Practical Approaches for Clinicians in Chronic Pain Management: Strategies and Solutions

Abstract

Effective management of chronic pain necessitates multidisciplinary approaches including medical treatment, physical therapy, lifestyle interventions, and behavioral or mental health therapy. Medical providers regularly report high levels of stress and challenge when treating patients with chronic pain, which recur in part due to improper education on contributors to pain and misalignment in patient and provider goals and expectations for treatment. The current paper reviews common challenges and misconceptions in the setting of chronic pain management as well as strategies for effective patient education and goal setting related to these issues. The paper also outlines key aspects of provider burnout, its relevance for medical providers in chronic pain management, and recommendations for burnout prevention in navigating issues of patient education and treatment planning.

Introduction

Chronic pain, a common and debilitating condition, can arise as a primary disorder like fibromyalgia or as a secondary issue from conditions like osteoarthritis or rheumatoid arthritis. Often managed by single providers, including primary care or specialists in rheumatology or pain medicine [1], chronic pain treatment is challenging and can lead to high stress and low satisfaction among medical professionals due to the intricate nature of balancing medical and psychosocial care needs [2]. Multidisciplinary approaches, integrating medical and complex psychosocial care, are more effective for chronic pain than any single therapy [3, 4]. This paper aims to provide a comprehensive guide, including practical scripts, to help healthcare professionals understand and communicate a personalized, multidisciplinary treatment plan for chronic pain.

Why is a team approach beneficial in chronic pain management?

Best-practice models for pain management advocate for a multidisciplinary approach that encompasses domains of physical activity and psychosocial factors alongside medical treatment. This involves integrating medicine, rehabilitative therapies such as physical therapy (PT) or occupational therapy (OT), and behavioral or psychosocial interventions. This method not only considers a patient’s medical history but also examines the impact of pain on their physical abilities, social and vocational activities, their ability to psychologically cope, and their personal goals. Due to the complexity of these factors, a single appointment often falls short; instead, a team-based approach is essential for thorough, personalized, and evidence-based care. Effective treatment planning may require patients to repeatedly hear and understand this comprehensive perspective from all involved healthcare providers.

As opposed to traditional multidisciplinary pain management models in which providers from various disciplines work with patients either concurrently or sequentially and often focus only on their area of expertise, we advocate for a “transdisciplinary” approach to patient education, where providers not only focus on their own discipline but also inquire into and reinforce goals set by other allied professionals [5]. For example, physicians should communicate that mood disturbance, insomnia, substance abuse, severe deconditioning, and unmanaged psychological stress are significant risk factors for poor pain outcomes. They should support and reinforce patients’ efforts to address these issues through physical therapy or psychotherapy. Similarly, PTs and mental health providers should be cognizant of concurrent medical issues and patients’ understanding of their diagnoses and treatment. This approach helps avoid confusion from receiving differing explanations about their pain’s cause or treatment from various providers (e.g., deconditioning, structural issues, or central nervous system (CNS) sensitization [6]. It also addresses the risk that not consistently tackling key pain management challenges, like substance use stabilization or enhancing physical activity in severely deconditioned patients, may lead patients to undervalue these aspects in their overall treatment plan.

Additionally, all providers should be aware that broader social and structural factors affect pain outcomes, including social determinants of health (e.g., homelessness, financial limitations, experiences of discrimination based on racial, ethnic, or gender identity, age, citizenship, or other demographic aspects such as rurality) [7]. Although these factors might not be directly addressable in individual care, acknowledging their relevance helps manage patients’ expectations about pain treatment and demonstrates a comprehensive, “whole-person” approach to healthcare. This transdisciplinary approach encourages consistency in clinical messaging, ensuring patients get a consistent understanding from all providers about how to manage their condition.

Introductory script: “What research has taught us over the past 40 years is that the best way to treat chronic pain is to treat it from multiple angles. In general, people who show the most improvement in their pain symptoms are the ones that use multiple approaches to manage pain and improve function: medical treatments (such as medication, injections, or surgeries), physical therapy or exercise, and ways of managing stress, mood, or sleep. So, when I ask you to see a physical therapist or psychologist or mental health provider, these steps are not meant to replace your medical treatments, but to add to them.”

Introducing pain neuroscience and psychological education principles in clinical care

Pain Neuroscience Education (PNE) is a method to educate patients about the neurobiological and physiological processes of pain in the body and brain, enhancing their understanding and management of chronic pain. Often called “pain literacy,” PNE aims to clarify the differences between nociplastic, nociceptive, and neuropathic pain, helping patients to safely adopt adaptive coping strategies [8]. The International Association for the Study of Pain (IASP) has guidelines for this education, focusing on ensuring patients grasp the biological underpinnings of chronic pain and its various forms. Recent studies show that combining PT or exercise with PNE can significantly improve outcomes in musculoskeletal pain treatment [9]. The key concepts of PNE [10] include:

• Pain is always real even if bodily tissues are not in danger.

• Pain is produced in the brain.

• Pain is a protective system, and it can be over- or under-protective.

• A goal is to shift patient understanding towards pain being a danger “detection” system that integrates both peripheral and central contributors to pain, rather than as a solely a reflection of sustained or ongoing bodily damage.

• Discuss the role of inflammation, environmental factors, and psychological factors (e.g., thoughts, emotions, and behaviors) that influence pain.

