Intractable Pain versus Chronic Pain

What is Intractable Pain and How Does it Differ From Chronic PainBy Forest Tennant, MD, DrPH, John Liu, MD and Laura Hermann, RN, FNP – Aug 2017

Protocols for a lifetime of pain management for patients suffering constant, incurable, excruciating, unrelenting pain.

Since IP [Intractable Pain] patients always have an underlying, incurable disease or condition causing IP, their clinical management is complex and may require a specialized clinical setting.

Just as renal failure or insulin-dependent diabetes require lifetime care by a cadre of specialized medical personnel, IP likewise requires similar lifetime care due to its incurable nature.  

Who Is the IP Patient?

The authors define IP as

  • “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.”

Honestly, my pain is rarely excruciating, but the rest of the description fits well. Even “significant” pain can induce the problems listed without being excruciating (which, to me, means something like a broken bone with the ends tearing through the skin).

In the authors’ clinical experience, bonafide IP patients suffer profusely and are fundamentally bed- or house-bound in the absence of intense medical management

IP patients become identified as they systematically fail the usual treatments for acute and chronic pain including anti-inflammatory, mild opioid and non-opioid analgesics, antidepressants, muscle relaxants, and anti-seizure medications.

They also don’t respond well to corticosteroid injections in and around the spinal column or peripheral nerves.

Physical therapy, exercise, and psychological interventions have usually been to little or no avail because the pain is so profoundly uncontrolled that participation in these therapies is not possible.

Potent opioid lifetime therapy is the only treatment to date that has proved to consistently control pain in these individuals.

This treatment should be regarded as an end-stage or last resort due to its expense and inherent complications.

Obligation Of Documentation

Goals Of Treatment

Physicians should initially attempt to determine one opioid that family and patient report to be effective and prescribe this opioid in a dosage and frequency adequate enough to stop emergency room visits and allow the patient to ambulate, begin a proper diet, and attempt to return to normal activities of daily living.

The long-term goals are to help the IP patient become ambulatory and be able to leave home to shop, socialize, and possibly work.

Psychiatric conditions, particularly depression and suicidal tendency should be treated.

A good quality of life, to the extent possible with medication, is the goal — rather than an impractical one, such as withdrawal from all medication or seeking a “miracle” treatment or the elusive cure. Life extension and improved quality of life is clearly possible if IP is controlled.

Management of Baseline and Breakthrough Pain

A long-acting opioid is used to suppress baseline pain

Baseline pain is the constant, ever-present pain that is consciously perceived be the IP patient.

Despite the administration of a long-acting opioid, there may be breakthrough pain, which is temporary and has excruciating intensity above the baseline pain.

Breakthrough pain is treated with a short-acting opioid

Tolerance may occur to either long- or short-acting opioids. When this occurs, a rotation to a different opioid is necessary.

Opioid therapy should be continued indefinitely, including a lifetime — unless the underlying cause of IP can be markedly reduced or eliminated.

Detoxification or withdrawal should not be attempted unless IP is permanently and markedly reduced, otherwise IP will simply re-emerge following detoxification and force the patient to return to a bed- or house-bound, vegetative state.

Physical Therapy and Exercise

Once opioids control IP, the patient can begin measures to strengthen his/her musculo-skeletal system and hopefully reduce pain on a permanent basis.

Stretching exercises involving the afflicted anatomical structures that produce IP are essential. Patients should be taught stretching and strengthening exercises that they can practically accomplish each day for their lifetime.

Stretching seems to harmless that it’s recommended for all chronic pain. However, it can cause physical harm and greater pain for people who have connective tissue issues, like EDS.

Adjuvant Medication

In addition to opioids, IP patients will invariably require some adjuvant medication for such problems as insomnia, muscle spasm, depression, and attention deficit.

Though I’m diagnosed with ADHD, I experience a different kind of attention deficit when I’m in pain: constant interruption of my thinking by the jab of pain signals.

I’ve found that doing my daily walk is much “easier” if I listen to podcasts, but when the pain is bad, I can’t even understand them. Repeated stabs of pain “jerk the chain” of my attention so often I can’t remember one sentence before the next.

