The medicolegal challenges of chronic pain: from diagnosis to treatment

Chronic pain is defined as pain that lasts for longer than 3 months, or persists beyond the expected healing time. It is an extremely common condition, affecting as many as 20% of adults in the UK at any one time. Therefore, most people can expect to experience some type of chronic pain during their lifetime, and in around 15% of adults, the pain can be severe and debilitating. Chronic pain conditions are amongst the commonest reasons for disablement, with low back and neck pain consistently being the leading causes.  

Chronic pain is often secondary to another disease or injury and is frequently viewed as a symptom, rather than a disease process in its own right. However, this view may not always be justified. Healthcare providers may also fail to take pain seriously because it is particularly difficult to diagnose. There are no objective tests to identify or quantify pain, so clinicians must rely instead on subjective self-reporting by the patient, which may or may not be corroborated by assessments of functional capacity and visible pathology. Therefore, conditions that are associated with clearly identifiable tissue or nerve damage are easier to diagnose and tend to be better understood.  

It is now recognised that pain is not just a physical experience but also encompasses psychosocial and environmental aspects that can contribute to the way in which it manifests. Conditions in which these latter factors appear to be more influential have historically been less accepted by the medical profession, and thus our understanding of them is incomplete. Illnesses such as fibromyalgia (FM) often present with no obvious physical cause or trigger and has been categorised in ICD-11 as a Primary Pain disorder. Conditions like complex regional pain syndrome are more widely recognised nowadays but still remains controversial for some clinicians. Therefore, under diagnosis is common and some patients remain untreated, with obvious consequences for their quality of life.  

One of the challenges is the fact that the symptoms of FM, CRPS and some other chronic pain conditions overlap with those of various psychiatric illnesses, including depression anxiety and somatic symptom disorder. There is also a two-way relationship between chronic pain and psychological symptoms: patients who suffer from anxiety, tension or depression, as well as those who have experienced violence or abuse, are more likely to report chronic pain, but the experience of living with chronic pain, particularly if it persists for months or years, is likely to lead to symptoms of depression and anxiety.  

Diagnosis is further complicated by the fact that the symptoms of many chronic pain conditions fluctuate over time, with patients reporting ‘good’ and ‘bad’ days. Therefore, a patient may not always meet the criteria for diagnosis and assessing the degree of disability caused by the condition can be particularly challenging. Furthermore, the definitions and diagnostic criteria for some conditions have changed over time, so patients who have previously been classified as suffering from a particular illness may find that they no longer qualify for a diagnosis.  

In the absence of definitive diagnostic tests, there will always be a suspicion that patients are fabricating or exaggerating their symptoms, particularly where they stand to gain financially from their condition. Some studies have indeed reported elevated rates of malingering in patients with chronic pain conditions, which appear to be highest for compensable injuries or illnesses. More recently, however, it has been reported that rates of malingering in patients with FM are in fact extremely low, and symptoms rarely resolve even when compensation has been awarded. While it is obviously important to identify malingering patients, it is also vital to bear in mind that for the vast majority of patients, their pain is all too real.  

Once a diagnosis has been made, the treatment of chronic pain still presents some important issues which may give rise to a medicolegal claim. One major problem is that there is no universally effective treatment for chronic pain, and a variety of approaches may be needed before adequate pain relief is achieved. Initially, management is through the use of analgesic and adjuvant drugs, and care must be taken to select an appropriate medication and dosage. If these first-line analgesics do not provide adequate relief, opioid medications are sometimes offered. However, there is little convincing evidence that these provide any long-term benefit. They are also associated with high levels of morbidity and mortality as well as a risk of addiction if their use is prolonged.  As such, national guidance now does not recommend opioids for many chronic pain conditions.   

Chronic pain is a complex condition, and both diagnosis and treatment continue to present challenges. Not surprisingly, the number of medicolegal claims relating to chronic pain conditions has risen in recent years. While some patients may exploit the subjective nature of pain symptoms in order to make a dishonest claim, it is important to remember that the pain experienced by the majority of patients is genuine. Pharmacological treatments often confer little long-term benefit. However, there is some evidence that a non-pharmacologic approach is often more beneficial to the patient and may also reduce the risk of complications and subsequent litigation.