Similarly, pain psychology treatments, especially cognitive-behavioral therapy (CBT) for chronic pain, focus on educating patients about the role of the brain and CNS in pain, addressing common misconceptions about the pain experience:

• Hurt vs. harm – Many patient endorse fear that their pain signals are indicators of ongoing and/or irreparable damage in the body. Psychoeducation is oriented around educating them that many forms of chronic pain are driven not by ongoing tissue damage but by alterations in brain and CNS function and thus can be considered non-dangerous.

• Acute vs. chronic pain – Helping patients understand that pain that arises out of a new injury or medical issue (i.e., acute pain) may have different treatment options than for chronic pain lasting longer than 3–6 months. Specifically, whereas new injuries may respond positively to rest and avoidance, chronic pain typically does not resolve and can in fact worsen if patients engage in prolonged periods of avoidance (e.g., due to deconditioning or peripheral or central sensitization). Thus, the emphasis of treatment shifts from rest and avoidance to active rehabilitation or retraining of the body and brain to reduce pain.

• Explaining the role of the brain in all forms of pain, which has typically reviewed the Gate Control Theory of Pain, implicating the dorsal horn and brain as modulatory factors in nociception. The key points in this discussion are that there is not a perfect 1:1 relationship between tissue damage and pain even in acute cases, and that the brain and nervous system can be conditioned to either amplify or suppress pain signals. This education is intended to de-emphasize a myopic focus on pain being an indication of an irreparably damaged body and ease the transition to active or rehabilitative approaches to pain management.

These concepts are often critical to shift a patient’s mindset from avoidance and fear to feeling safer and re-embracing movement or activities in their lives. As a provider, it is beneficial to shift treatment goals from solely reducing pain to enhancing a patient’s overall functionality, mood, stress management, and participation in meaningful activities, thereby improving their quality of life. This approach offers tangible and achievable goals and aligns with clinical research showing that improvements in areas like emotional well-being, function, or sleep often precede pain relief [11, 12]. Such a perspective helps clinicians foster a supportive environment, benefiting both patient care and professional satisfaction.

Example script: “Pain is a complex signal. If we want to understand the cause of pain it is not as simple as looking at the results of an x-ray or an MRI; we must consider what both the body and brain are doing, especially when pain is chronic. So, our goal is to treat both the physical/structural parts of your body and changes to the brain and nervous system that contribute to pain. This is why we prescribe medication (to calm down brain, nerve function, or inflammatory processes) but also ask you to work on exercise and manage your mood, stress, and sleep. What research tells us is that we sometimes need to stabilize other things that pain can affect (like your mood or physical activity levels) before pain itself will get better. So, pain is a “lagging indicator”. This means that we must approach this as a team: I will manage the medical aspects that may be contributing to your pain, but I will also ask you to work on the other factors that could be playing a role. So, medications are part of the plan, but so are strategies that you will build to keep the nervous system calm and healthy, like exercise, deep breathing, meditation, or dietary changes.”

Introducing acute and chronic pain: “Pain is the body’s alarm system to warn the brain that something is wrong and that the body needs to be protected. For instance, if you step on a rusty nail, you wouldn’t want to keep walking on it, so the pain is an indicator from your brain that the foot needs to be protected and allowed to heal. This is called acute pain: pain travels from the site of injury (in this case the foot), through the spinal cord, and then to the brain to be processed. It is only after this signal is processed by your brain that you’ll feel pain. When people have inflammatory or neurological conditions that are not well-managed, they may experience pain from deterioration of their joints or changes in how their nerves function. This is an example of why we use medical treatments for specific conditions to treat pain.

When these nerve signals are repeatedly sent to the brain from the same area of the body, the brain can learn to “overprotect” that part of the body. In other words, the brain learns to be on high alert about threats to the body and starts to amplify those nerve signals that lead to pain. This is an example of chronic pain: the brain and nervous system, in their attempts to keep you safe, become overly sensitive and may overreact to pain signals or even normal, non-dangerous sensations. Chronic pain can occur when pain lasts beyond the amount of time it takes for damaged tissue to heal or stabilize or in conditions that continue to lead to structural changes in the body such as arthritis.

Conditions like fibromyalgia are also an example of this process, which is sometimes called nociplastic pain: they can experience very high levels of pain even though the body isn’t being damaged at all. It is important to know that this type of pain is just as real and can be as severe as other types of pain, but its cause is different – it’s more about sensitivity and processing of pain signals in the nervous system and not necessarily about damage to the body. Some people even have a combination of both types of pain – they can have some pain that is due to a structural, inflammatory or nerve issue but also have a “fibromyalgia-like” pain that increases their pain levels overall.”

The role of the medical provider in chronic pain management

The medical provider plays a vital role, particularly in the assessment, diagnosis, and treatment of pain. Through detailed patient histories, physical examinations, and interpretation of laboratory tests and imaging studies, rheumatologists’ most crucial role is to identify inflammatory and connective tissues diseases that would benefit from targeted therapeutics such as disease-modifying antirheumatic drugs (DMARDs) and biologics to prevent joint damage and disability. Physicians are also integral in differentiating and counseling patients on the different types of pain they may be experiencing (nociceptive, neuropathic, nociplastic, or any combination of the three).

