Intractable Pain – By Forest Tennant, MD, DrPH, John Liu, MD and Laura Hermann, RN, FNP – June 2018
Protocols for a lifetime of pain management for patients suffering constant, incurable, excrutiating, unrelenting pain.
The current thrust to humanely identify and treat pain is uncovering a group of patients with severe, chronic intractable pain (IP).
While epidemiologic surveys indicate that over 40% of the adult population has chronic, recurrent pain, mainly due to musculo-skeletal degenerative conditions, there is a sub-group of tragic individuals who suffer constant, excruciating, unrelenting pain.
Since IP 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.”
In the authors’ clinical experience, bonafide IP patients suffer profusely and are fundamentally bed- or house-bound in the absence of intense medical management.
A variety of traumatic and medical conditions may be the underlying cause of IP (see Table 2). Note that over half of them involve spine degeneration.
Common Characteristics of the IP Patient
Underlying Causes of Intractable Pain in 100 Consecutive Patients
IP patients become identified as they systematically fail the usual treatments for acute and chronic pain including
- mild opioid and non-opioid analgesics,
- 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
This obligation rests on the patient and/or caretaker as well.
The physician and ancillary clinical staff must carefully document the presence of IP on the patient’s chart.
Not only do most states require documentation for legal purposes, medical management of IP is a lifetime treatment that utilizes potent medication having potentially deleterious complications.
At a minimum, the documentation must include medical records that reveal the presence of an incurable, painful condition and unsuccessful treatment attempts with the usual therapies for chronic, recurrent pain.
Patients, together with family members or caretakers who are required to accompany them to their appointments, need to provide a detailed history of the onset of IP and subsequent failed treatment attempts.
A physical examination is directed toward identifying physical evidence of the cause of pain and neuro-muscular abnormalities that are fixed, incurable, and irremovable.
IP, in an uncontrolled state, will invariably demonstrate physiologic or laboratory abnormalities, since IP causes over-excitation of the cardiovascular, autonomic, and hypothalamic-pituitary-adrenal systems.
Common physical signs and symptoms include tachycardia, hypertension, mydriasis, hyperreflexia, anxiety, and depression.
Goals Of Treatment
Once the diagnosis of IP is established, both immediate and short-term treatment goals should be quickly established.
Often, the undiagnosed or under-treated IP patient is so ill and bed-or chair-bound that diet, ambulation, and hygiene have been severely neglected.
Some uncontrolled IP patients make frequent visits to an emergency room just to obtain a modicum of relief.
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.
Physiologic abnormalities such as tachycardia, hypertension, and altered adrenal hormone concentrations should be identified and serve as biologic markers to gauge treatment effectiveness
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
Baseline pain is the constant, ever-present pain that is consciously perceived be the IP patient. A long-acting opioid is used to suppress baseline pain.
I thank God my EDS hasn’t progressed to the point that my pain is absolutely constant. Instead it usually “only” only hurts when I move my literally falling apart body (EDS means all my tissues are loose and fragile) and/or subject it to gravity’s force.
Occasionally and for days on end, something gets torn or twisted in my abdomen and then the resulting visceral pain becomes constant until the situation eventually resolves itself.
The following medications are available for this task: methadone, sustained-release morphine and oxycodone preparations, and transdermal fentanyl
My variety of pain locations and causes lead me to need mostly immediate-release opioid medication, but often just the downward pull of gravity causes nerves to be pinched between some bodily structures, like vertebrae, and that pain lasts as long as I’m upright.
Once entrapped like this, the nerve will continue sending nociceptive signals even when I lie down because the surrounding muscles have been alerted and stimulated to contract in order to “protect” the painful area.
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 such as hydromorphone, hydrocodone, meperidine, or oral transmucosal fentanyl (see Table 3)