"Nothing Works For My Pain": A Qualitative Study of Barriers and Facilitators to Chronic Pain Self-Management

Bair MJ, Damush M, Matthias. "Nothing Works For My Pain": A Qualitative Study of Barriers and Facilitators to Chronic Pain Self-Management. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2008 Apr 9; Pittsburgh, PA.

BACKGROUND: Patient self-management is critical for the optimal treatment of chronic conditions, yet is complex and not well understood. Little is known about the challenges patients with chronic pain face in becoming effective "self-managers." Our objective was to identify barriers and facilitators to self-management of chronic musculoskeletal pain in an effort to improve the delivery and effectiveness of pain self-management strategies. METHODS: We conducted a qualitative study of four focus groups. Patients were recruited from VA and university primary care clinics after their participation in a randomized clinical trial. The trial was designed to test a combined intervention, delivered by nurse care managers, of optimized anti-depressant therapy and a 6-session pain self-management program versus usual care for patients with comorbid chronic pain and depression. All patients completing the trial intervention were eligible for the current study. Focus groups were stratified by gender and three to six patients participated in each session. An experienced moderator facilitated the sessions, guided by semi-structured questions addressing self-management strategies delivered during the trial. Groups were audio-taped and transcribed. Analysis of each transcript identified conceptual themes present in the focus group guide as well as emergent themes from patient narratives of their self-management experiences. Three researchers independently coded transcripts with MAXqda software using constant comparison methodology. Discrepancies were resolved by consensus. RESULTS: Patients (N = 18) were 27 to 84 years old (M = 54.8), 61% women, 72% White, and 22% Black. Barriers to the use of pain self-management strategies included: 1) lack of support from friends and family; 2) limited resources (e.g. transportation, financial); 3) depression ("I have no hope", "I don't want to do anything when I am depressed"; 4) ineffectiveness of pain-relief strategies ("I hurt more"); 5) time constraints and other life priorities (e.g. work, child care and other family demands); 6) avoiding activity because of fear of pain exacerbation (" don't want to end up hurting myself"); 7) lack of tailoring strategies to meet personal needs; 8) not being able to maintain the use of strategies after study completion; 9) physical limitations ("problems walking"); and 10) difficult patient-physician interactions ("the only thing they (primary care providers) want to do is put you on an antidepressant"). Facilitators to improve pain self-management included 1) encouragement from nurse care managers ("she can get me back on track, because I'm off track"); 2) improving depression with treatment ("the depression went away and I was able to do more"); 3) supportive family and friends; and 4) providing a menu of different self-management strategies to use. CONCLUSIONS: Given the cross-cutting relevance of patient self-management, the barriers and facilitators identified in this study may lead, not only to improved management of chronic musculoskeletal pain, but also to improvement in the care of patients with many other chronic conditions. Because our sample was relatively small, future research is planned to confirm these findings and design interventions to capitalize on the facilitators identified while at the same time addressing the barriers to pain self-management.