Medical providers also play an important role in counseling patients on the role of multidisciplinary approaches to pain management: to effectively manage pain medication-based approaches will need to be complemented with physical or occupational therapy, psychological or behavioral interventions, and lifestyle modifications. It is crucial that medical providers, who are often the first point of contact for chronic pain care, discuss non-pharmacologic options with as much enthusiasm as pharmacologic options; if these approaches are not introduced into management plans early, patients may view them as secondary or optional in a way that will ultimately prove detrimental to their care. Relatedly, medical providers who provide reassurance (after reasonable physical examinations are conducted) that patients are safe to engage in physical activity can bolster these efforts; if these concerns are not addressed, patients may continue to experience fear about whether physical activities may be bad for the body and engage in unhelpful avoidance patterns that slow their responses to pain treatment.

Discussing the role of medical treatment

Many patients perceive medication as the sole treatment option, shaping clinical interactions significantly. This perception can lead patients to expect medication changes either in the form of analgesic pain medication (e.g., opioids, neuroleptics) or disease-specific medications (e.g., DMARDs) as the primary goal of most clinical encounters. It can be helpful to clarify the mechanisms of pain experienced by a patient and discuss how medication may or may not be helpful (e.g., when discussing rheumatoid arthritis (RA) versus osteoarthritis (OA)).

“In RA the body is accidently attacking itself. Inflammation will build up between the spaces in a joint, which leads to swelling and pain. DMARDs and biologics specifically target this type of inflammation by reducing the immune system activity. The downside of these medications is that they can lead to increased risk of infections, and we do not want to immunosuppress people unless we truly need to.

This process is different than OA, which is caused by mechanical wear and tear leading to loss of cartilage, which is the smooth surface that reduces friction between the joints. The pain in OA happens because every time you move the joints are hitting each other. That’s why DMARDs and biologics won’t help this type of pain. As OA pain is from the bones hitting each other with movement, the best way to reduce the pain is by strengthening the muscles around the joint by physical therapy and exercise. There is a common misconception that exercise wears away the joints faster, which is not true; in fact, physical activity helps improve the adaptive capacity of the body. So, for OA, strengthening the areas around an affected joint can offset the loss of cartilage so that the body can still move without leading to pain.”

When talking to patients about nociplastic pain, it is important to stress that medications are only one part of the treatment strategy:

“One form of chronic pain is nociplastic pain, which is best understood as when the volume control of the brain is too high, and it amplifies signals to create more pain than is needed to protect the body. Our goal is to focus on treatment that turns down the pain processing amplifier in the brain. One of the tools we have is medication and this can be partly effective in reducing pain and keeping things stable so that other treatments may be possible. However, they are just one part of a broader pain management strategy, which may also include working on sleep hygiene, physical therapy, lifestyle changes, and stress management.”

Patients may not be immediately receptive to non-pharmacologic or self-management approaches, which can be disheartening for providers. However, changing perceptions about these methods often requires more than one consultation. A more realistic goal may be educating patients on the benefits of combining pharmacological and non-pharmacological treatments, which can be more effective than a strictly medication-based approach. Transitioning to a comprehensive, multidisciplinary pain management plan may require multiple appointments. During these sessions, sustainable strategies are discussed, aiming for a gradual change that empowers patients and is supported continuously by the provider.

Introducing psychological and physical therapy in pain management

Introducing PT and mental health treatment in pain management should emphasize their benefits and highlight their role as complements to (rather than replacements for) medical treatment. Below is an example of how a physician might approach this conversation:

“Part of our comprehensive approach to managing your condition includes working with a physical therapist and a [pain] psychologist. The physical therapist will focus on helping you improve mobility, strength, and flexibility, which are crucial for pain relief and functional improvement. They will tailor exercises and therapy techniques to your specific needs, helping you manage pain more effectively and enhance your quality of life. Physical activity can also teach your body to adapt better and offset the loss of cartilage so that the body can still move without leading to increased pain.”

“A pain psychologist teaches strategies for addressing the emotional and psychological aspects of pain. Chronic pain isn’t just a physical experience; it impacts and is affected by your emotions, behavior, and thoughts. Pain psychologists will work with you to develop strategies to cope with pain, manage stress, improve sleep, and address mood problems that can accompany chronic pain. We know that when we do not treat issues like sleep, depression, anxiety, trauma, or stress, it is harder to get pain under control because the brain continues to operate with high levels of threat. So, talking to a psychologist even just for an evaluation can let us know if there are any other steps that need to be taken to help you get better.”

“Together, seeing a physical therapist and psychologist complement the medical treatments we’re providing – this multifaceted approach makes sure we are treating everything that can contribute to pain so that you have the best possible chance of getting better. These steps are not meant to replace the medical treatments we are talking about, but rather to help extend their benefits long term.”

Introducing the role of physical therapy (PT) or occupational therapy (OT) in pain management

Interest in rehabilitative therapies (PT/OT) varies among patients. Some are immediately interested in seeking PT/OT or movement-based exercises (e.g., Pilates, yoga, tai chi) for functional recovery. For such patients, having easily accessible resources like contact details for PT or OT providers, free or low-cost online exercise classes, or local gyms or studios that accommodate their needs, ready for immediate referral, is beneficial. An example of such a resource is Stanford University’s Free Wellness Programs (https://stanfordhealthcare.org/for-patients-visitors/neuroscience-supportive-care-program.html#:~:text=Take%20care%20of%20your%20mind,others%20who%20have%20similar%20experiences).

