Could 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.
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.”
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.