Part one of a two part series on caring for patients with chronic pain

With few exceptions, opiate therapy should be reserved for the short-term treatment of acute somatic pain due to tissue injury.

Patients with acute pain should be informed early on that once tissue healing starts, opiates will be discontinued and the goal of therapy will be to improve function.  The goal is not a painless life.

Opiates are an unfavorable option for those with chronic pain.  

Patients who cannot tolerate chronic pain may choose maladaptive substances, such as alcohol or tobacco, as a means of “chemical coping”.

Case:  A 45 year old man presents with chronic back pain.  Prior imaging reveals mild disc herniation.  He has tried epidural steroid injections and, over the years, has become a consumer of increasing doses of narcotics.

What advice can be given about the initial treatment of a patient with the acute onset of pain which is likely to become a chronic condition?  Patients with acute, somatic pain (such as a fractured ankle or vertebral disc herniation) may benefit from opioid therapy, in addition to anti-inflammatories and perhaps muscle relaxers, to treat the acute condition.  The tricky question is knowing when the acute phase ends.  Once the acute mechanical signs begin to resolve, which is usually in a few days, we need to start thinking about neuromuscular function and begin long-term planning.  This may include physical therapy with an endpoint of return to function, not a return to a painless life.

Total elimination of pain is often not possible with a significant injury.  If you try to completely eliminate the pain, the patient will be led down a dangerous road to overtreatment, loss of function and, eventually, drug dependency.

Chronic pain is when the nervous system goes haywire.  It is pain the lasts and persists longer than expected; it’s pain that is there when it “should not be”.  Somatic pain can be thought of as end-organ pain and neuropathic pain is more central.  With a somatic tissue injury, the peripheral and central pain receptors inform us using the sensation of pain.  Once the pain is relieved, the signal turns off.  In the situation of chronic pain, the organ for reporting and localizing pain is damaged and continues to fire, even after the somatic injury has resolved.

Is there a way to differentiate true pain from somatization, factitious disorder, or malingering?  There’s always a psychological component to pain, and in neuropathic or chronic pain, the emotional aspect can be greater than the somatic component.  A good history, physical exam, and proper imaging can usually determine the level of true tissue injury.  If there’s no physical evidence of trauma and no injury that can be found, the assumption can be made that the pain the patient is reporting is, at least in large part, psychological or neurological.  Somatizers who are not faking are the victims of their nervous systems exaggerating symptoms.  If you’re confident that the symptoms are manufactured or exaggerated, simply limit the acute intoxicating treatments and move quickly to the non-intoxicating pathways where the goal is to increase function.  In most cases, more narcotics correlate with less function.

What is the role of opioids in the treatment of chronic pain that is not related to cancer?  Opioids are an important tool and, like any treatment, can be used well or poorly.  An evidence-based approach to the treatment of pain can vastly minimize the over and under diagnosing that happens with most treatments.  Narcotics are necessary in acute pain and have a role in cancerous pain or ongoing tissue injury (such as severe arthritis).  In chronic pain, the longer the pain persists without clear somatic signs, opioids become less effective and more harmful.  Opiates are not benign substances, and their use is associated with loss of function due to side effects.  Chronic narcotic therapy contributes to sedation, lethargy, lack of engagement in physical therapy, and limited exercise.  It leads to poor socialization, isolation, and assumption of the sick role as pain patients.

Patients often get blamed for their opioid use.  But aren’t doctors in part responsible for opiate addiction, by writing the first prescription?  Patients need to be informed with the first prescription of narcotics that the longer they are on the medication, the harder it will be to get off of them.  As physicians, we are responsible for using the least dangerous, damaging, addicting medication for the shortest possible amount of time.  Patients must be educated about this at the beginning of treatment, and we need to let them know the medication will be tapered later.  It should not come as a surprise when we are no longer willing to be the prescriber of opiate therapy.  Patients should recognize from the outset that our goal is not the total elimination of pain and that, in order to recover long-term, they’re going to have to tolerate some pain so that they can continue to function.  In some ways, more discomfort equals more recovery.

Some patients are able to endure living with a degree of pain.  Others feel that any iota of pain is completely intolerable.  Patients who decide that they cannot live a life of pain will often get to a point where they’ve had enough.  They believe that they can’t tolerate anymore suffering and may become what’s termed a “chemical coper”.  They may find a substance or chemical that numbs their experience of life.  The substance is used to avoid and escape.  At this point, the condition is no longer medical; it is psychiatric.

Alcohol, tobacco, and marijuana are all substances that patients with chronic pain may use, hoping it will alleviate their discomfort.

Alcohol does not treat pain, but it is certainly used to escape reality.  It is dangerous when used in combination with opiates.  Heavy alcohol use leads to worsened symptoms the following day:  anxiety, depression, frustration, and increased pain.

Tobacco is used by many for chemical coping.  Like alcohol, it has no analgesic properties.  Nicotine is problematic in chronic pain for at least two reasons.  First, it damages the vascular system and interferes directly with healing.  Thus, tissue injury is not improving, nor will the pain.  Second, tobacco is a hepatic inducer, which increases the metabolism and breakdown of medications, including those prescribed to treat pain.  Therefore, this lowers the effective dose of painkillers.

Marijuana is complicated.  It can increase appetite and curb nausea.  There is some evidence that it can provide chronic pain relief.  The downsides to marijuana are that it impairs lung function, can increase anxiety and depression, and induce psychosis.  It also is constipating and is associated with deleterious cognitive effects.

To Be Continued in "Chronic Pain Part II"