What is Intractable Pain and How Does it Differ From Chronic Pain – By 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.
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.