Do Difficult Encounters Affect Pain Treatment Outcomes? A Prospective Cohort Study

w liu, e gelderen, r mawalkar, e wang, g treisman, s cohen

Background: Difficult encounters represent an enormous burden and drain on resources in pain medicine, but their effect on outcomes has not been studied.

Objective: To determine the effect of “difficult” encounters on chronic pain outcomes.

Methods: In this prospective study, new chronic pain visits were rated by an attending physician and trainee on a 6-point Likert scale and stratified into “difficult” and “non-difficult.” The main outcome was successful treatment, defined as a ≥2-point reduction in average pain 4 weeks after initiation of pharmacological, integrative, or simple injection therapy, or 12 weeks after more invasive procedures. The secondary outcome was being lost to follow-up.

Results: Among 428 patients seen for new-patient evaluations, 299 patients had follow-up, of whom 127 (42.5%) experienced a positive outcome. Patients involved in difficult encounters were less likely to experience a positive outcome (28% vs 46%; P = .02) than those not involved in difficult encounters. When stratified into quartiles, difficulty continued to be associated with an unsuccessful outcome, with the easiest encounters translating to a 53% success rate, versus 28% for patients involved in the most difficult encounters (P = .02). Difficult encounters were not associated with loss to follow-up. In multivariable analysis evaluating factors associated with difficultness, missing ≥10% of appointments (OR 0.69, 95% CI: 0.48–0.97; P = .04), non-organic signs (OR 0.42, 95% CI: 0.18–0.90; P = .03), visit taking longer than expected (OR 0.49, 95% CI: 0.25–0.96; P = .04), and refusal to try a treatment (OR 0.25, 95% CI: 0.08–0.70; P = .01) were associated with poor outcome.

Winnie L Liu, Evelien van Gelderen, Resham Mawalkar, Eric J Wang, Glenn Treisman, Steven P Cohen, Do difficult encounters affect pain treatment outcomes? A prospective cohort study, Pain Medicine, 2025;, pnaf027, https://doi.org/10.1093/pm/pnaf027