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Jessica Liaw
Professor Loeser, Professor Mayer
HONORS 222C: PAIN
9 June 2014
Chronic Pain: Brewing Distrust between Doctor and Patient
The high prevalence of chronic pain in the United States serves as a
continuing frustration for both patients and physicians. In the U.S., at least 116
million adults suffer from chronic pain (Simon, 2011). The inherently complex
and subjective nature of chronic pain contributes to numerous challenges
primary care providers face when caring for chronic pain patients. In the U.S.,
opioid therapy is considered a standard of practice for non-cancer chronic pain.
Over the past twenty years, the increasing issue of opioid abuse has raised ethical
concerns around chronic pain, addiction, and the publics health. Although the
debate over chronic pain treatments is within the healthcare system, patients end
up caught amidst the controversy. Patient-physician relationships are becoming
increasingly strained as patients feel they are being betrayed by biomedicine
while physicians fear legal risks and patient safety. These conflicting interests
have brewed a sense of distrust regarding chronic pain treatment. In order to
increase mutual trust between patient and doctor, the medical community must
develop a standard approach for assessing pain treatment and opiate withdrawal.
Furthermore, the healthcare system must prioritize patient care over business
interests by putting greater focus on research and education of chronic pain
treatments besides opioid therapy.

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Pain is an inescapable human experience. The brain is responsible for
producing all types of pain including acute, cancer, chronic, and experimental
pain. Pain is defined as chronic pain instead of acute pain once it persists for at
least 3 to 6 months after the first episode (Birse 1998). Since most things in the
body are healed as well as they can be within 3 to 6 months, chronic pain is
oftentimes less about structural changes in the body, and more related to the
sensitivity of the nervous system (Morris, 1976). As Morris puts it, modern
medicine knows what to expect from acute pain since it comes, it goes, it follows
the rules (Morris, 1976). Contrastingly, chronic pain can loom with the threat of
never disappearing. Chronic pain affects people in various forms such as
recurrent and low back misery to tic douloureux, phantom limb, and the
completely mysterious pain of unknown etiology (Morris, 1976). It is a
relentless frustration for patients and doctors because there is not a single reason
for why people feel chronic pain. Furthermore, there is no simple explanation for
why the brain continues to produce painful sensations after body tissues are
restored. This uncertainty triggers anxiety in patients, which can worsen pain and
further reduce quality of life.
As aforementioned, oftentimes there is no physical evidence to explain
chronic pain. This situation makes it difficult for chronic pain patients to get
satisfying explanations and care from their doctors. Furthermore, physicians
cannot measure a patients pain, so most of the evidence they have to determine
appropriate treatment is based on a patients verbal communication or body
language. This disconnect makes it difficult for patients and doctors to see eye to

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eye when it comes to adequacy of therapeutic interventions, assessments of pain,
disability determinations, and influence of voluntary control (Singer, 1994). As
time passes, dissatisfaction with the healthcare increases if the patients level of
pain remains unchanged. Eventually, chronic pain patients and their families
become disillusioned with their healthcare, every component of which has failed
them (Singer, 1994). As unsettled issues of trust, frustration,
misunderstandings, and failed expectations between doctors and chronic pain
patients build, both sides undergo negative interactions that lead to mutual
distrust. The growing suspicion and doubt between patient and provider poses
problems for patients quality of care because negative patient-provider
relationships have been correlated with poor patient care and stagnant or
negative health outcomes. If the healthcare community hopes to strengthen
bonds between patient and physician, it must examine existing pressures causing
the rift and seek alternatives to current methods.
During the 1990s, more physicians began embracing the use of opioids to
treat non-malignant chronic pain. Between 1997 and 2006, retail sales of opioids
increased by 176% (Turk 227). However, the healthcare community was not
prepared for the negative consequences that followed. Opioid abuse and misuse
occurred for a variety of reasons, including self-medication, use for reward,
dependence due to addiction, and diversion for profit (Setnik, Roland, 2013).
Additionally, death due to accidental opioid abuse has more than tripled since
1990 (Sullivan, 2013). The correlation between increased opioid prescriptions
and death from opioid overdose has put the medical community under fire for

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not regulating opioid prescriptions tightly enough. Doctors are being blamed and
having their licenses suspended for careless prescribing practices.
Many doctors feel unprepared for dealing with this controversy and have
resorted to methods of avoidance by stopping opioid prescriptions. As physicians
become more wary of drug abusing patients, people who are hurting are
experiencing increasing difficulty obtaining opioid prescriptions. Patients of all
backgrounds have described experiences in which providers have stopped or
limited opioid prescriptions due to concerns about abuse or addiction. Even
patients with no addiction history sometimes feel they are automatically treated
with suspicion when they ask for opioids (Upshur, 2010). The medical
community is struggling with where to draw the line for opioid medications. On
one end, there is the risk of fostering an environment for drug abuse and on the
other there is the risk of ignoring untreated pain. Physicians are being told to be
more vigilant about putting patients on opioid treatment, but patients feel they
are being betrayed by biomedicine when they are not given satisfactory
treatment. This reiterates the struggle for physicians to provide adequate
treatment for patients without risking prescribing opioids to someone with
addiction or abuse.
In general, chronic pain patients are reported as having low levels of
satisfaction with their pain care. Many pain patients feel their physicians
downplay the pain they feel by trying to convince them it is not real, or not as
serious as they think (Mattias, 2010). Some patients feel that doctors avoid
dealing with them by trivially dismissing their self reported symptoms and

