There was a time in our history that treating even cancer pain with opiates was considered risky. The Journal of the American Medical Association in 1941 strongly recommended against this practice due to fears of causing addiction. It has taken many years to liberalize the use of opiates in the treatment of cancer pain. There have been even more barriers for using these agents for non-cancer pain treatment. In the late 80′s and 90′s, there was a trend toward increasingly utilizing opiates long term for non-cancer pain. The previously held belief that these would always cause addiction was challenged. The number of specialists treating chronic pain increased during this time as did the number of medications to choose from. There was a very large study quoted over and over, showing that the rate of addiction was minimal when treating non-cancer pain with opiates. In retrospect, the study population in no way reflected the chronic pain population receiving chronic opiate therapy. This study proposed that the risk of addiction was less than 1%, but the evidence was based on the treatment of acute pain, and the study did not extend very long. On the face of it, the professional community should have questioned how the addiction rate would be less than the expected addiction rate for the population as a whole.
Therapy during this time was often adjusted to try to bring down the pain rating number reported by the patient, 1-10. Unfortunately, many times this number would not move in spite of significant increases in medication. This was partly due to the person becoming tolerant to the medication, and partly due to the inherent weakness of self reported numbers to measure pain. We now focus on functional improvements to help determine appropriateness of medications. Imagine if we were to have to treat blood pressure problems without being able to directly measure it. The patient would report that they thought it was high due to pounding in their temples and having a headache. The physician might respond that they did not think it was high because the patient’s face was not flushed. The matter is of course settled by the application of a blood pressure cuff and an objective measurement. Pain is subjective in nature and the experience of pain is incredibly interwoven in the meaning it has for the individual, based on past and present.
We in the medical field often unknowingly train people to use a higher number to rate their pain. If the patient reports an 8/10, there typically will be a treatment to address this. If they report 4/10, the practitioner may think that is good and not do anything, whereas the patient is not happy with 4 at all. The next time, for the same amount of pain, the number will be reported higher. This is sometimes subconscious, but is certainly understandable.
In the past few years, prescription opiate abuse has markedly increased. News of Oxycontin abuse, with details of various routes of administration shown in the media contributed to this. There is a perceived safety by the abuser due to the medications being well defined in their appearance, bearing a stamp on each pill. As the trend toward more active prescribing for pain occurred, the amount of opiates in the community increased. Access increased. Unfortunately, this has led to regulatory concerns that may lead to access problems for those that really need these medications for best control of intractable pain. The DEA, FDA, and medical specialty societies are working to try to balance the somewhat conflicting goals of control of opiate abuse and the optimal treatment of pain under a physician’s supervision.
An additional problem with opiates has been recently recognized. When taken long term, they seem to lead to hypersensitivity – hyperalgesia. For instance, someone could have been treated for a few years for pain related to an ankle fracture that didn’t heal right, and eventually develop total body pain. Instead of going up on the pain meds, the better therapy would be to go down and maybe off the meds when this occurs. The problem is that there is no test to determine whether this is what has caused the total body hypersensitivity.
So, what do we do now. We proceed with caution. We follow what has evolved as best practice and follow the developments in our specialty closely.
Keys to success:
1) A thorough evaluation with a secure diagnosis
2) Preferably exhaust more conservative measures
3) Risk stratification for possible substance abuse
4) Opiate agreement with informed consent
5) Regular and relatively frequent office visit followups (often monthly)
6) Urine drug screening to assure compliance
7) Careful adjustments with reassessment
8) Incorporation of other physicians/ team members as indicated.
Through the above, pain specialists are able to use opiates still for non-cancer pain. They are only a tool, and should be used in the setting of a comprehensive treatment plan that employs other modalities as well.
Ed McCluskey, MD
Pain Relief Specialists Northwest
www.prsnw.com
Great job, Ed. Congratulations!