The way physicians treat chronic pain has evolved since I began treating pain while serving in the United States Air Force. Back in the mid 90’s we would prescribe copious amounts of opioids and non-opioids liberally mainly because we were informed that we did not do a good enough job in relieving pain. Before my time as a physician, we discovered better sedatives and hypnotics that we regularly and very frequently prescribed for anxiety (or neurosis as we coined it) and other forms of anxiety using mainly valium. Some of my professors and attending physicians were told that these benzodiazepines were harmless and did not cause overdoses or withdrawal. This information was relayed to us, the new budding doctors. This, of course, would turn out not to be entirely accurate. Anti-anxiety medications do help people if taken conservatively. Before organized medicine dominated the medical field (insurances, medical associations with examination boards etc.), morphine and codeine were prescribed for nearly anything. One could purchase, over the counter, cocaine and morphine derived products. Cough syrup with codeine mixed in could be had right down the aisle with no prescription and mothers would give it to their sometimes inconsolable children. Further back, how could we forget the leeches and bleedings therapy that we performed to treat, well, everything. Many did not survive our rather unscientific and desperate methods. But, unfortunately that was all we had in our doctor bags. There were no other known remedies. Now fast forward and we find ourselves in what is seemingly the golden age of “medical evidence based treatments”. No more leeches thank goodness (well some doctors still use leeches for some things but not me because I am afraid to touch them). It is very difficult keeping up with all the changes. In some instances physicians are allowed use non-evidenced based treatments for some types of pain but not so much like in the medieval days of early medicine. For example, we can use ketamine, a type of anesthesia that was first used in battlefield hospitals in Vietnam during the 60’s for major depression since the FDA has enthusiastically approved it for recalcitrant (hard to treat) major depression (off label). What about medicinal marijuana (yes that marijuana) for pain, seizures, anxiety, PTSD, and many other ailments. State governments have approved it for medicinal uses while the federal government is on the fence about it. Ever heard of magic mushrooms? The government is allowing research into a mushrooms active ingredient, psilocybin, for mental health issues. We have many arrows in our quiver or armamentarium to treat chronic pain. There is something for everybody these days.
Medications that doctors use to control pain can be naturally occurring in nature but changed so that humans can consume them (poppies “Papaver somniferous” where we get opium; coca leaves “Erythoxylon Cocaa” where we synthesize cocaine from). There are others. Of the synthetic or partial synthetic or laboratory made pain meds (oxycodone is a partial synthetic made from an opium derived chemical named Thebaine or fentanyl which is totally synthetic and very similar to morphine). This was a great idea until people began abusing and misusing them and gradually in some cases began dying from the misuse of them, like Oxycontin (we now have tamper or abuse a deterrent Oxycontin pill form which has decreased overdose deaths). But it could be that the limited prescribing of strong opioids by doctors and the new tamper proofing of the pill, hence, the scarcity of them on the street, we are now looking at a resurgence and abuse of heroin. Heroin prices have lowered to a fraction of the cost of designer drugs like oxycodone products, so we now again have a new heroin use problem. As if heroin use wasn’t bad enough or if it were not strong enough we are now fighting backyard chemists who synthesize the strongest synthetic opioid that we are aware of, fentanyl (and fentanyl analogs). Not impressed? How about persons getting their hands on elephant tranquilizers for injection! (One doesn’t have to inject it, just touch it or casually breathe it, which can be fatal). Finally, heroin is being mixed with fentanyl for injection. Fentanyl costs less than heroin on the street, so for a bigger profit, illicit drug dealers are leaving out the heroin and selling pure fentanyl. Fentanyl is embraced by addicted persons. Further, we are finding fentanyl that is shaped and colored to look like oxycodone pills adding to this very dangerous public health problem. I see the ravages of its use every day in my addiction practice. In this section on the treatment for chronic intractable pain, I will try to make sense out of the current state of various treatments for the pain. On my addiction page I discuss some treatments for illicit substance use.
Many physicians have discontinued treating patients with chronic pain using opioids. The reasons for this vary but essentially we physicians have been told (or it has been intimated) that “non-specialist or generalist”, of which I was at one time in my career, was not treating pain adequately. This may have been true. Training and specializing in treating chronic pain had been rare or nonexistent at some period in our medical training career. But studious physicians, those who found treating pain fascinating, went further in their education by specializing in Anesthesiology, or Physiatrist (physical medical and rehabilitation) who, among other things, treat pain both acute and chronic. A physiatrist is the top specialist with enough training to treat this human condition. But there are not many of them. That deficit left others to do what they could to help their patients to lower their pain and ease. Besides physical therapy and other modalities to treat pain, pharmaceuticals became a way to reduce pain allowing patients to improve and carry out their physical functions. The opioids were used for most cases with good and ethical intentions. But some opioids ended up in the hands of persons with the intention to sell them or use them to get high. These scenarios certainly contributed to our current opioid problem.