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claiming they do not warrant medical attention. Patients have detailed
experiences in which doctors could not find a physiological cause for their pain
and claimed the sensation was merely in their head (Jones, 1985). This can be
detrimental to their recovery because patients oftentimes seek validation of their
pain from doctors. When medical professionals refuse to diagnosis their pain,
patients pain tends to increase due to the anxiety they feel about not being
listened to.
In other cases, patients have been under the impression of being suspected
of drug seeking. These doubts are followed by concerns of whether their
treatment is being influenced by their physicians suspicions. Patients have
described experiencing hurried encounters in which providers implied the
patient was burdening them by keeping them from other patients with real
illnesses (Upshur, 2010). Under these circumstances, patients begin losing
confidence in their caretakers as they feel the medical community views them as
a nuisance. Patients have also reported being refused treatment by physicians
even after undergoing painful procedures and surgeries that failed to bring relief.
After undergoing repeated negative experiences with various doctors, patients are
left feeling disrespected, distrusted, and failed by their health providers. This
cycle can eventually cause hostility to develop on the patient side of patientprovider interactions.
Though patient care should be the priority of healthcare, it is also
important to consider the needs of primary care providers. The current
healthcare system is a social construct in which physicians must factor in

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personal interest when caring for patients in order to keep from losing their
license or losing credibility in their field (Loeser, 2014). Providers have voiced
problems encountered when caring for patients with chronic plain including
pressure to treat with opioids, believability of patients report of pain, and worries
about secondary gain and abuse (Mattias, 2010). Though physicians do not
express distrust towards every patient, previous negative experience with drug
abusing patients remain powerful influences on their practices. When physicians
work under the fear of being manipulated into inappropriate prescribing for
chronic pain patients, both parties begin doubting each others words and
actions. It is important to remember even physicians endure an emotional toll
when caring for chronic pain patients. This includes feeling frustrated,
ungratified, and guilty. Doctors often dread the demoralizing and professionally
damaging consequences of being accused by patients of not providing adequate
care. Mattias classifies these feelings as compassion fatigue due to recurrently
discouraging or negative encounters with chronic pain patients (Mattias, 2010).
Ultimately, these negative pressures doctors face compromise the quality of pain
care.
Doctors also struggle with feeling that their ability to deliver
unimpeachable and often complex healthcare has been compromised, and,
second, physicians lack the ability to manage health care in a socially responsible
manner and therefore control should be removed from them (Loeser, Cahana,
2012). Since economics and business interests drive our healthcare system,
patients are oftentimes not getting the best treatment based on evidence-based

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medicine. During the 1980s and 1990s, multidisciplinary pain clinics (MCPs)
began flourishing as the medical community began to recognize the effectiveness
of it. Chronic pain patients began undergoing treatments involving medication
management, physical treatments, vocational rehabilitation, and appropriate
interventions with needle or knife (Loeser, Cahana, 2012). However, by 2000,
hospitals and physicians began removing support for MCPs due to greater
facilitation of revenue producing procedures (Loeser, Cahana, 2012). Since
hospitals are businesses that produce profit by providing clinical services, they
try to increase clientele by attracting patients with fancy, expensive equipment.
This is especially true for chronic pain patients, for which hospitals see potential
consumers of diagnostic and therapeutic procedures in radiology and operating
rooms (Loeser, Cahana, 2012). Our healthcare system has become entangled in
business views and lost sight of the most important end goal: alleviating pain
and suffering (Loeser, Cahana, 313). Rather than investing in expensive
equipment, hospitals should increase focus on educating their patients on
understanding and managing their pain. Though business ideologies have already
infiltrated the medical world, health professionals must push back to put patient
care first.
One overarching reason for patient disappointment towards chronic pain
care is lack of accessible specialized pain centers. Primary care clinics end up
responsible for managing most chronic pain patients (Matthias 1689). Primary
care providers face various challengers in regards to providing effective
treatment, including lack of training in pain management, time constraints, lack

