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When Is a Person with Chronic Pain a Patient? | American Pain Society


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Description: 2005 American Pain Society Bulletin article by Dennis Turk on pain medicine