Prioritizing patient values for chronic pain care: a path out of the pain reduction regime?

Opioid prescribing and the pain reduction regime

Recently, the Centers for Disease Control and Prevention (CDC) updated their Clinical Practice Guideline for Prescribing Opioids for Pain.¹ Although the guidelines focus on prescribing opioids for pain, the initial recommendations strongly encourage providers to prescribe nonpharmacologic and nonopioid medications in lieu of opioids. Recommendation 1 begins: “Nonopioid therapies are at least as effective as opioids for many types of acute pain.” Recommendation 2 begins: “Nonopioid therapies are preferred for subacute and chronic pain.” These recommendations echo other guidelines. The first recommendation of the 2022 Veterans Administration (VA) Opioid Guidelines begins: “We recommend against the initiation of opioid therapy for the management of chronic non-cancer pain.”² The American College of Physicians (ACP) guideline on low back pain recommends nonopioid and nonpharmacological treatments³ and the United Kingdom’s National Institute for Health and Care Excellence (NICE) instructs providers to not initiate opioids as part of chronic pain treatment and to wean when there is a lack of evidence of benefit.⁴ Nevertheless, opioid treatment of chronic pain remains common. In 2020, 43.3 prescriptions were written per 100 US residents, a total of more than 142 million opioid prescriptions.⁵ While the United States has the highest level of opioid prescription rates in the world, and consequently the highest level of opioid-related problems, there is evidence of continued elevated opioid prescription and related problems in many developed countries.⁶

Why do opioids remain a common treatment for chronic pain requested by many patients despite a limited evidence base, recommendations against their use, and established risk of harm? One reason is that opioids offer a swift means of reducing pain, as pain reduction begins soon after ingestion of the first dose. Opioid tolerance and dependence develop gradually and may not be apparent to patients taking opioids, nor will increases in symptoms of withdrawal between doses which may be mistaken for worsening of the original pain problem.⁷ Second, patients with chronic pain may assert that they have a right to pain relief.⁸ They may ask clinicians: “Don’t you believe I have pain? Don’t you believe that I deserve relief?” Finally, patients and clinicians often believe that pain reduction is a necessary first step in the chronic pain treatment process. They believe that only after pain reduction is achieved can life improve. However, recent research suggests this is not true: during chronic pain treatment, reductions in pain more often follow than precede improvements in function, mood, and sleep.⁹

Pain reduction is also prioritized in chronic pain care because this goal is given ethical authority as a preeminently patient-centred goal. Pain is important to patients. It is aversive, impairs quality of life, and is one of the most important causes of disability for the global population.¹⁰ Clinicians seek pain reduction out of respect for their patients as suffering humans.

We refer to these experiences and beliefs about the role of pain reduction in chronic pain care as the “pain reduction regime.” We believe that many primary care clinicians feel trapped in this regime and compelled to prescribe opioids to achieve pain reduction.¹¹ Denying patients access to analgesics which may produce pain reduction feels like denying them access to a quality life. A major problem with recent pain management guidelines (e.g. CDC, ACP, VA, and NICE) is that they do not specify practical and actionable ways out of the pain reduction regime that are appropriate for chronic pain care. Primary care providers need a goal for chronic pain care that is more patient-centred and evidence-based than pain reduction through analgesics. The problem is that these patient-centred goals vary from patient to patient and are difficult to assess and target in clinical care. To achieve outcomes beyond pain reduction that are meaningful to patients, we introduce a model of “values-based care” as an alternative.

Defining values-based care

Shared decision-making (SDM) has been referred to as “the pinnacle of patient-centered care.”¹² It aims to not just obtain patient permission for a clinician-proposed course of care, but to collaboratively decide on treatments. Traditional SDM interventions focus on identifying patient preferences regarding specific treatments, but patients often do not understand the detailed pros and cons of the treatments, so they may not have informed opinions to honour.¹³ Decision aids to support specific decisions (e.g. treatments for prostate cancer) have been developed, but they are often cumbersome, difficult to implement, and therefore not that feasible or popular with patients and clinicians.¹⁴

SDM has been advocated as a way to make chronic pain care more patient-centered and to give clinicians a supportive structure for chronic pain care.^15,16 But achieving SDM in chronic pain care is difficult, especially when opioids are involved, due to differences in patient and provider goals for care.¹⁷ The SDM approach recognizes that chronic pain treatments are preference sensitive and often require active patient participation. But SDM models do not fully account for disagreement about treatment goals and options, nor do they suggest strategies for managing this disagreement when it occurs. Reaching beneath treatment decisions to identify patients’ life values and health care goals and creating pain care plans that reflect these values and goals may offer a feasible alternative to traditional SDM. Identifying patients’ values and their related goals constitutes an important first step in achieving values-based chronic pain care.

Identifying patients’ values and goals for chronic pain care

Tinetti et al. have developed Patient-Priorities Care (PPC) as a strategy for setting care priorities among older adults with multimorbidity. PPC appears to have substantial promise as a brief and highly scalable tool that can improve pain care outcomes.^18,19 PPC involves having patients meet with a coach (e.g. nurse, social worker) to: (i) clarify their life values (i.e. what matters most), which are more stable than care preferences; (ii) set meaningful activity goals that reflect these values in a manner that is specific, realistic, and actionable (e.g. being able to walk a pet around the block, socialize regularly with family or friends, re-engage in daily activities); and (iii) describe their health care preferences (i.e. care that is helpful or burdensome, including tradeoffs patients are willing to make to achieve progress on valued goals). In a final step, the coach encourages patients to share their health goals with their health care provider. This series of steps typically takes less than 1 h to complete.

