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ould the way doctors, nurses, and other health care professionals measure a patient’s pain be contributing to the epidemic of opioid addiction? Indeed it could, says an article in this week’s New England Journal of Medicine.

Clinicians commonly use something called the pain intensity scale (see image above) to rate a person’s pain. It asks an individual to rate his or her pain on a scale from 0 (no pain) to 10 (worst possible pain).

The answer is often used to determine the “correct” dose of an opioid to reduce the intensity of pain. For individuals with chronic pain, especially those who have become dependent on opioids, getting to a lower pain intensity score often means increasing the dose — which can interfere with the ability to function, decrease quality of life, and may lead to addiction.

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An author of the new article and other experts weigh in on the pain intensity scale and what’s needed to better control chronic pain.

Jane Ballantyne: Look beyond pain intensity
Philip Pizzo: Almost a casualty of “undiagnosed” pain
Roger Fillingim: Safe alternatives to opioids are needed
Bakul Dave: Current path leads to frustration and addiction

By Jane Ballantyne: As my colleague Mark Sullivan and I explore in the New England Journal of Medicine, pain intensity may not be the best way to measure how well the treatment of chronic pain is working. What’s more important for people with chronic pain is their ability to function day to day and their quality of life.

For many people with chronic pain, keeping the pain intensity score low requires continuous or increasing doses of opioids. But this can worsen a person’s ability to function and his or her quality of life. It may also lead to opioid abuse, addiction, or even death.

The best way to treat chronic pain requires a multimodal approach that includes physical therapy, changes in behavior, medication, and strategies that help people accept pain. But physicians tend to resort to drug therapy because it is easy, it’s what they’ve been trained to do, and it’s the only thing they have time to do. Providing multimodal therapies in our current health care system is difficult. This is something we absolutely need to change.

“Self-management of pain is feasible and doable for many people. ”

Dr. Jane Ballantyne

Self-management of pain is feasible and doable for many people. That’s the norm in most countries. Ice, heat, stretching, yoga, tai chi, reading books, using the Web, cognitive behavioral “talk” therapy, apps for managing pain, and other approaches can help many people live with chronic pain. We need to make it the standard of care in the United States.

It’s unlikely that any quantitative measure will adequately capture how chronic pain affects an individual. The best way to do this is with a conversation between a patient and his or her clinician. This lets the patient be heard. It also lets the clinician appreciate the patient’s experiences and offer empathy, encouragement, and hope, all of which can go a long way to helping ease a patient’s pain.

Jane Ballantyne, MD, is professor of anesthesiology and pain medicine at the University of Washington Medical Center in Seattle.

By Philip Pizzo: A few years ago, I chaired the panel that wrote the Institute of Medicine report Relieving Pain in America, which has become the blueprint for the National Pain Strategy. As part of the information gathering component for this project, we listened to hundreds of people with chronic pain recount their stories. Little did I know that I would soon join their ranks.

As I wrote in a Perspective in the New England Journal of Medicine in 2013, I experienced a twinge of back pain when I lifted a suitcase. It soon evolved into pain so severe I couldn’t walk across a street. I tried everything — medication, physical therapy, deep-tissue massage, acupuncture — but nothing worked. Magnetic resonance imaging of my spine, hip, and pelvis didn’t show anything suspicious. Countless doctors were stymied about what was going on. Some of them even suggested that the pain was “in my head.” After 10 months of unremitting nerve pain, a unique diagnostic test called a neurogram showed a problem with my sciatic nerve — not in my back but deep in my pelvis. (It turns out I was born with an unusual routing of a branch of the sciatic nerve through the middle of a muscle called the piriformis.) Surgery was able to fix the problem. A week after the operation, my pain was gone and what had been gathering as clinical depression had lifted.

Had the unusual diagnosis not been made, I would almost certainly be one of the casualties of unremitting and “undiagnosed” chronic pain whose life would have been radically altered.

I tell this story because it brought home to me how far we still need to go to diagnose, treat, and prevent chronic pain. Treatment based on the pain intensity scale is fine, but there is so much more we need to do. Easing pain is an important goal, but so is helping people cope with pain.

“Easing pain is an important goal, but so is helping people cope with pain.”

Dr. Philip Pizzo

I strongly believe in adding alternative and complementary approaches to traditional medicine. But to do this we need a health care system that makes it easy for people to go beyond drug therapy and that adequately pays clinicians for making that possible. We need doctors who have the time to spend with patients and who have the knowledge to address their problems. Our current health care system (which is really more of a non-system) puts up roadblocks all along the way. We need better diagnostic tests and much improved therapies beyond opioids and related painkillers. Before that can happen, we need much more basic and clinical research related to the causes, diagnosis, management, and prevention of pain.

