Comparing Chronic Pain Treatment Seekers
Comparing Chronic Pain Treatment Seekers
Overall, results indicated that the patient populations in primary care versus tertiary care were quite similar. Demographically, patients differed only on age; those presenting at primary care were 6 years younger, on average. Primary care patients also reported more severe pain than their counterparts at tertiary care. However, tertiary care patients reported more pain-related catastrophizing than those in primary care. Given that pain magnification and self-reported pain tend to be strongly related, it was unexpected that the group reporting more severe pain (primary care) did not also report more pain-related rumination.
Although we would expect these measures to correlate more strongly within each setting, there may be several reasons that this relationship was not supported. First, patients in tertiary care were significantly older than those in primary care, and it may be the case that these individuals feel more hopeless about their pain, given their increased age. This type of reaction could be captured by a measure such as the PCS, accounting for their increased scores. Similarly, they may have exhausted all other conservative treatments. If they have seen many other physicians and have not received adequate pain relief, pain-related catastrophizing may increase. Furthermore, patients who have a tendency to magnify their pain may be more likely to seek specialized treatment or request a referral to a tertiary care clinic.
As expected, there was a positive association between this type of thinking and pain severity, even when adjusting for age, and this corroborates past research indicating that pain magnification predicts pain severity independent of physical impairment or injury in the patient. Simply put, as pain-related rumination increased in the current sample, so did self-reported pain severity. Unexpectedly, this association was significantly stronger for primary care versus tertiary care (see Figure 1). This may suggest that while psychological variables—including catastrophizing—are always important in understanding the pain experience, this seems to be particularly relevant for those presenting for treatment in primary care.
Further, the relationship between pain severity and psychological distress seems remarkably similar between groups. Notably, both pain severity and catastrophizing independently predict depressive symptoms in both populations. However, when including both variables in a statistical model, only pain catastrophizing continues to display a significant relationship with depressive symptoms. Of note, even though there were no significant differences between groups in terms of the relationships between pain severity, catastrophizing, and depressive symptoms, it is difficult to determine the directional nature of these variables because depression can affect the pain experience and vice versa.
In terms of group differences, it is unclear why patients in primary care report significantly greater pain severity, but there are several possible explanations for this finding. First, it is possible that these individuals have not been experiencing chronic pain for as long as the tertiary care group, and they may have just recently started seeking treatment for their pain. As such, they may not currently be taking part in treatment aimed at alleviating their pain. Further, it is possible that some of the primary care patients could be "shopping" for opioid medications. As such, they may tend to exaggerate their pain. Given that opioid abuse is negatively correlated with age, the younger age of patients in primary care would tend to support this hypothesis. Certainly, patients also attempt to obtain opioids at tertiary care facilities, but many tertiary care facilities use strict standards for their opioid program, and patients may feel that it would be easier (and possibly quicker) to obtain opioids from their PCP. It is important to note, however, that risk for opioid misuse and abuse as measured by the SOAPP-R and COMM did not differ between patient populations.
There are several noteworthy limitations of this study. First, patients were not assessed for physical injury and/or impairment. As such, it is not possible to determine the degree to which physical damage contributed to the current physical and psychological difficulties that patients were reporting. Similarly, the data that we used did not include information regarding ongoing treatments for pain. As such, it could be that significantly more patients in tertiary care were already being treated for pain, which could serve to lower their self-reported pain compared with patients in primary care. In addition, it may be the case that some patients who initially presented for treatment in primary care were eventually referred to the tertiary care setting, in which case they may have completed questionnaires on 2 occasions. Although it is not likely that this would have occurred for a large amount of cases, it remains a possibility, and given the confidential nature of the data (removal of identifiers), we were unable to assess for such cases. Also, while the pain management center in this study requires a psychological evaluation before dissemination of opioid medications, such an evaluation is not standard at all pain clinics and represents a factor that may distinguish this pain center from many others.
Furthermore, data on the duration of patients' pain was not collected. Prior research has produced mixed findings regarding the influence of pain duration on other pain-related variables. For example, one study found that self-efficacy and pain intensity both predicted quality of life measures in patients with chronic pain but that duration of pain did not. On the contrary, alternative research noted that pain duration was correlated with several outcome variables in those with nonspecific spinal pain, including pain expectations and pain catastrophizing. Given the mixed findings regarding pain duration, the lack of information regarding this variable in the current study represents an important limitation. Finally, this study was completed only in one state, and the sample was racially homogenous. As such, generalizability is somewhat limited. Even with the above-mentioned limitations, this study provides novel insight into the similarities between patients seeking treatment for chronic pain in primary care versus tertiary care settings.
