Reframing chronic pain conversations

Issue: BCMJ, vol. 66, No. 2, March 2024, Pages 38-39 Letters

High-impact chronic pain affects quality of life and causes anxiety.[1] Affected individuals are more frequently prescribed opioids than those suffering from mild to moderately bothersome pain.[2] Management of this complex condition adds to the burden experienced by burned-out family doctors.

Psychosocial factors influence pain and patients’ ability to manage their symptoms. Patients overwhelmed with chronic pain may find supportive self-management programs difficult to follow. An effective patient–provider partnership can be compromised if the patient feels they are to blame for their lack of progress.

Chronic pain already comes with the burden of stigma.[3] The experience of chronic illness may change the way individuals view themselves and the world. They can experience the environment as dangerous and feel they cannot effect change.[4] This leads to a decreased sense of self-efficacy. Reframing the pain conversation can reduce the risk of provoking a shame-based response.

Introducing the limbic system as an umbrella term used to explain neuroplastic changes in the brain explains associated anxiety with pain.[1] Framing the conversation around chronic pain causing alert or alarm in the limbic system turns the focus to chronic pain as the culprit, not the patient. The stress of pain is then connected to emotions, actions, memory,[5] and the downstream consequences of high alarm: maladjusted survival responses, associated neurohormonal changes, increased inflammation, and central sensitization causing a cycle of pain and anxiety.

Multiple other pain influencers can then be addressed, including the stress of unemployment, financial hardship, health inequities, and compromised interpersonal relationships and social interactions, which negatively impact coping mechanisms.

A structured approach and Internet-based chronic pain tools make this approach possible in a busy medical practice.

Pain questionnaires can be used prior to an appointment to identify the presence of high-impact chronic pain. A 20-minute counseling appointment is essential for a narrative interview, with the opening question “Please tell me everything you feel I should know about your pain.”

Subsequent follow-up counseling appointments are used to address biological causes for chronic pain. Endorse symptoms, and acknowledge that exact causes for pain cannot always be identified. Repeatedly assure patients of negative findings. Reassure patients there is no imminent harm and that conditions requiring surgery have been eliminated. Explore other forms of medication that can impact central sensitization and chronic inflammation.

Ask patients what they feel is the cause of their pain. Using questionnaires, reassess the impact of pain on their quality of life and use these measures as a tool to address movement, sleep, diet, socialization, and mental health.

Multiple tools for patients are available to explain pain, neuroplasticity, central sensitization, and the inflammatory neurohormonal cascade of sympathetic arousal.

Education tools are available online (

Links to management tools for overwhelming pain, physical and emotional, can be emailed to patients (

Pain coaches and education can be accessed through and

Regular office visits providing supported self-management can assist patients to change entrenched negative cognitions and behavior and help improve emotional and physiological regulation.

An understanding of the biological and psychological effects of chronic pain through a graduated education program will decrease a sense of shame and increase interpersonal effectiveness and interest in social connectedness. The goal is to empower patients and support them in discovering joy in their lives again.
—Judy Dercksen, MD


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1.    Chen T, Wang J, Wang YQ, Chu YX. Current understanding of the neural circuitry in the comorbidity of chronic pain and anxiety. Neural Plast 2022;2022:4217593.

2.    Von Korff M, DeBar LL, Krebs EE, et al. Graded chronic pain scale revised: Mild, bothersome, and high-impact chronic pain. Pain 2020;161:651-661.

3.    Perugino F, De Angelis V, Pompili M, Martelletti P. Stigma and chronic pain. Pain Ther 2022;11:1085-1094.

4.    Gatchel RJ, Neblett R, Kishino N, Ray CT. Fear-avoidance beliefs and chronic pain. J Orthop Sports Phys Ther 2016;46:38-43.

5.    Rolls ET. The cingulate cortex and limbic systems for emotion, action, and memory. Brain Struct Funct 2019;224:3001-3018.

Judy Dercksen, MD. Reframing chronic pain conversations. BCMJ, Vol. 66, No. 2, March, 2024, Page(s) 38-39 - Letters.

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