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of consensus on optimal treatments, and controversies surrounding the use of
opioids for chronic noncancer pain (Matthias 1689). A study in the Journal of
Pain reported that upon reviewing 117 medical school primary care education
programs in the U.S. and Canada, most devoted less than five hours to pain
related curriculum. Furthermore, only 30% of US medical school require
instruction in opioid prescribing, and 10% require instruction about abuse and
addiction (Morley-Forster, 2013). Clearly, primary care physicians are not being
adequately prepared for treating chronic pain patients. Along with more
extensive training for treating pain, doctors also require greater emotional and
institutional support as they care for patients with chronic pain (Mattias, 2010).
This support system could greatly benefit both patient and practitioner by
helping the doctor from becoming compassion fatigued and encouraging greater
patience and empathy when treating chronic pain.
Along with more comprehensive pain education programs and stronger
emotional support systems, primary care physicians would benefit greatly from
the implementation of a standard approach for assessing and treating pain and
opiate withdrawal. Currently, physicians lack basic guidelines for treating chronic
pain patients (Merril et al. 327). Due to this gray area, they have struggled with
finding solid criteria for appropriate chronic pain diagnoses and opioid
prescriptions. Many physicians have expressed uncertainty in their approach to
treating pain patients because they recognize their own inconsistency in
evaluating patients for chronic pain (Merril et al. 327). Patients are also
aggravated by the inconsistency of care because they sometimes interpret

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physician inconsistency or hospital inefficiency as signs of intentional
mistreatment (Merril et al. 327). It is clear that the absence of a standard
procedure for treating pain patients is contributing to the increasing distrust
between chronic pain patients and their doctors. Although pain is unique to each
individual and doctors must treat each case separately, a standard approach
towards pain diagnoses and opioid treatment is required to maintain strong
doctor-patient rapport when dealing with the subjectivity associated with chronic
pain. Perhaps the implementation of a standard procedure for prescribing
opioids will eliminate some of the ambivalence and discomforts expressed by
doctors and patients on the subject and cultivate more mutual trust.
In order to move forward from the patient-provider distrust surrounding
treating chronic pain with opioids, both healthcare professionals and patients
must recognize people suffer for various reasons that a pill cannot solve.
Prescription opioids are rarely the answer for eliminating someones pain. Each
persons experience of pain is unique depending on an assortment of biological
psychological, and social factors (Drewes et al., 2013). Due to differences in
peoples biochemistries, individuals respond to medications differently (Drewes
et al., 2013). Although taking opioids can be a good starting point for helping
reduce pain enough for patients to return to their daily routine, healthcare
professionals have yet to complete extensive research on the long-term
effectiveness of opioid therapy. Thus far, it is unrealistic to expect opioids to be a
quick fix for eliminating long-term pain.

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The healthcare community should begin shifting its focus towards more
research and education about treatments other than opioids that can be more
effective and less risky. These alternatives include psychotherapy, physical
therapy, cognitive behavioral therapy, etc. Although these methods have the
potential to be more effective than opioid prescriptions, they tend to be less
popular because they can be affiliated with higher costs and greater
inconvenience for patients. In the meantime, it would be greatly beneficially for
chronic patients if doctors put more emphasis on educating about understanding
and managing chronic pain on a daily basis. Patients must understand the
importance of taking an active approach to facing their pain. Oftentimes, patients
believe their only job is to get into the doctors office and once they do, it is solely
the doctors responsibility for alleviating their pain. Doctors can provide
suggestions, medications, and recommendations for patients, but it is up to the
patient to make critical lifestyle choices in their journey to improve reducing their
pain.
Since the cause of ones pain is frequently unclear, it is difficult to know
what to do about it. Recent research is suggesting for patients to try retraining
their brain (Dunford, Thompson 2010). In order to retrain the brain, it is
necessary for patients to take an approach more active than simply taking their
medications. Peoples responses to a noxious event involves much more than the
pain stimulus. The environment in which the painful stimulus occurs affects how
pain is felt since the brain is capable of focusing on what is of interest through
downstream modulation. The process of retraining the brain involves examining

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how thoughts and emotions affect the patients nervous system. Just like pain is a
brain impulse, thoughts and beliefs are brain impulses as well (Dunford,
Thompson 2010). It is essential for pain patients to be educated about how
lifestyle choices can contribute to how they feel pain. Lifestyle choices such as
poor nutrition and smoking can make the nervous system more sensitized, which
magnifies the pain felt. Reducing factors that increase stress in ones life has been
proven to help ones emotional wellbeing and reduce pain. If doctors help
patients achieve a better understanding of the complexities of chronic pain,
patients may be less doubtful and resentful towards their caretakers. Increasing
the understanding between both groups will help build more trust in the
relationship and set the stage for more effective patient care.
Our current healthcare system is fostering an environment for distrust
between chronic pain patients and their medical providers. Various factors
including doctors wariness about prescribing opioids, lack of pain management
education, and hospitals motivated by profit have contributed to the lack of good
quality pain care in the U.S. The medical community must work to refocus
chronic pain care more towards multidisciplinary treatments and educating
patients about pain management techniques.

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