I have been hearing the term “intractable pain” (IP) to refer to patients with chronic pain more often of late. To me, it’s about time, as it conveys a simple, needed message—is the pain curable or incurable. Now is a good time to review the history and origin of this term.
In contrast to most pain terms developed by academics that describe the type (or cause) of pain, such as neuropathic, nociceptive, visceral, myofascial, the term IP was used by the Federation of State Medical Boards in 1985 when they created guidelines for the treatment of chronic intractable pain. In 1990, Texas and California both passed Intractable Pain Acts(Table 1).
The motivation, jointly agreed to by legislators and practicing physicians, was to the make opioids available to truly needy and legitimate pain patients while protecting the prescribing physician from regulatory discipline
The definition of IP in the legislation of both states was “a pain state in which the cause of the pain cannot be removed or otherwise treated and which in the generally accepted course of medical practice, no relief or cure of the cause of pain is possible or none has been found after reasonable efforts.” This definition is mirrored in federal controlled substance regulation.
To follow is my own definition:
Pain that is excruciating, constant, incurable, and of such severity that it dominates virtually every conscious moment, produces mental and physical debilitation, and may produce a desire to commit suicide for the sole purpose of stopping the pain
Lack of Awareness
Very few opioid prescribers are aware that IP is defined in federal control substance regulations
the most basic principle of pain management is whether the patient is intractable, incurable, and does or does not respond to standard therapies and dosages.
Alphabet Soup of Definitions
All these clinical names are fine, but none of them clearly imply whether the patient’s pain is or is not curable
Lost in the multitude of writings and debates involving these issues, however, is the simple question, “Is the patient’s pain curable or incurable?” One of the first jobs of a pain practitioner is to determine and record this fact in a chart.
The basic failing is almost always that nowhere in the chart is there a declaration of intractable or incurable pain, and the physician has simply attempted to prescribe treatment on purely symptomatic grounds.
Today, we’ve got plenty of agents to try before resorting to opioids and invasive interventions to treat pain, but the concept of a Patient’s Bill of Rights continues (Table 2).
My message is straightforward. After you have described (or identified) the cause of pain (neuropathic, nociceptive, centralized, etc.), make a determination as to whether the patient does or doesn’t have an intractable (incurable) pain.
Intractability and curability are far more important to patients, families, and regulators than to know if hyperalgesia or neuropathy is present.