Discussion
Overall, results indicated that the patient populations in primary care versus tertiary care were quite similar. Demographically, patients differed only on age; those presenting at primary care were 6 years younger, on average. Primary care patients also reported more severe pain than their counterparts at tertiary care. However, tertiary care patients reported more pain-related catastrophizing than those in primary care. Given that pain magnification and self-reported pain tend to be strongly related, it was unexpected that the group reporting more severe pain (primary care) did not also report more pain-related rumination.
Although we would expect these measures to correlate more strongly within each setting, there may be several reasons that this relationship was not supported. First, patients in tertiary care were significantly older than those in primary care, and it may be the case that these individuals feel more hopeless about their pain, given their increased age. This type of reaction could be captured by a measure such as the PCS, accounting for their increased scores. Similarly, they may have exhausted all other conservative treatments. If they have seen many other physicians and have not received adequate pain relief, pain-related catastrophizing may increase. Furthermore, patients who have a tendency to magnify their pain may be more likely to seek specialized treatment or request a referral to a tertiary care clinic.
As expected, there was a positive association between this type of thinking and pain severity, even when adjusting for age, and this corroborates past research indicating that pain magnification predicts pain severity independent of physical impairment or injury in the patient. Simply put, as pain-related rumination increased in the current sample, so did self-reported pain severity. Unexpectedly, this association was significantly stronger for primary care versus tertiary care (see Figure 1). This may suggest that while psychological variables—including catastrophizing—are always important in understanding the pain experience, this seems to be particularly relevant for those presenting for treatment in primary care.
Further, the relationship between pain severity and psychological distress seems remarkably similar between groups. Notably, both pain severity and catastrophizing independently predict depressive symptoms in both populations. However, when including both variables in a statistical model, only pain catastrophizing continues to display a significant relationship with depressive symptoms. Of note, even though there were no significant differences between groups in terms of the relationships between pain severity, catastrophizing, and depressive symptoms, it is difficult to determine the directional nature of these variables because depression can affect the pain experience and vice versa.
In terms of group differences, it is unclear why patients in primary care report significantly greater pain severity, but there are several possible explanations for this finding. First, it is possible that these individuals have not been experiencing chronic pain for as long as the tertiary care group, and they may have just recently started seeking treatment for their pain. As such, they may not currently be taking part in treatment aimed at alleviating their pain. Further, it is possible that some of the primary care patients could be "shopping" for opioid medications. As such, they may tend to exaggerate their pain. Given that opioid abuse is negatively correlated with age, the younger age of patients in primary care would tend to support this hypothesis. Certainly, patients also attempt to obtain opioids at tertiary care facilities, but many tertiary care facilities use strict standards for their opioid program, and patients may feel that it would be easier (and possibly quicker) to obtain opioids from their PCP. It is important to note, however, that risk for opioid misuse and abuse as measured by the SOAPP-R and COMM did not differ between patient populations.
There are several noteworthy limitations of this study. First, patients were not assessed for physical injury and/or impairment. As such, it is not possible to determine the degree to which physical damage contributed to the current physical and psychological difficulties that patients were reporting. Similarly, the data that we used did not include information regarding ongoing treatments for pain. As such, it could be that significantly more patients in tertiary care were already being treated for pain, which could serve to lower their self-reported pain compared with patients in primary care. In addition, it may be the case that some patients who initially presented for treatment in primary care were eventually referred to the tertiary care setting, in which case they may have completed questionnaires on 2 occasions. Although it is not likely that this would have occurred for a large amount of cases, it remains a possibility, and given the confidential nature of the data (removal of identifiers), we were unable to assess for such cases. Also, while the pain management center in this study requires a psychological evaluation before dissemination of opioid medications, such an evaluation is not standard at all pain clinics and represents a factor that may distinguish this pain center from many others.
Furthermore, data on the duration of patients' pain was not collected. Prior research has produced mixed findings regarding the influence of pain duration on other pain-related variables. For example, one study found that self-efficacy and pain intensity both predicted quality of life measures in patients with chronic pain but that duration of pain did not. On the contrary, alternative research noted that pain duration was correlated with several outcome variables in those with nonspecific spinal pain, including pain expectations and pain catastrophizing. Given the mixed findings regarding pain duration, the lack of information regarding this variable in the current study represents an important limitation. Finally, this study was completed only in one state, and the sample was racially homogenous. As such, generalizability is somewhat limited. Even with the above-mentioned limitations, this study provides novel insight into the similarities between patients seeking treatment for chronic pain in primary care versus tertiary care settings.
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