Ouch! Managing Chronic Pain

Opiate medications not the only option for chronic pain management.


Pain management is complex. But is it possible--or even desirable--to eliminate all pain?

Thomas H. Lee, MD, raised the question in a recent commentary published in the Journal of the American Medical Association.

Dr. Lee said that relieving pain completely is not possible in most cases and should not be the goal. Rather, the objective should be to increase the patient's functional capacity for work and other daily activities.

Dr. Lee is a cardiologist and the chief medical officer of the healthcare consulting firm Press Ganey. Press Ganey is a healthcare consulting firm specializing in quality and performance improvement.

The use of opiate pain medications (opioids) for chronic pain has increased in recent years. This prompted the Centers for Disease Control and Prevention (CDC) to issue new guidelines for their use. The CDC estimates that one in five patients who visit doctor's offices do so because of chronic pain.

Opioids include hydrocodone (brand name Vicodin), oxycodone (brand names OxyContin and Percocet), morphine (brand names Kadian and Avinza), codeine and similar medications. Opioids carry a significant addiction risk. Opioids can also be dangerous, especially when combined with sedative medications like benzodiazipines.

In a related commentary in the New England Journal of Medicine, Thomas R. Frieden, MD, MPH, and Debra Houry, MD, MPH, said that some studies indicate long-term opioid use doesn't relieve pain. Dr. Frieden and Dr. Houry are the director of the CDC and the director of the National Center for Injury Prevention and Control, respectively.

The CDC guidelines incorporate a number of strategies designed to minimize patient risk when prescribing opioids. The guidelines apply to treating conditions like musculoskeletal pain, not cancer.

Among these guidelines are establishing treatment goals with the patient. The CDC guidelines say doctors should use additional treatments like physical therapy, exercise and sleep management. Doctors should also monitor all patients on opioids, according to the guidelines.

Doctors should use the lowest possible dose and short-release rather than long-acting medications. They should be alert to the possibility of complications or side effects, and the potential for abuse of the medications.

Dr. Frieden and Dr. Houry said that the management of chronic pain is an art and a science.

"The science of opioids for chronic pain is clear: for the vast majority of patients, the known, serious, and too-often-fatal risks far outweigh the unproven and transient benefits,” the doctors said.

Dr. Lee said that there is, quite simply, no getting it right when it comes to pain.

"It is both undertreated and overtreated," Dr. Lee said. "It is ubiquitous, subjective, and sometimes feigned. Its experience is influenced by culture and varies among individuals, and its diagnosis easily distorted by bias.

"Clearly, giving sufficient analgesia to eliminate all pain for all patients is a wrong target, but so is treating pain insufficiently," Dr. Lee said.