Some patients may consider rehabilitation to be a “band-aid” or non-diagnostic, and they may state that they need a diagnosis to move forward with the correct treatment to reduce their symptoms. However, exercise treatment consistently demonstrates measurable effects for chronic pain even in the absence of a specific diagnosis [13]. In these cases, it is ideal to “meet patients where they are”: acknowledge and validate their concerns and explore their willingness to try a movement-based approach that is safe, evidence-based, and supervised. Some additional useful points to discuss with patients are as follows:

• Ask patients if they are willing to move forward with a movement program while diagnostic tests are being completed.

• Remind them that physical therapists are trained to work with a variety of medical conditions (cancer, neurological disorders, musculoskeletal disorders) and will meet the patient at their current functional level.

• Set expectations that the goal is to develop a movement program that a patient can perform consistently. This approach may necessitate starting at a lower level of physical activity than they are expecting or ultimately want to reach but is focused on being gentle with the body and taking time to build up (“Start low, go slow”).

• Let patients know that PTs and OTs prefer to set goals that are personally meaningful for their patients. This gives an opportunity to discuss the patient’s long-term goals and expectations for recovery and increase their engagement and buy-in to a treatment plan.

• Emphasize that an exercise program has several goals: to allow them to stay healthy, address their functional difficulties, and reduce their pain symptoms.

Unfortunately, patients sometimes will report negative or ineffective experiences with PT or OT (e.g., pain symptoms flared after every appointment). In these cases, it is useful to ask open-ended questions, such as “What did you do at PT/OT?”, to get more detailed information about their rehabilitation program. In some cases, patients’ prior experiences with PT/OT may have been more focused on passive modalities (e.g., heat, stretching) without delineating a clear rehabilitation plan. If a patient’s reports suggest that their experience was largely passive, it can be an opportunity to educate them on the need for more active, rehabilitative approaches to pain management. Alternately, if patients report that the exercise plan they followed was too intense and led to unsustainable levels of pain, it can be an opportunity to educate them on the need to communicate these issues with their physical therapist and to find a more sustainable set of activity goals to pursue.

Another key question to consider is “Does your PT/OT talk about how pain works, or do you understand what is safe for you to do in your movement program?” to gauge whether patients have been exposed to PNE as a component of their treatment. As noted previously, it is common for patients to fixate on biomedical causes to pain (e.g., a damaged joint, spinal pathology); structured neuroscience-based education can help patients understand the complexities of chronic pain and to increase their willingness to engage in rehabilitative treatments. Asking patients about their understanding of their pain symptoms can also help reinforcing efforts in rehabilitation, ensuring that all providers are working together to help the patient, thereby increasing confidence in their treatment plan.

Introducing the role of psychology in chronic pain management

Mental health treatment may take several forms for patients with chronic pain management. First, several well-validated behavioral interventions exist with an explicit focus on treating psychological aspects of chronic pain such as stress, negative cognitive and emotional reactions related to pain, improving sleep, and building sustainable patterns of physical, occupational and interpersonal function. These treatments include CBT, mindfulness-based stress reduction, and acceptance and commitment therapy, all of which have shown efficacy in reducing negative consequences related to pain including negative thought patterns related to pain (catastrophizing) and improvements in disability and mood disturbance, as well as significant but smaller reductions of pain intensity [14, 15].

It is important to note that patients do not need to be diagnosed with a mental health disorder to benefit from pain psychology treatments; instead, pain psychology treatments are better viewed as a common component of multidisciplinary pain management. It is important for patients to understand that working on behavioral aspects of chronic pain does not reflect that they “secretly” have a mental health disorder or that their pain is “all in the head”. Instead, we recommend reframing behavioral treatment for pain as treating other factors that pain can affect (e.g., mood, severely compromised physical/psychosocial function, sleep) to ensure that they do not interfere with the broader pain management process. There is evidence to support that pain intensity may be a “lagging indicator”, such that other symptom clusters (disability, sleep disturbance, symptoms of depression, anxiety, or post-traumatic stress disorder) may need to be stabilized before meaningful improvements in pain can be achieved [11, 12].

In cases where patients do demonstrate more significant levels of mood disturbance (e.g., severe depressive symptoms, daily panic attacks, untreated/severe post-traumatic stress disorder symptoms, unmanaged manic or psychotic symptoms), targeted psychotherapeutic and psychiatric treatment to stabilize these symptoms may be indicated prior to initiating pain-specific behavioral treatment. As above, the rationale for this approach is to ensure that psychological symptoms do not interfere with pain treatment.

Introducing the role of psychology in pain management: “There are several reasons why psychological treatments are part of pain management. First, chronic pain can cause significant stress, depression, anxiety, or insomnia, even if you never had any history of these problems before. We know that when people experience severe depression, anxiety, or insomnia, they are less likely to show a strong response to pain treatment. So, seeing a psychologist for an evaluation is not because your pain is “all in your head” or as a means of stopping your medical treatment; instead, it’s an opportunity to make sure that you are going to get the greatest possible benefit from the treatments we discuss and to ensure that other problems (like severe stress, mood, or sleep problems) don’t prevent you from getting a good response to our treatments or otherwise negatively affect your life.

These behavioral treatments sometimes reduce the intensity of pain itself, but not always. Even in cases where people do not get changes in pain intensity from the treatment, they often find other things that are useful in their pain management, such as ways of managing stress, improving mood or sleep, or building up levels of physical activity in ways that cause less pain.”

Importantly, not all mental health treatments are equally effective for managing pain and mood. As in the case of PT/OT, patients may report limited benefit to their pain or overall functional levels from previous psychotherapy, especially when it was predominantly supportive without a focus on educating, conceptualizing, or planning for chronic pain self-management. Generally, treatments emphasizing active self-management yield better outcomes than non-directive supportive therapy for both pain and mood disturbances [16, 17]. The following questions can be helpful to assess the types and effectiveness of mental health treatments patients have received.

