Barriers and mitigation strategies for appropriate pain management
| Barrier: Previsit bias Mitigation: Eliminate any bias or negativity before the visit when the primary reason is “chronic pain” or “fibromyalgia” to improve clinician receptiveness and reduce frustration13 Avoid dismissive attitude toward the pain complaint10,11 Believe patient reports of the severity and adverse effects of pain |
| Barrier: Difficulty connecting with patients and winning their confidence and trust Mitigation: Be empathetic and acknowledge that the pain is real; validating and legitimizing the pain can be emotional for patients and helps increase their trust and receptiveness11 Let patients narrate their symptoms and fully explain the impact of pain in their lives, which provides a crucial sense of being heard10 Debunk the myth that nociplastic pain is not a real condition and explain that the pain is not imagined or all in their head to make patients feel believed and heard12,13 Express to patients that we understand their pain and we will partner with them to help manage it as best we can Share decision-making to reduce frustration toward clinicians and increase patient receptiveness, motivation, and adherence to therapeutic recommendations |
| Barrier: Unrealistic or unreasonable expectations Mitigation: Patients may hope that a “magic pill” will fix the problem, and that can lead to frustration Set realistic expectations upfront (eg, improve physical function), but be extremely empathetic14 Reassure patients that adequate pain control can be achieved, although the fix is not easy Enable patients to take charge of their pain management, but provide assurance that they will always be supported |
| Barrier: Overexpectation to completely eliminate the problem Mitigation: Focus on legitimizing and validating pain while also determining any acute causes of a pain flare Accept that adequate pain management may not be curative, but even limited pain relief may enable patients to revive skills, renew social interactions, and improve quality of life Modest gain in pain relief can significantly increase patient confidence in overcoming the pain and is a vital clinical accomplishment11 Focus on both the biological and psychosocial determinants of chronic pain (ie, mind–body dualism)13 |
| Barrier: Poor understanding of nociplastic pain and contributory factors Mitigation: Explain pain physiology to patients, which may improve health status (less worry about pain and long-term improvement in physical functioning, vitality, mental health) and increase endogenous pain inhibition in patients with fibromyalgia15 |
| Barrier: Appointment time constraints Mitigation: Schedule a separate appointment focused only on pain management; defer rest of care to another visit Schedule a few extended appointments at first to allow time to really listen to patients |
| Barrier: Diagnosis challenge and lack of knowledge and training Mitigation: Diagnosis is difficult due to inconsistent symptom recognition and diagnosis validity and lack of robust guidelines; even when guidelines are available, level of awareness may vary11 Learning about nociplastic pain and management principles is crucial |
| Barrier: Referrals and resources Mitigation: Multidisciplinary approach can be helpful, but avoid unnecessary referrals that can lead to frustration Create achievable short- and long-term pain management goals |