Pain management is in many ways the oldest specialty of medicine with evidence of pain control through use of naturally occurring substances many thousands of years ago. Serious pain usually accompanies (and sometimes continues after) healing of wounds and tissue injury including contusions, sprains, strains, bone fractures, lacerations, nerve compression, and the like. In other ways pain management is one of the very newest of medical specialties, carving an important niche with advanced “modern” tools to combat pain. The specialty has met with remarkable success in acute pain – to such an extent that there is virtually no reason why anyone with acute pain and access to a pain manager cannot expect good to excellent symptom control. This expectation was even codified by the U.S. Congress in the form of a somewhat unfortunate patient “bill of rights.”
But for CHRONIC pain…ahhh if it were only that simple. Attempts to use the same approaches as with acute pain conditions have often failed, and failed miserably in the long course. A prime example is the use of NSAIDs and opioids, two fantastically reliable drug classes for acute conditions, and in the early stages of more chronic conditions, but commence to spiral downward in efficacy as time drags on. NSAID intolerance in the form of gastrointestinal bleeding and perforated ulcers and even coronary emboli (Celocoxib), severely limits usefulness when applied for more than a few months. And once the need for opioid use has begun, NSAIDs fade into the background, and are usually and purposefully discontinued.
Opioids, the epitomy of a ‘double edged sword,’ are often prescribed for years for chronic pain patients with rather sparse evidentiary support for long term daily use from the medical literature. Tolerance is the inevitable concomitant, and serves to erode the pain relieving qualities of the very drug that worked so well initially. Dependence, meaning the development of withdrawal symptoms upon discontinuation, is also an expected concomitant even with very mild/low doses (but persistently consumed) opioids. Withdrawal is perceived by the patient as evidence of the usefulness of the opioid, when in fact this withdrawal pain is only partly the patients underlying pain, but largely a “pain inflation” induced by the lack of the drug that suppresses the pain.
It is easy to understand how spiraling doses of opioids for chronic pain develop, and yet also to understand the false sense of analgesia opioids provide in the chronic setting. This mechanism is hardly different from the use of beta blockers, diuretics, ACE inhibitors and other drugs for hypertension chrono/inotropic cardiac control. When the patient suddenly discontinues such medication, hypertension can quickly become malignant to the extent of precipitation of a life threatening event such as a stroke or myocardial infarction. This example serves to highlight one of the only positive features of opioid withdrawal….it is generally quite safe…supremely uncomfortable, but safe.
At PainCare, 70% of referrals are currently consuming daily opioids, the great majority on highly potent agonist opioids such as oxycodone, morphine and fentanyl. Such patients are referred because the “easy” treatment of the pain (opioids) has worn out its welcome. The primary care practitioner is no longer comfortable with the increasingly higher doses needed to defeat tolerance, and prescribing for ‘early outs’ (i.e. overuse). The patient then becomes our problem.
The very laborious solution to this quagmire, is to first gain the trust of the patient by continuing the regimen, then to [only] suggest a gradual wean from the opioid, then finally institute said wean. For a patient who firmly believes the opioid is “the only thing that works,” weaning is extremely difficult to institute and maintain and will often take months to years. This patient resistance can only be broken down through herculean efforts at education, counseling, and reassurance by the pain practitioner. At PainCare we find that at some point, a transition to buprenorphine is a most viable and valuable step. Buprenorphine is a very weak opioid, but an avid binder to opioid receptors. Due to the strong binding, the receptor remains occupied, thus alleviating the anxiety and physical (but largely emotional) stress of eliminating the beloved full agonist opioid (oxy, morphine, fentanyl) the patient has depended on for years. Patients who successfully make this conversion routinely feel alert, engaged with life, and are now responsive to physical rehabilitation and conditioning, occasional steroid injections, medication previously eschewed such as gabapentin, tramadol, tapentadol, and anticonvulsants. Again, the primary hurdle is establishing the degree of trust necessary to lead the patient toward this goal.
None of the above should imply that all patients will comply. There will always be those who take a drug for unintended purposes (e.g., sedation for a sense of well being over analgesia). If these patients have verifiable pathology that can generate the pain that is described, they can be extra difficult to identify and transition to more appropriate drugs to treat the underlying problem. Also, the above should not imply that some chronic pain patients are simply addicts. Many practitioners make the mistake of identifying all dependent opioid treated patients as addicts. While all addicts are dependent (have withdrawal upon cessation of their drug), not all opioid dependent patients are addicts. Most studies suggest that the small minority of patients with verifiable severe pain generators are addicted. That minority grows when patients with less severe pain generators are considered. It is therefore important that general practitioners of medicine not start full agonist opioids on patients with only modest evidence of pain generating pathology.
In conclusion, it is optimal for general practitioners of medicine to refer pain patients within a few weeks of continuous opioid use and allow the experienced pain practitioner to decide whether the patient requires subspecialist attention (ortho, neuro, etc.) or simple diagnostic injection with more specific definition of the pain generator, targeted physical rehabilitation with or without benefit of even temporary pain relieving blocks, viscosupplements for arthritic joints, radiofrequency lesioning of sensory nerves to pain generators, botulinum toxin for tight trigger points, spinal cord or peripheral nerve stimulation, etc. (i.e. the more advanced techniques).