• Did treatment involve education about the patient’s specific diagnosis? Was the patient informed about how their condition developed or how they could get better?

• Did treatment involve developing new skills or practices (e.g., relaxation practices, meditation, hypnosis, cognitive reappraisal strategies, communication skills, ways of planning exercise, problem solving, journaling or writing exercises for emotional distress or trauma)?

• Do patients recall having “homework”? In other words, were they expected to practice anything outside of session that would lead to longer-term improvements in their symptoms?

• Do patients recall any structured parts of the treatment other than having regular “check-ins” on how their week was going?

In the broadest terms, supportive therapy is non-directive and prioritizes provision of social support and short-term problem solving for immediate issues. These therapeutic components do play a useful role in psychotherapy but are less effective if presented as monotherapies [17]. If patients report receiving only general support without new insights or a proactive self-management plan, it’s advisable to explore the advantages of a more focused, active approach to pain management. When mental health treatment fails to equip patients with specific strategies or a “toolbox” for managing symptoms like pain, stress, or sleep disturbances, further mental health referrals may be necessary for better symptom control.

More recently, novel behavioral interventions (e.g., Emotional Awareness and Expression Therapy, Pain Reprocessing Therapy) have emphasized that treating negative emotions (intense or pain-related fear, suppressed anger, grief, guilt or other emotions) can yield significant reductions in pain, particularly among patients with high levels of nociplastic pain [18, 19]. In patients with chronic life stress or high levels of psychological trauma, an explanation of pain being at least partially driven by a sensitized nervous system is useful. If the brain and CNS can be re-taught to recognize safety (as opposed to prolonged periods of hypervigilance, threat-related hyperarousal, or avoidance or suppression of normal emotional responses), pain symptoms (as well as mood and sleep) can improve.

“When people have a history of significant life stress or trauma, it is more likely that they will develop a chronic pain condition. This can be because the brain loses the ability to tell the difference between when the body is safe and when it isn’t safe. So, working on symptoms related to stress, emotions or trauma can help reduce pain. It may not be everything you need to get better- everyone needs certain things to be healthy, such as good sleep or exercise, so we will also work on these things. However, if this process is present and we do not treat it, it can be hard to treat pain as effectively.”

Addressing misconceptions about pain management

A key barrier to receptivity to multidisciplinary care is addressing common concerns for patients, who commonly view pain through a strictly biomedical or structural lens. These concerns include:

• A concern of a “missed” and medically urgent diagnosis.

• A fear that pain is a signal of continued damage in the body.

• A fear of being “psychologized” (i.e., an implication that their pain symptoms are not real, not legitimate, or driven entirely by their psychological state).

• A concern that engaging in other forms of treatment may impede their own priorities (e.g., seeing a physical therapist or psychologist may mean that they do not get further medical evaluation or medical treatment).

A fear of being “psychologized”, or the concern that working on psychological aspects of pain may imply that pain that patients are having is not “real” or is “all in the head”; this concern is particularly elevated among female patients and those with nociplastic or chronic overlapping pain conditions [20]. There is also a common overemphasis on structural causes for pain, like spine or joint imaging, despite the weak correlation between chronic pain intensity and structural pathology [21–23].

Clinicians treating chronic pain should expand their explanatory models beyond a sole focus on structural pathology, incorporating other relevant factors like brain and CNS function, as they significantly contribute to current pain symptoms. It is important to remember that many patients have “mixed” chronic pain presentations, involving nociplastic and nociceptive, neuropathic, or inflammatory contributors [24].

It can be tempting to offer a singular explanation of pain symptoms but can ultimately be a disservice to patients in the long run if they have brain/CNS and medical disease/peripheral contributors to pain. Accordingly, we recommend informing patients that pain treatment is a step-by-step process focused on the most immediately salient aspects of their symptoms: severe deconditioning, stabilizing an unmanaged autoimmune or neurological condition, or addressing aspects of nociplastic pain. Stabilizing one contributor to pain may not fully resolve pain itself (as is common in chronic pain) but can act as a foundational step that can enhance overall pain management in the long term. For example, patients with severe insomnia may be resistant to the idea that this could factor into their pain but explaining that that treating insomnia can help “turn down the volume” on the brain’s hyperreactivity to nerve signals may improve the acceptability of this treatment plan.

Explaining non-pharmacologic approaches to pain management:

As noted previously, multidisciplinary pain management approaches heavily emphasize non-pharmacological approaches, including physical activity, health behavior interventions (e.g., for diet and sleep), and psychological/behavioral treatments for mood and sleep. Some additional scripts for introducing these topics are listed below.

“While the specific exercises may differ for specific conditions, staying active is generally beneficial for chronic pain. It helps maintain joint mobility, muscle strength, and overall well-being. Exercise also helps improve stress, mood, and sleep, so it is used not only for chronic pain conditions but also for people with depression, anxiety, or insomnia. So, if you have noticed that your mood or sleep are worse since your pain condition started, working on physical activity may improve multiple areas at the same time.”

“Good sleep hygiene is crucial. Poor sleep can worsen pain, mood, and affect your ability to cope with chronic pain. Research tells us that prolonged periods of poor sleep are risk factors for developing chronic pain, and we have evidence that improving sleep can help calm the brain down and contribute to longer-term pain relief.”

