Behavioral health treatment is vital given the prevalence of depression, anxiety, and other mental health problems among pain sufferers. A psychiatrist describes his experience that “many patients who report to primary care with complaints of pain or fibromyalgia actually have an underlying primary depressive disorder.” As numerous responding pain specialists observe, the failure to address psychological problems and provide psychological support undermines effective pain treatment. A primary care physician respondent finds that for primary care physicians, “chronic pain management requires complex skills in managing psychiatric and behavioral sequellae (including addiction) for which training and reimbursement are woefully inadequate. The low reimbursement of both cognitive work and behavioral medicine in primary care creates time pressures that limit the ability to carefully assess complex, multifaceted conditions like pain.” Ultimately, he writes, “for many [primary care physicians] it is easier to let the patient become dissatisfied with care so that they seek care elsewhere. … Research is needed into alternative reimbursement strategies that will encourage primary care physicians to accept and retain these often complex patients.”

A neurologist and pain medicine specialist sums up what many providers agree are some of the primary barriers to effective pain treatment: “1) too many pain providers give one-dimensional care; 2) patients often expect simplistic answers or injections; 3) medical providers too often refer pain patients to specialists (e.g., orthopedic surgery) rather than to a comprehensive pain center; 4) multidisciplinary pain treatment is not well-developed throughout the country.” Another pain specialist—and director of a pain clinic—decries how “cost cutting has led to limited access to modalities such as injections, neuromodulation, chiropractic care, mental health care, massage, and acupuncture for chronic pain.” An internist notes, “it seems easier to get help with chronic diabetics or heart failure patients, but not the same kind of support for chronic pain patients.”

There were some reports that providers justify invasive procedures to patients by convincing them that structural abnormalities in MRIs require surgical intervention, despite the extensive evidence that MRIs reveal many abnormalities in people who have no pain and that surgical interventions often are unnecessary and even harmful. A pain specialist writes, “The main problem I encounter are patients who have … been convinced by health care professionals that an invasive procedure is warranted.” Another provider in the Department of Veterans Affairs (VA) system writes, “one significant problem is the overuse of diagnostic testing. Patient[s] now have an expectation of the need for imaging and surgery when they could use self care or non-invasive treatment. Current evidence suggests that imaging studies may create a level of anxiety and fear that may affect the prognosis of someone suffering from a pain syndrome.” Instead, he advocates public education, such as that in Australia about staying active and not overtreating pain (see Box 4-1 in Chapter 4). Chronic pain sufferers seeking disability status or with pending litigation themselves may have perverse incentives.

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