Topical analgesics are also especially helpful — with the following providing satisfactory outcomes: morphine, carisoprodal, aspirin, and dehydroepian-drosterone (DHEA).

I disagree because I haven’t seen evidence of significant pain relief from topicals when the cause of pain lies deeper in the body.

Hormone and Neurotransmitter Replacement

Testosterone deficiency appears very prevalent in males and females, so serum testosterone concentration should be determined.

The authors routinely determine serum pregnenolone concentration, since it is the precursor of all sex and glucocortioids, as well as being a neurotransmitter.

Research shows that IP over-stimulates the hypothalamus-pituitary-adrenal axis, which initially causes over-secretion of pituitary and adrenal hormones, but uncontrolled, chronic IP may also cause suppression of cortisol and other adrenal hormones which may require replacement for pain control, health maintenance, and proper immune function.

8 thoughts on “Intractable Pain versus Chronic Pain

  1. taylo138

    Ohio had an “Intractable Pain” law until 2018.
    Since politicians started practicing medicine, the law has been changed.
    Now, there is no differentiation between “Intractable Pain” and “Chronic Pain.”
    Both require treatment but the former law protected doctors and patients; now, the DEA is part of our treatment plan…

    Liked by 1 person

    Reply
    1. canarensis

      Sorry to hear that my birth state has gone so spectacularly backwards (like the rest of the country). At least I can claim to have moved out prior to 1979, so I don’t feel so responsible. Let us pray that sanity prevails…and very soon. And that someone, fa God’s sake, sits on the DEA & reins their insane, corrupt, evil butts in.

      Liked by 1 person

      Reply
      1. peter jasz

        ” …And that someone, for God’s sakes its on the DEA & reins their insane, corrupt, evil butts in.”

        That “someone” is called ‘The Court of Law’ -with sharp-minded lawyers defending the sanity, life, liberty of Americans, but also from the torture and agony imposed upon its Intractable Pain Patients. Lawyers must defend against such arbitrary and vicious ‘Crimes Against Humanity’.

        The days (years) of polite talk, suggestions, requests. pleading and begging is OVER.
        The disturbing delay of legal action (defense) is shocking and truly inexplicable. What an impotent system/society we have. What a travesty. What a shame …

        Can you, are you willing (and/or friends) to throw in $10-$20 for the ’cause’ ?

        pj

        Liked by 2 people

        Reply
        1. canarensis

          too true. Have you found an attorney with a spine that’s willing to take up the case? I’d donate, tho honestly I can’t do much (my version of “wild spending on luxuries” is a quart of ice cream per year or so, haven’t eaten out in 6 years, etc: barest of bare bones budget).

          I’m trying to find one in Oregon that’ll go after the incredibly inbred, conflict-of-interest bunch that’s dictating Oregon pain/health policy. Not going to start a go-fund-me until I find one, tho.

          Liked by 1 person

          Reply
    2. Zyp Czyk Post author

      A not just immoral, but possibly illegal, activity of the DEA since only States are allowed to regulate the practice of medicine, not the federal government.

      Like

      Reply
  2. canarensis

    “This treatment should be regarded as an end-stage or last resort due to its expense and inherent complications.” Is there a law now that states that everyone writing about opioids (even those promoting them) must include a statement about their dire dangers & complications? Most/nearly all are MUCH less expensive than the “harmless” non-opioid alternatives they throw at us, & I for one have never had any complications other than constipation…which I was literally born with, so can’t even call that a side effect or a complication.

    I love the comment about the quality of life being possible with medication, tho. If only we could get it in adequate, appropriate amounts for the amount of relief possible.

    As for topicals…it drives me crazy the way they’re being pushed, as if they’re effective & harmless.
    1. They don’t work much at all for most people.
    2. They are NOT without dangers: you can definitely get systematic side effects & “complications” even from topicals. I had a compounded topical with ketamine that made me so dizzy I literally couldn’t walk. Another, topical diclofenac, gave me the exact same bleeding/agonizing GI issues that the oral diclofenac did.
    3. Talk about expensive!!

    Liked by 1 person

    Reply

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