“A balanced diet aids in overall health and can have an impact on inflammation levels, weight management, and general pain control.”

“The best pain management plans involve a holistic approach. It’s about finding a balance that works for your specific situation and condition. We don’t expect that you will change everything right away or that you will necessarily need to make every change that we discuss, but these are all options that can be helpful in reducing your pain and improving your overall health. Would you be open to trying any of these approaches?”

Burnout: Why it matters to clinicians and patients

A key challenge to patient education occurs when the goals of the patient are not aligned with the goals of the provider. This mismatch can be challenging for several reasons but can escalate to the point of interpersonal conflict or harsh interactions between patients and providers. Unfortunately, when interaction patterns between patients and providers regularly involve conflict, it can adversely affect the treatment alliance, worsen treatment adherence and outcomes, and contribute to greater burnout by providers.

Estimates indicate that between 36% and 60% of medical providers in fields associated with pain management report significant levels in at least one of 3 indicators of burnout (emotional exhaustion, feelings of depersonalization, or low feelings of accomplishment in their work)[25, 26]. Causes of clinician burnout are diverse and include low levels of satisfaction or autonomy in clinical decision-making, poor peer support (e.g., isolation, lack of access/contact with other clinical disciplines) or organizational support (e.g., high workload, lack of resources), difficulty managing patients, and conflictual or emotionally charged interactions with patients[25, 26].

Notably, when asked about particularly challenging aspects of interacting with patients with chronic pain, providers report feeling ill-equipped to manage patients with histories of complex psychological trauma or complicated familial or social situations [25], as these aspects of care are not commonly emphasized in medical education curricula [25, 27]. From a provider perspective, there are also several personal and professional risks of burnout, including higher rates of engagement in suboptimal medical provider behaviors (e.g., taking less time to care for patients, taking unnecessary risks in care provision, or inattentiveness to key details of evaluation or treatment)[28] and higher rates of medical and psychological problems (e.g., mood disturbance, substance abuse, insomnia, and marital dysfunction) [29]. Providers who experience high levels of burnout also appear more likely to leave their jobs or clinical practice entirely [29].

Pain management providers are thus vulnerable to a vicious cycle, in which the high-demand interactions with patients with chronic pain and complex psychosocial histories contribute to heightened burnout, which in turn leaves providers with fewer resources to devote to future clinical interactions. This idea is supported by existing reviews on provider burnout that suggest that prevention of burnout is a more effective and less costly solution than treatment of burnout [30, 31]. We would like to acknowledge that both the treatment and prevention of burnout require interventions at the individual and organizational levels [30, 31]; it is not possible to resolve burnout by simply asking providers to behave differently (e.g., through increased stress management or self-care behaviors) without corresponding changes at the organizational level (e.g., alterations in clinical encounter scheduling, modification of rigid scheduling or unreasonable clinical output expectations, devoted time for professional consultation). Although a full review of burnout prevention is beyond the scope of this paper, the next section offers scripts and recommendations to help manage challenging aspects of interacting with patients with chronic pain and complex psychosocial histories.

Understanding and communicating about professional boundaries

It can be useful to clearly communicate to patients what is possible to accomplish in the context of their clinical visit. Patients may not understand what is and is not possible to get from a single clinical visit – it may be possible to conduct a physical examination, prescribe some medications (but not others), or place referrals for specific services. We recommend that each provider consider what the limits of their clinical practice may be – this may involve specific interventions (e.g., opioid or benzodiazepine prescription), interventional therapies, or pain-relevant aspects of clinical care that might fall outside of traditional clinical disciplinary boundaries (e.g., assessing mood, trauma, or unstable housing). When a provider thoroughly considers what they can and cannot provide in a clinical encounter, it becomes easier to subsequently communicate these limits to patients. A sample script is below:

“It is useful for us to talk about the areas of my practice that might be helpful for you. There may be things that we agree would be helpful but are outside of my area of specialty or that I don’t have any control over. If this comes up, I am happy to discuss these issues with you but I may ultimately say that you will need to find someone else to provide this service for you.”

When addressing a patient’s request for pain medications that are not medically indicated, it’s important to be empathetic, confirm that the patient and provider do share common goals (i.e., finding ways to feel better that are sustainable long term and do not lead to greater medical risk) while setting clear expectations and boundaries.

“It can be very difficult to deal with high levels of chronic pain; I hear that it’s really been affecting your life, as you haven’t been able to do [valued life activities they’ve missed out on]. My goals are to work on a plan so that you can do more of what you enjoy doing. The specific medication you’ve mentioned may not be very helpful because [provide a brief, clear explanation specific to their condition and the medication in question]. While this medication might seem like a good solution, in your case, it could potentially cause more harm than good due to [mention any potential side effects, risk of dependency, or lack of effectiveness for their type of pain].

In the case of opioids, many people think the only risks are dependency and overdose. However, there are many other issues that are equally or more concerning. Their effectiveness rapidly declines to only 25–30% in a few weeks. In fact, opioids were found less effective at 1 year compared to NSAIDs in the only trial they’ve been studied in. There are also higher risks of cardiac events, adrenal insufficiency, higher risks of infections and fractures, and negative effects on sex hormones. They can negatively affect mood and because of the way they act on the brain pathways even after tapering off some people may not fully recover to their baseline.

