Treating patients with pain: how to make it less painful

KEYWORDS:

• Pain
• psychology

When I lecture about pain to large groups of health-care providers, I begin by asking the audience, ‘Please raise your hands if you care for people with pain’; virtually everyone raises their arm above their head. I then go on, ‘Please keep your arms raised if you enjoy taking care of patients with pain’; one can almost hear an audible whooshing sound as everyone adducts and internally rotates their arms to their sides, which is quickly followed by the audience’s craning of necks, and then chuckling. Yes, it is a rather sophomoric attempt to endear myself to the audience and illicit a cheap laugh, but it also serves to acknowledge that taking care of patients with pain can be extremely challenging. However, I go on to tell them that by the end of the session, while I can’t promise that they will ever truly enjoy taking care of patients with pain, they will have more tools in their armamentarium, make better clinical decisions, and will be less likely to cause patient harm. Personally, I now enjoy the challenge.

As eloquently elaborated by Dr. White in this edition of Postgraduate Medicine [1], physicians trained in the traditional biomedical model and practicing in an environment in the late 1990s and early 2000s where ‘pain as a fifth vital sign’ was being enforced and opioid pain medications were being heavily promoted by the pharmaceutical industry frequently fell into the trap of initiating opioid medications, often maintaining them for prolonged times, sometimes with escalation of doses, despite the lack of any proven benefit for long-term non-cancer pain reduction. Needless to say, before long, our country was in the depths of an opioid epidemic and crisis. Luckily, the medical profession and society, at large, have recognized this maelstrom, and rates of prescriptions for opiates started decreasing in 2012; the rate accelerated after the CDC guidelines for prescribing opioids for chronic pain were released in 2016 [2].

However, death rates from opioids increased from 1.0 per 1000,000 in 1999 to 4.4 per 100,000 in 2016 [3] and even as the non-prescription use of opioids decreased after 2012, the use of heroin has markedly increased, as opioid abusers find it increasingly difficult to procure prescription opioids and use the more readily available, cheaper, and more powerful opioid, heroin [4].

While there has been legislative and regulatory action to curtail opioid abuse, in my opinion, less emphasis has been placed on what we can or should be doing for patients suffering with pain, both pharmacologically and non-pharmacologically. Regarding medications, we should consider employing more of ‘sequential rational polypharmacy’; we know that many different medications act at different points in the pain pathway, so some medications will act peripherally, some medications act at the level of the spinal cord, and others act in higher brain centers. For example, non-steroidal anti-inflammatory drugs, lidocaine, and tricyclic anti-depressants work peripherally, tricyclic anti-depressants and gabapentin act on the spinal cord, while serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, tapentadol, and tramadol work on CNS modulation [5,6]. Therefore, if we sequentially combine medications active at different sites, we may find that we get better analgesia at lower doses, and by using lower doses, we may avoid some of the more bothersome adverse effects.

In elaborating upon what we can/should do for patients with pain, while I started discussing pharmacotherapy, I cannot emphasize the importance of incorporating non-pharmacologic therapies, such as patient education with respect to chronic pain, improving patient self-efficacy and self-management, and involvement of a multi-disciplinary team, which may include a pharmacist with expertise in pain management, and practitioners of psychology, pain management, physiatry, physical therapy, social work, chiropractic medicine, acupuncture, and psychiatry. In fact, sometimes effective use of these modalities may obviate the need for attendant pharmacotherapy. There is ample evidence that acupuncture (including both whole body and auricular acupuncture), chiropractic manipulation, tai chi, yoga, aquatherapy, physical therapy, low-intensity exercise, and behavioral treatments such as cognitive behavioral therapy, mindfulness, meditation, deep breathing exercises, and progressive muscle relaxation can also be beneficial in pain [7]. Personally, I have been astonished by the success of an early learned form of auricular acupuncture, battlefield acupuncture, which is easy both to learn and use in practice [8,9]. Additionally, chronic pain can be influenced by a multitude of biopsychosocial factors, including poor sleep, poor nutrition, stress, depression, and environmental exposures [10] and these factors should also be addressed. Sometimes devices or more invasive techniques including trigger point injections, targeted corticosteroid injections, transcutaneous electrical nerve stimulation units, Botox injections, and others can also be beneficial.

As you can see, the list of non-opioid modalities to treat pain is legion and therefore practitioners looking for publications in prestigious, peer-reviewed articles to practice strict evidence-based medicine will not find easy answers. It would be impractical and nearly impossible to study every possible combination of therapies for every possible type of patient and their particular type of pain. While studies such as one in this journal [11] are important contributions, they must be incorporated into a rational, proactive, personalized, and patient-driven plan utilizing whole health and incorporating self-care [12].

It would be disingenuous of me to imply that I never have to resort to prescribing opioid medications. However, there are so many non-opioid options, either alone or in combination, that rarely do we need to write for long-term opioids in non-cancer pain. By both having a facility with these therapies, and more importantly, connecting with the patient and understanding his/her functional goals, we can we more safely and effectively reduce the burden of pain. We must remember that according to that often-quoted personality, Anonymous, ‘Pain is inevitable, but suffering is optional.’ This applies to both to our patients and the health-care providers attending to their needs.

Declaration of interest

The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. Peer reviewers on this manuscript have no relevant financial relationships to disclose.

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Funding

This manuscript was not funded.