The “right” goal when managing pain – Harvard Health Blog – Harvard Health Publications | Harvard Health Blog | December 18, 2015 | Robert T. Edwards, Ph.D.
It makes sense that the primary goal of pain treatment should be to reduce pain. However, a recent editorial in The New England Journal of Medicine makes a strong case for looking beyond pain intensity when evaluating what is “successful” pain management.
I posted my objections to this in “Intensity of Chronic Pain — The Wrong Metric?“
However, beneath the rhetoric and propaganda of this editorial, there lie some important aspects of dealing with pain that are too often overlooked, like the importance of having access to appropriate multimodal treatment, including opioid therapy.
Additionally, this article repeatedly stresses the need to tailor pain treatment to the individual. Ironically, this is the perfect argument against proposed treatment standards, like the CDC guidelines.
The “balancing act” of managing chronic pain
Here is the problem:
- For people with chronic pain, the pain affects nearly all aspects of their lives.
- But at the same time, treatments to relieve chronic pain also have the potential to influence many aspects of a person’s life.
This means that, if we prioritize pain reduction over every other outcome, we may wind up doing as much harm as we do good
In a narrow sense, this is possible, though highly unlikely. But, it can be just as true for some of the alternative treatments suggested, which can have their own harms.
Pain reduction is intended to make people more functional, and this, more than simply “comfort level”, is the goal of opioid therapy. Accomplishing maximum functionality will determine how high a dose of opioids is appropriate for an individual:
Too high a dose could result in
- compromised mental function
- overwhelming fatigue
- unmanageable constipation
- feeling “zoned out”
Too low a dose could result in
- poorly controlled pain
- inability to focus or concentrate
- inability to do even mildest exercises like walking
- damaging levels of stress
- damage to relationships
- excessive irritability and anger
- becoming housebound
- dependency on caregivers
- psychologically damaging emotional distress
- too much inactivity
- inability to socialize
Patient surveys also show that people with chronic pain care about more than just experiencing less pain.
Of course! They care about the things that experiencing less pain enables them to do.
Lowering pain is the prerequisite for being able to participate in life and enjoy the benefits they list:
They [patients] care about
- enjoying life more,
- having a strong sense of emotional well-being,
- increasing their physical activity,
- improving sleep and reducing fatigue, and
- participating in social and recreational activities.
These are exactly what I get when my pain is reduced by opioids. When I lived without opioids for a few months, these were exactly the aspects of my life that I lost.
These goals need to be balanced against the downsides of pain treatment.
How the benefits and harms stack up is entirely personal and will vary from patient to patient.
This is exactly the point: no two patients will have the same cost/benefit ratio, so opioids must be prescribed on an individual basis and should not be governed by a bureaucratic entity like the CDC.
For some people, the risk of abuse is small, the side effects are minor, and the drug reduces their pain by a lot. For others, these drugs reduce pain only a little, while the fatigue and cognitive side effects are so bad that it is hard to carry out routine activities like driving or going to work.
Again, this emphasizes the need for individually tailored pain treatments, not just a simple semi-ban on opioids.
The editorial’s authors also suggest that pain-management treatments that are not just individualized but also multimodal (that is, they combine several different therapies) may produce the largest benefits with the fewest harms. A strong foundation of scientific research supports this position.
I believe most pain patients would agree that we need access to multimodal treatment, but this means not just being prescribed such treatments, but also finding them affordable. For some of us, opioid pain medications are needed just to participate in multimodal treatments, like PT and exercise.
Even in the midst of this “opioid crisis”, as patients are pressured to use multimodal treatments, there is no corresponding pressure on insurance companies to provide benefits for this treatment.
How is that supposed to work?
The “success” of pain treatment is very individual. So you can’t assume that what you read online or hear from other people (for example, “drug X is great, you should try it” or “drug Y is terrible, why would anyone prescribe this”) will represent how a drug will work for you.
Rigid standards of treatment and prescribing
are inappropriate for pain management.
The field of pain management needs a lot more research to determine which patients are more likely to benefit from a given treatment.
categorizing, known as “phenotyping,” would provide a foundation for personalized pain management that, ideally, would improve the clinical care of people with pain and minimize treatment-related harms.
Over all, I believe that combined therapies that not only reduce pain but help meet quality-of-life goals—along with a renewed focus on individualized treatment—represent important advances for the field of pain management and are critical steps toward more effectively fulfilling our duties to suffering patients.