My priority is to ensure the best and safest treatment approach for you now and long term. There are alternative treatments that might be more beneficial for you, such as [offer alternatives – other medications, physical therapy, lifestyle changes, etc.]. These options have shown good results for pain like yours and come with fewer risks. We may need to trial and combine several things and we can reassess and adjust our plan as needed. Do you have any questions or concerns about these alternatives that we can talk through?”

Building treatment alliance with patients who expect a “cure”

A key aspect to chronic pain management is fostering self-management approaches that patients can utilize by themselves. Patients may present to clinical visits with an expectation of being “fixed” or “repaired”, but this outcome is uncommon in most forms of chronic pain. When providers regularly perceive patients to have these kinds of unrealistic expectations, it can be a significant predictor of burnout [32].

Encouraging patients to become active participants in their own care is a longstanding recommendation for most forms of chronic disease management [33]. Passive or avoidant coping responses are associated with increased risks of greater long-term chronic pain and pain-related disability [34]. As a result, it is important to frame clinical visits around chronic pain as collaborative: patients are the experts in their own pain experiences (particularly given the lack of objective tests for pain) and their goals feature centrally in any treatment plans that are put in place. Conversely, it is incumbent on patients to find ways to self-manage their symptoms as much as possible to maximize treatment effects. This collaborative approach also typically means that providers are not pressured to find a cure to chronic pain; as with most chronic conditions, many forms of chronic pain do not have clear cures and thus require a long-term focus on management of symptoms.

“We usually think about pain management as a “team sport”. A long line of research tells us that we need to work on multiple aspects of chronic pain in order to get the best chance of improving your pain symptoms. It also means that part of pain management is self-management. No matter what medications or other interventions I provide, a major way that people manage chronic pain is by finding ways to manage these symptoms themselves. I will help you with as much of my knowledge and interventions as I can, but I will also ask you to try some things on your own that may be helpful in managing your symptoms. This might mean trying out different forms of movement, changes in your diet or medication, seeing other providers, or other things that you can control such as working on your sleep or your mood. If we don’t take care of these other issues, they can build up and make it harder to treat your pain symptoms.

This means that we are a team. When we discuss possible options for how to treat your pain symptoms, I am interested in knowing what you think about the plan. If something doesn’t seem like a good fit for you right now or you try something and it doesn’t work, I want to know that. Neither of us benefits if I suggest something that isn’t possible for you or that you are unwilling to do. We will try and identify other options if we find that a treatment does not work or seems like a bad fit for you.”

Managing negative emotions or misbehavior during clinical encounters

When patients are in distress, they may have difficulty regulating their emotions. This issue can occur in an indirect way (e.g., crying in the room, expressing anger towards someone else not currently in the room) or directly (e.g., expressing blame or anger directly towards their providers or medical team). When patients exhibit strong emotional responses in a clinical encounter, a few key things should be kept in mind:

• Chronic pain not only involves physical symptoms, but also significant emotional distress, such as anger, sadness, frustration or fear, which patients may struggle to regulate, especially when in high levels of pain (which are common reasons they present for treatment in the first place). This emotional distress can stem from both pain itself and from previous negative experiences with the medical system and can lead patients to act in ways they normally wouldn’t. While this observation is not intended to excuse inappropriate patient behavior, it can be useful to view these behaviors as products of distress rather than being reflective of a poor relationship with their current provider.

• It is often useful to validate these emotions whenever it is reasonable to do so – patients may report feeling frightened, sad, or angry because their conditions are difficult to treat or because their conditions have caused significant problems in their lives. Letting them know that these reactions are understandable and common among people with their condition can reduce the burden on both patient or provider to “fix” these feelings.

• Related to the prior point, allowing patients to vocalize what they are feeling (within reasonable limits) can be a way to build a stronger treating relationship. As noted above, treatment providers are not responsible for “fixing” a patient’s emotional response. Allowing a patient to verbalize what their concerns or frustrations are without defensiveness or denying these feelings can allow the provider to acknowledge their difficulties while still orienting them towards proactive next steps (e.g., new treatments, aspects of self-management).

• Conversely, while medical providers should aim to approach patients with optimism and empathy, their ability to do so can vary due to stress from clinical challenges or personal issues, particularly during difficult clinical encounters. It is important for clinicians to be aware of their own vulnerabilities that may lead to counterproductive behaviors like defensiveness or retaliation (or, conversely, a tendency to overpromise or over-extend their treatment in unsustainable ways). Recognizing one’s limits in handling severe patient misbehavior is crucial; in extreme cases, this may mean ending a clinical appointment or seeking additional help to maintain safety. Acknowledging these factors is key to preventing burnout and ensuring sustainable clinical practice.

• Clinicians are not obligated to accept or condone abusive behavior. Patients who repeatedly act in harsh, accusatory, or threatening ways despite efforts to redirect the focus of the visit are not likely to be at a point where treatment planning is possible. In these situations, refocusing the communication towards de-escalation and/or behavioral planning (i.e., communicating what is considered acceptable behavior in future clinical appointments) is strongly indicated. Providers who feel unsafe in their interactions with patients should vocalize these concerns to other members of the clinic staff or leadership (if available) and engage as much organizational support to manage problematic behavior as possible. A de-escalation script can be found below.