Nearly 100 million Americans suffer from chronic pain. We need to do more for them.

Philip Pizzo, MD, was the dean of the Stanford University School of Medicine from 2001 to 2012. He is now the founding director of the Stanford Distinguished Careers Initiative.

By Roger Fillingim: The New England Journal of Medicine article gets it right. By focusing so intently on pain intensity as an outcome measure, we have come to rely on passive treatments — like opioids — that have failed to deliver long-term improvements in quality of life while harming patients and society.

Thirty years ago, when opioids weren’t really an option for anyone except those with acute pain or cancer pain, we used a variety of techniques to increase the ability of our patients with chronic pain to function, decrease their psychological distress, and improve their mood and quality of life. If their pain intensity went down too, that was great, but it wasn’t the main focus of treatment.

The desire to relive pain is completely understandable. When I am in pain, the main thing I want is for the pain to go away. That’s what people with chronic pain want, too. Opioids can make pain go away, at least for a while. Keep in mind, though, that the increased use of opioids for chronic pain was based on their ability to reduce acute pain and cancer pain. In both of those situations, clinicians didn’t worry too much about long-term consequences — acute pain tended to get better on its own so opioid use was temporary, and people with severe cancer-related pain tended to die before concerns about long-term use came into play.

“Opioids … often require increasing doses to maintain the same level of pain control.”

Roger Fillingim

It’s a very different scenario for the 45-year-old ironworker with chronic low back pain. Opioids may work well at decreasing pain for a few weeks, but then often require increasing doses to maintain the same level of pain control.

A major problem here is the absence of useful alternatives to opioids for pain control, partly because pain research has not been a high priority. We spent more money on cancer research last year than we have spent on pain research in the last 20 years. If we are truly serious about managing chronic pain more effectively and safely, we need to get serious about investing in pain research.

Roger Fillingim, PhD, is professor of dentistry and director of the University of Florida’s Pain Research and Intervention Center of Excellence.

By Bakul Dave: Many doctors treat pain by trying to lower the patient’s pain intensity number, usually with medication. But there is much more to pain than that number. Pain is a complex state that emerges from the intersection of an individual’s physiology, genetics, psychology, culture, and more. We need to take these factors into consideration and address them whenever we can.

It is important to ask about things other than pain intensity, such as “How are you feeling?” and “Are you able to work, do daily activities, and sleep?”

There is no question that opioids effectively combat pain. But there are so many downsides to them. They can cause constipation, sedation, dizziness, and nausea, not to mention addiction. We need to find new pathways for treating pain that go beyond giving patients opioids. The path we are on now isn’t taking us anywhere except toward frustration and an epidemic of addiction.

Bakul Dave, MD, is assistant professor of anesthesiology and pain management at the Washington University Pain Center in St. Louis.

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  • Several threads of thought seem intertwined in this article, not all of them constructive or helpful. In the many years which I have served chronic pain patients as an advocate and community moderator, I’ve communicated with thousands who were referred by a medical doctor for “treatment” by a psychologist or psychiatrist in learning to manage their pain. Among this large population, I’ve heard from patients themselves that such measures most commonly operate “at the margins”. It is unusual for non-medication therapies to make a substantive difference in quality of life and function. By contrast, delays in the evaluation and use of medication may contribute to progression of both pain and the underlying conditions which produce it. Non-opioid medications such as the TCA drugs and NSAIDS can help some people, despite their own very real hazards (30,000 people die of Tylenol toxicity every year). But very often opioids are the ONLY measure which works, and in significant numbers of people, not even opioids work.

    Not mentioned in the article is the fact that large numbers of people display natural genetic factors which make them poor metabolizers of opioids. For many of these people, opiods can indeed work, but only at levels that might be said colloquially to be enough to “knock over a horse”. There are tens (perhaps hundreds) of thousands of people in the US who are stable and well managed on doses exceeding 200 morphine milligram equivalent per day. These people are being royally screwed over by efforts of people like Jane Ballantyne to deny them effective pain management.

    Also mistaken in this article is the idea that pain patients often become addicted to opiates because they “need” ever increasing levels of medication to control pain. While this can happen in a few cases, it is actually relatively rare. One prominent physician whom I interviewed at length is both a specialist in pain management and one of the founders of the American Academy of Addiction Medicine. He informs me that in over 40 years of practice he has never seen a case of hyperalgesia (opioid-induced hypersensitivity to pain) in any patient except those who use a pain pump for constant intrathecal delivery of opioid medication. Likewise, there are no generally accepted diagnostic criteria for hyperalgesia and no accepted protocol for treating it.

    So we all need to recognize that treatment of pain is a real medical crisis in America. Addiction is also a serious public health problem — but one which is not at all improved by denying pain relief to people in agony.