Opioids can be used for pain both acute and chronic. There are standards in prescribing opioids that we physicians are encouraged to follow (safe prescribing). But as you may have heard in the media or from family or friends that are prescribed them that they may, at times, be inappropriately prescribed. Some physicians may too liberally prescribe them and some are very conservative in their prescribing habits. Opioids should be prescribed by physicians knowledgeable in their use. Every physician should be expert in knowing at least one opioid thoroughly. There is special training in prescribing them, monitoring their use, and treating the complications of their use for both short term and if needed long term use. Long term use has been found to be not very efficacious, but may be the only option. Patients should be given an adequate dose to relieve the pain to a more tolerable level but only if they are going to be used properly and not given in too high of a dose. The high doses may help pain, but a smaller dose may help that pain. Besides, higher dose prescribing often lead to tolerance (but smaller doses may lead to tolerance as well). When tolerance begins to develop, higher and higher doses may be needed or requested by the patient, but this does not mean that higher doses must be used. Acceleration (increase) of the dose rarely leads to any place good (what goes up must come down). Again, increases in dosage may result from requests from the patient or from the physician’s observations of the patient’s needs. No one is wrong here. But when manipulating the dosage we must keep in mind the long term consequences of using opioids. Long term use of opioids always leads to some form of suffering in the patient’s life. Examples you ask? If opioids are used beyond a therapeutic level they may enter the lethal use zone. This level may cause problems with ones breathing (breathing is controlled by the brainstems’ RETICULAR ACTIVATING SYSTEM.) Let’s just say that opioids turns off the breathing drive. That’s the worst outcome. But I have treated patients who had overdosed and who did wake up after some period of time. They may have loss some bodily function. They may awake with Paralysis, awake but can’t speak, or awake needing a feeding or breathing tube for the remainder of their lives. Pain may resolve or go away after a surgical correction or just as a result of the healing process? Even though there is no longer a need for the opioids, dependence (not addiction) may/will have occurred. We give this state the term IATROGENIC or medical treatment induced dependency. When opioids are first discontinued, a WITHDRAWAL SYNDROME occurs. What happens is that the brain and the body will send signals that the usual blood level of the opioid is low after having maintaining a high level for a while. Signals are then sent to the body to do things to remind one that they need to take a dose to build up to the normal level in the blood again. The colon, having been dormant (sleeping on the job), will wake up and get things moving again. Cramps are the colons’ way of squeezing thereby pushing out the backed up stool suddenly (diarrhea). Diarrhea occurs in withdrawal. The parasympathetic nervous system begins to release or become very active again leading to nasal discharge and cold wet clammy skin and nausea and vomiting. There are more consequences of discontinuing opioids after prolonged use. After the initial or acute phase of withdrawal is over the second phase begins.
Stopping opioids may also leave one not feeling 100%. This may manifest as weakness, low energy, low motivation, almost like having a low level influenza (10% of the flu symptoms). We all have glands on top of our kidneys called adrenals. They are needed to help keep our bodies running at peak efficiency, described as “using only high octane gas” for a while and then using only low octane gas. This is the second phase after the acute phase of withdrawal or as Dr. George F. Koob discusses in his publication: Neurological circuitry “Homeostatic Dys-regulation” which begins the 3rd or 4th wave of opioid abstinence. Simply speaking the long term opioid user will have a long term syndrome of not feeling 100%. This may last for years.
We have arrived at a point from lightly regulated opioid prescribing to a now heavily regulated system for monitoring the distribution of opioids into society. We now know that there can be serious long term repercussions for long term opioid use. Further, short term prescribing has risks to society as well. I know that opioids can play a useful role in the treatment of moderate to severe pain, both acute and chronic. I believe that the ADDICTION MEDICINE SPECIALIST PHYSICIAN and one with board certification as a specialist in FAMILY MEDICINE can and should play a crucial role in treating this complicated patient population.
Can a pain free life be achieved?
It is unlikely that one with chronic pain will return to a premorbid (before the pain began) level or pain free life. That’s depending on the pathology (what was injured in the body) to begin with. Some chronic pain will seem to totally resolve. That may depend on the patient. The arthritis in my big toe is there but I rarely focus on it. It became background pain. But I don’t usually get visits from well healed patients so I can’t comment very much on them. My patients all have some type of pain complaint. Patients should know, up front that physician specialist cannot get the pain level from a level 10 (very severe pain) to a zero pain level. Achieving levels of 2 to 4 are more realistic. If we add cannabis, we may achieve another 20-30% pain relief, along with physical therapy may additional relief. The goal is to make it all add up to near total pain relief. But, it will all depend on the initial pathology. We have many modalities to treat pain. It usually takes a combination of different modalities- Pain meds, cannabis, acupuncture, chiropractic or manipulation, physical therapy, psychological counseling and spiritual thinking, and more. Treating chronic pain and complications of the chronic pain is complicated and takes a long time. Patience is required.