“It sounds like things have been very difficult for you. I can tell that you are (frustrated/scared/angry) and it makes sense to me that you feel that way. However, during our appointment I am asking that you try and remain as calm as you can. I will do my part to make sure that happens as well – if I say or do something that upsets you, please let me know and I will do my best to address the issue. It is harder for me to make a plan to help you if either of us is very stressed or upset, so I think we would both benefit if we can find a way to communicate calmly about the issues we are discussing. If you don’t think you will be able to stay calm in our appointment today, we can reschedule for another day.”

“I am glad to work with you, but in order to make sure our work together is successful I will also need certain things from you. This means that you should be able to show up to our appointments on time and treat me and our staff with respect, in the same way that we should treat you in a respectful way. If you don’t think this expectation is reasonable, it may not be possible for us to continue working together.”

How to redirect or prioritize treatment goals without being rude

Particularly in clinical settings where time may be limited (e.g., primary care) or while caring for patients with multiple medical and/or psychological conditions, a significant barrier to effective communication can be time pressure. It is incumbent on both providers and patients to understand what may be possible to accomplish in brief visits. Accordingly, if a provider identifies a situation where the visit length is likely to be insufficient for the overarching clinical issues it can be useful to address this issue early in the appointment:

“It sounds like you may have multiple things to discuss with me today. I know we only have ___ minutes for our visit today. I will need to leave at the end of our scheduled time to make sure I am on time for other patients I need to see today. In the interest of time, I will try and make sure I get as much information from you as possible, but I may interrupt you if I feel that we are starting to run out of time. If I end up interrupting you, please know that I am not trying to be rude but rather that I’m trying to get as much done for you as I can in our limited time. Is that OK with you?”

“It sounds like you have multiple goals for our appointment today, but I’m concerned that we may not be able to get to everything today. It may be helpful for us to pick out the top one or two priorities for our appointment – what are the most important things that we could accomplish for you today? If we do not get everything settled today we can schedule another appointment to discuss other things that may need to be addressed.”

Developing a sustainable clinician mindset

Clinicians who focus on their own health and on finding ways to create a sustainable clinical practice may notice benefits in terms of higher satisfaction, better outcomes in clinical care, and reduced feelings of burnout. Accordingly, a key responsibility for all providers is to work on maintaining good health so that they can continue providing clinical care – caring for one’s own health in the workplace is an investment in being able to continue providing care to others in the long run.

On occasion, distressed or agitated patients may challenge a clinician’s authority, feelings of competence, or credentials or try to shame or guilt a provider for not doing enough. Exploring and being mindful of your own vulnerabilities and emotional triggers can help you to avoid engaging in behavioral or communication patterns that are counterproductive in clinical care. These may include impulses to become defensive, retaliate, argue, or otherwise failing to maintain a neutral and professional tone while interacting with patients.

Recognize your limits. Clinical providers regularly join their fields to help people, and do not need to tolerate abusive or otherwise inappropriate behavior. In some cases (e.g., manipulative, dishonest, or threatening behavior), the most appropriate steps to be taken may include discontinuation of a clinical appointment, referral to other providers, or seeking of additional help (e.g., other clinicians, clinic leadership, security or police if safety concerns are noted). These steps are particularly important in preventing burnout and promoting more sustainable long-term patterns of clinical practice. A key resource that may be useful to review is “Self-Compassion for Caregivers” by Kristin Neff, PhD (https://www.youtube.com/watch?v=jJ9wGfwE-YE).

Conclusions

Effective chronic pain management involves integrating various clinical perspectives due to the interplay between disease-specific medical processes and CNS changes. Accordingly, it is crucial to educate patients effectively on multidisciplinary and self-management models of pain management. Clinicians should develop strategies to explain the complexities of chronic pain and the limitations of relying solely on imaging or physical exam findings to assess pain. Being prepared for common misunderstandings, disagreements, or conflicts in pain management can reduce stress in clinical interactions and prevent burnout in the long term. Repeated, in-depth discussions help align patients with the healthcare team, acknowledging that pain affects not only physical movement but also their lifestyle choices and participation in social activities.

Practice points

• Key educational goals for patients with chronic pain include the complex nature of pain, a de-emphasis on strictly biomedical definitions of pain, and engagement of non-pharmacological and self-management aspects of pain treatment.

• Consistency in messaging around the meaning of chronic pain and the need for multimodal treatment is crucial. Multidisciplinary treatment is the standard and not a reflection of something uniquely wrong with any particular patient.

• Preventing burnout is a key responsibility for all providers. Although this responsibility is always shared by care organizations as well, there are key aspects of sustainable practice that may be possible to reduce burnout risk. These practices include boundary-setting in session, setting appropriate expectations for chronic pain management and in the context of any individual treatment session, and referrals and consultation with allied providers whenever possible.

• Clinicians providing pain management services should consider beforehand the aspects of treatment they can and cannot provide, so that they are prepared to discuss these issues with patients. It is also useful to practice ways of communicating with patients when their goals are not aligned with the treatment setting (e.g., focusing on a “cure” for chronic pain, asking for medical treatments that are not clinically indicated).

Research agenda

• Transdisciplinary care models, successfully implemented in other diseases, have yet to be specifically explored in chronic pain populations. Given their strong conceptual fit with the needs of patients with chronic pain, future research on transdisciplinary care models in chronic pain is indicated.

• With increasing evidence of patients experiencing mixed pain types (i.e., including features of both nociplastic and nociceptive/inflammatory/neuropathic) pain, there is a need to develop and study treatment protocols for patients with mixed chronic pain.

• Research on strategies for preventing and treating burnout among pain management clinicians is limited but crucial for maintaining a robust and effective pain management workforce.