    Fair disclosure:

    I am not a medical doctor. I have volunteered time as an advocate and research analyst for chronic pain patients for over 20 years. I wrote a recent release of the NINDS Fact Sheet on Trigeminal Neuralgia, and most of the Wikipedia article on Atypical Trigeminal Neuralgia. I write widely on the crisis in US restriction of pain treatment using opioid medications, including a recent article on the American Council on Science and Medicine titled “The CDC Opioid Guidelines Violate Standards of Science Research.” [http://acsh.org/news/2017/03/25/cdc-opioid-guidelines-violate-standards-science-research-11050]

  • I have had pain in my knees and stiffness for years I would like to have something natural I take Hydrocodone right now that does not take care of it for you doctors don’t want to do surgery on my knees what is taking quality away

    • You really think surgery is the answer to every question?I agree with Richard and I see honest people..vets who have served for years and been hurt in the line of combat protecting this country and our way of life be denied treatment just because they read an article.So far as iv seen there is no real expertise on this.I served in the U.S. army for 9 years then became a mechanic…years of study.Maybe mechanics isn’t being a doctor but believe it or not we have to go to school also.I have been hurt many times in my life and as I grew older those older injurys crept up.Most of wich I had surgery to fix.That was the trend then I guess…My last surgery to fix my lower spine and left leg left me in far far worse shape then I was in BEFORE the surgery.I should have known better when the surgeon says to you “There’s no garautee this will help and may make the condition worse.” He was giving me a “not responsible if it don’t work”speach.I should have listened to him.Now in my early 40’s iv been thru 9 surgerys because I wanted to FIX the pain and the…limitations.Maybe I’m a minority hear but after having so many surgerys iv learned NOT to have surgerys!Surgery is something you should only have done if its life threatening or a guarantee to not have side affects…wich there is none.In the last 10 years iv watched my life get STOLEN from me!I cant do my job anymore…wich was also a hobby.Iv lost my livleyhood and been forced into disability because I cant stand up straight for more then 10 mins at a time without this stabbing cutting pain in my lower back pelvis.Its the side affects from the surgery.It wasn’t like that before.I don’t blame the surgeon for doing what I asked him to do…I blame the people making it IMPOSSIBLE for someone who is obviously medically hurt.Most of wich don’t deal with this problem themselves because I can promise you this right now if one of these people were to lose there lifes…and I mean that in the way of being able to have a decent normal life…because that isn’t possible for me now.Those people would switch sides VERY fast.Honestly all I see anymore is doctors who are SCARED to treat there patients since when has that been American!!!I could go on in great length on this because I live this every day and I have to find happiness and purpose in what life I have left…wich isn’t much.I run a website that helps vets cope with PTSD and gives them access to other vets who can better understand what they have been thru and ARE going thru now because yesterdays hero’s are todays VILLAINS!!That’s how we are treated anyway.Why is it that no one pays attention to the past btw?In the past a person could walk into a pharmacy and buy a large bottle of morphine over the counter.There wasn’t a damn epidemic then.The epidemic is coming from heroin and coke and all the illegal drugs.I hate that people lump me or anyone else who is on controlled pain medication into a regular heroin addict group…and that’s exactly what they do!When you go to your doctor you should feel relief right?I feel fear…not because I’m doing anything wrong..shit this is how I have to live my life if I want a life…wich I do!I fear that doctors are being convinced that they..or there patients are the problems and not the heroin dealers who get there product across the damn borders without fail!Why is the DEA focused on americans who are being monitored like there on parol instead of focusing there efforts on the HEROIN EPIDEMIC! don’t lump me into your numbers to justify your falures in doing your job.I wouldn’t want to be a DEA officer I imagine its not easy nor fun trying to do there job but to turn on the people there trying to protect…to make there lives hell to boost there numbers…wth is going on in this country?!and why aren’t more doctors standing up for there patients?I mean There are 3 major persons an individual trusts intimitaly there spouses there family and there DOCTORS!We have faith in you but because the government puts some pressure on you you fold?if I would have done that…if my platoon would have done that in afghanastan….or maybe world war 2 or Vietnam or any of the other wars we americans fight to protect our communitys…then there would be no America…there would be no doctors with bad opinions looking down there noses indignently at someone who is only there asking them to HELP them manage there life!I can handle my home life as best I can.I just need help from my doctor to get me thru the everyday agony I suffer.I feel for doctors I really do…but from the mind of a soldier I cannot understand it because I WASNT GIVEN THE OPTION TO TURN AND RUN!! I wouldn’t have even if offered!Thank you and sorry for the long post as I said I feel strongly on this topic because the doctors don’t realise that the medication is only one part of a persons life who has been railroaded by pain from axcidents or SURGERYS!God bless and take care.

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