PPC also has a training component where providers learn how to discuss patient health outcome goals and develop treatment plans to help meet these goals. This approach has helped older patients set realistic and actionable goals focussed on improved engagement in valued activities as an alternative to symptom reduction alone.¹⁹ Prior studies further demonstrate the feasibility of PPC among older patients with multiple chronic conditions receiving primary care.¹⁸ In PPC research to date, pain was the most common barrier mentioned to achieving these goals, which suggests that PPC may provide useful structured priorities for the primary care of patients with chronic pain. Further, PCP’s report that applying PPC leads to improved patient-centeredness, prevents burdensome care, and enhances clinician–patient relationships.²⁰ The PPC model lays the necessary foundation for successful chronic pain care by providing a strategy for patient values clarification that builds trust with the patient and provides actionable goals for the clinician. Often it is assumed that patients desire pain reduction over all other goals, but data suggest that other goals concerning independent living and quality of life are more important.²¹ Eliciting and prioritizing patients’ goals may improve the appropriateness and safety of analgesic pharmacotherapy.²²

We conducted a small pilot where we enrolled 6 older adults with chronic pain (mean age = 78) and administered the patient portion of the PPC (unpublished data). All 6 participants were able to successfully complete each step in the process. The average time to complete was 30 min (range = 22–45). All 6 patients reported that they enjoyed answering the questions and that the questions asked were not part of customary care, but perhaps should be.

We believe PPC may not just help prioritize primary care medical interventions for chronic pain but may function as a patient activation intervention itself. PPC engages the patient about what is most personally meaningful while de-emphasizing symptom reduction goals. In doing so, it may activate the patient to participate in care, including both prescribed care and self-care. In fact, PPC may function to activate patients to seek out and achieve valued activities in a way similar to that of Acceptance and Commitment Therapy (ACT), a psychological treatment proven effective in treating chronic pain. Both approaches may foster activation to participate in life with ongoing pain through identification of, and engagement in, what matters most.

ACT is a flexible model of intervention, closely related to Cognitive-Behavioral Therapy, but with more focus on values and willingness to experience symptoms in the pursuit of valued activities. ACT can be understood as having 3 core components that seek to: (i) increase awareness of ongoing experiences, (ii) facilitate an increased openness to the experiences, and (iii) increase participation in valued activities. The ultimate goal of ACT is increased engagement in values-based activities with ongoing pain.^23,24 When ACT is used in the treatment of chronic pain, it theoretically achieves a deprioritization of pain (i.e. pushing pain off the front burner) rather than pain reduction (i.e. reducing pain intensity). Pain reduction is often achieved without being specifically sought, but that is viewed as a by-product of improved engagement in valued activities and enhanced overall quality of living.

Numerous trials support the efficacy of ACT when delivered by clinical psychologists or as part of an interdisciplinary programme.²⁵ We believe that ACT is particularly well suited to affect a shift to values-based care in the primary care setting. For example, we conducted research with an ACT-based chronic pain self-management intervention that offers a template for research with PPC and values-based care. PainTracker Self-Manager (PTSM) is a web-based ACT-derived education and assessment tool for chronic pain. The web-based intervention included a module on reviewing one’s “Life Navigation System.” This assisted pain patients with clarifying values and developing an action plan to improve 1 life area out of 4: (free time, relationships, health/self-care, work/education). This module was adapted from a treatment manual written by Vowles and Sorrell²⁶ and incorporated the Values Bullseye exercise of Lundgren et al.²⁷

A controlled pilot study demonstrated that PTSM, in combination with nurse or social worker phone coaching, was more efficacious than specialty chronic pain care alone.²⁸ The full study sample (N = 99) showed greater improvements over time in pain self-efficacy and satisfaction with pain treatment. Among study completers (n = 82), greater improvement occurred in activity engagement, pain intensity, and pain interference. Although the Values Bullseye values clarification exercise was the least directly related to pain of all the PTSM modules, it was the favourite of the intervention arm participants who reported it as both pleasant and activating. While it is commonly recognized that patients with chronic pain are physically and socially deactivated, it is not as widely recognized that they are also “values deactivated”: they get locked into a “constant crisis” mindset where they focus on just trying to survive from one day to the next, forgetting what they are most passionate about, what defines them as a unique person. This is what PTSM helped them reclaim.

Primary care clinicians must balance many competing demands during brief clinic visits. This means that it has been difficult to find feasible alternatives to analgesic prescribing (opioid and nonopioid) in primary care. The interventions discussed above may be feasible options. PPC enlists an ally (e.g. nurse or social worker often available in primary care) to facilitate values exploration and priority setting. PTSM uses online modules to support an intervention derived from ACT allowing a nurse or social worker to deliver an intervention that formerly required a psychologist. Nurses and social workers are common participants in team-based primary care for chronic diseases like diabetes and depression. Team-based primary care is less common for chronic pain, so this may represent a challenge for some practices.

A path forward with values-based chronic pain care

Rather than assuming that patients desire pain reduction first and foremost, we encourage clinicians to first explore what life values and goals matter most to their patients with chronic pain. It is not true that chronic pain reduction must happen before patient improvement is possible. Improvements in activity, mood, or sleep often occur before pain reduction. Clarification of values may help direct medical treatments for pain more efficiently (PPC original intention), but may also serve as a form of chronic pain treatment unto itself (as per ACT). Adapting PPC as a psychological treatment similar to ACT may offer a path forward using values-based chronic pain care to look beyond pain reduction to the values and goals that matter most to patients.

Conflict of interest

None declared.

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