Obesity and Chronic Pain: Monu Khanna, MD, on Breaking the Vicious Cycle

Chronic pain and obesity often go hand in hand, creating a cycle that complicates treatment for many patients. In this interview, Monu Khanna, MD, a board-certified obesity medicine and internal medicine expert, discusses how obesity exacerbates pain, the difficulties clinicians face in managing pain in these patients, and the complex balance between treating pain and avoiding medication-related complications. She emphasizes the importance of understanding these challenges to provide effective care for this vulnerable patient population. Watch the video above for more about this complex issue and how to approach it in your practice.

The following transcript has been edited for clarity, flow, and style.

Patient Care: How does obesity impact chronic pain conditions and vice versa?

Monu Khanna, MD: Obesity and chronic pain have a bidirectional relationship—they feed into each other. For example, patients with obesity carry more weight on their joints, which affects the cartilage and tendons, leading to arthritis and other cartilage issues. This, in turn, creates pain and inflammation. On the flip side, patients dealing with chronic pain are less likely to stay active, which often results in a more sedentary lifestyle. This can lead to emotional eating, where individuals turn to food for comfort. When we're stressed, we're more likely to reach for processed foods—quick fixes that contribute to weight gain. It's a vicious cycle, and that's why it's crucial to bring awareness to this issue. As clinicians, we need to understand the challenges of treating patients with obesity who also suffer from chronic discomfort and stiffness.

Patient Care: What challenges do clinicians face in managing pain in patients with obesity?

Khanna: Managing pain in patients with obesity is challenging for several reasons. First, many research trials on medications or non-pharmaceutical pain management strategies often exclude patients with obesity. If a patient has a certain BMI, they may not even be included in these studies. As a result, we lack a clear understanding of how medications work for patients with larger body sizes. Additionally, there's a constant worry about either under-treating or over-treating pain. Pain management guidelines often base medication dosages on ideal body weight, which can be vastly different from the patient's actual weight. This creates a situation where a clinician might start a patient on a certain medication dosage that isn't effective, leading them to increase the dosage. However, because the medication may be stored in fatty tissue, the patient could eventually reach a critical point, experiencing complications from the pain medications. Managing these patients carefully, and finding the right balance, becomes very tricky to avoid both under-treatment and complications from excessive medication use.