The scope of the problem
Chronic pain is a health epidemic. Estimates suggest that up to a third of adults or a hundred million Americans live with chronic pain conditions that interfere with their work and life. From back pain to headaches to diabetic neuropathy, chronic pain is widespread and debilitating. These patients suffer tremendously, and societal consequences are significant; back pain is one of the most common causes of missing work and prescription drug abuse is a consequence of our struggle to manage these chronic conditions.
Pain syndromes span a wide spectrum of diseases
Patients who come to a pain clinic include veterans with phantom limb pain after a traumatic amputation, women with fibromyalgia who cannot leave the house, business executives whose migraines debilitate them and those with end stage cancer. Pain syndromes result from brain injuries like stroke, nerve damage like complex regional pain syndrome, musculoskeletal problems, and psychological trauma, yet they all have a common end result: functional debilitation affecting every sphere of life. By the time patients see a pain specialist, they are at their wit’s end, exhausted, frustrated, angry, sad and scared.
Most physicians fear the “pain patient”
For most doctors, chronic pain is a red flag. The problem with pain is that it is mostly subjective; if a patient feels pain or says she’s in pain, then we must treat her like she has pain. Many pain syndromes, however, don’t have obvious or impressive objective signs. There aren’t blood tests, and imaging is imperfect; there’s no way to measure how bad someone’s pain really is. General practitioners may feel uncomfortable prescribing high doses or extended regimens of opioids simply because a patient says she needs them. As a result, many patients with legitimate pain conditions are undertreated.
Pain management requires a multidisciplinary approach
Specialists in pain medicine come from a variety of backgrounds including anesthesiology, neurology, rehabilitation, and psychiatry. As a result, they recognize the most important aspect of successful pain management: a multimodal approach. Most patients focus on medications, but physical therapy, psychology and interventions such as nerve blocks are equally important. When we see patients in our pain clinic, we de-emphasize the focus on getting a pain pill prescription. We try to understand how their pain affects their life, set achievable goals and engage our multidisciplinary team. For many pain syndromes, opiates are not as effective as physical therapy, cognitive behavioral therapy or surgery. As pain management has become more and more complex, specialists provide a critical approach in tackling this health epidemic.
When talking about pain management, we have to think about prescription medication abuse
While chronic pain has become more prevalent over time, abuse of prescription pain medications has followed. Although appropriate use of opiates allows some patients with pain to maintain a job and raise a family, opiate abuse can impair addicts dramatically. Both groups can develop tolerance, requiring higher doses, and both can demonstrate withdrawal so that abruptly stopping their medications leads to symptoms. Thus, differentiating the two can actually be quite challenging.
This problem has grown so much that prescription opiates are rivaling traditional street drugs like heroin and cocaine in the number of emergency department visits and deaths from abuse. The costs of addiction to our health care system and to society are significant. To curb this trend, we need to design pain medications with less abuse potential, provide addiction specialists to those who need them and train more pain specialists so that multimodal approaches, rather than opiate monotherapy, are used.
Managing pain is a focus of today’s medicine
Although it seems like doctors should have figured out how to treat something as basic and simple as pain, it is not that straightforward. Only in the last few decades have we started considering pain a “fifth vital sign” and turned our attention to treating it aggressively. For outpatients, successful pain management means controlling someone’s symptoms such that she can return to a productive and fulfilling life. For inpatients, appropriate pain control will help someone heal faster and leave the hospital sooner, hopefully leading to decreased health care costs. Nevertheless, there is still tremendous room for improvement and research.
Craig Chen is an anesthesiology resident. This article originally appeared in The American Resident Project.
