Intractable Pain: Time To Understand and Use the Term (Again)
I have been hearing the term “intractable pain” (IP) to refer to patients with chronic pain more often of late. To me, it’s about time, as it conveys a simple, needed message—is the pain curable or incurable. Now is a good time to review the history and origin of this term.
In contrast to most pain terms developed by academics that describe the type (or cause) of pain, such as neuropathic, nociceptive, visceral, myofascial, the term IP was used by the Federation of State Medical Boards in 1985 when they created guidelines for the treatment of chronic intractable pain.1 In 1990, Texas and California both passed Intractable Pain Acts.2,3 In both states, physicians led the charge—C. Stratton Hill, Jr., MD, in Texas and Harvey L. Rose, MD in California. The motivation, jointly agreed to by legislators and practicing physicians, was to the make opioids available to truly needy and legitimate pain patients while protecting the prescribing physician from regulatory discipline (Table 1).
The definition of IP in the legislation of both states was “a pain state in which the cause of the pain cannot be removed or otherwise treated and which in the generally accepted course of medical practice, no relief or cure of the cause of pain is possible or none has been found after reasonable efforts.” This definition is mirrored in federal controlled substance regulation.4
My Own Definition
Following the examples of California and Texas, many states have adopted laws and regulations using the term IP. About a decade ago, I personally expanded the traditional definition of IP for my own patients, and began to educate others that IP patients are the most severe and needy of pain patients. To follow is my own definition:
“Pain that is excruciating, constant, incurable, and of such severity that it dominates virtually every conscious moment, produces mental and physical debilitation, and may produce a desire to commit suicide for the sole purpose of stopping the pain.”
Lack of Awareness
I am truly shocked by the number of physicians and other practitioners who prescribe opioids, but aren’t aware of their states’ definition, regulations, and legislation concerning IP. Very few opioid prescribers are aware that IP is defined in federal control substance regulations. I’m further shocked and dismayed that very few continuing education courses, conferences, and guidelines written by professional associations even mention the word intractable. Put another way, the most basic principle of pain management is whether the patient is intractable, incurable, and does or does not respond to standard therapies and dosages.
Alphabet Soup of Definitions
The alphabet soup of pain definitions, names, and descriptions is mind-boggling, and has overlooked the basic purpose and concept of IP laws and regulations. In my readings this past week, I came across these names in medical literature as applied to pain and its descriptions: persistent, acute, chronic, breakthrough, neuropathic, incident, spontaneous, nociceptive, central, referred, centralized, radiculopathy, allodynia, hyperalgesia, hyperpathia, dysaesthesia, myofascial, visceral, and lancinating.
All these clinical names are fine, but none of them clearly imply whether the patient’s pain is or is not curable. Recent controversies abound over the use of opioids in the treatment of chronic noncancer pain, as evidenced by the promulgation of treatment guidelines, restrictions of supplies (see article on page 50) and dosages, and the current epidemic of abuse, diversion, and overdose.
Lost in the multitude of writings and debates involving these issues, however, is the simple question, “Is the patient’s pain curable or incurable?” One of the first jobs of a pain practitioner is to determine and record this fact in a chart.
In the past 20 years, I’ve had the displeasure of reviewing an abundance of patient charts compiled by physicians who have regulatory, legal, or malpractice problems. The basic failing is almost always that nowhere in the chart is there a declaration of intractable or incurable pain, and the physician has simply attempted to prescribe treatment on purely symptomatic grounds. The original and basic concept of declaring a patient’s pain intractable is to allow the patient and physician to try non-standard treatments, including high doses of opioids, if warranted. Implicit in all the states intractable pain laws and federal regulations is that the physician must document intractable and incurable pain in the record, and show the patient has tried and failed standard therapies and dosages. Today, we’ve got plenty of agents to try before resorting to opioids and invasive interventions to treat pain, but the concept of a Patient’s Bill of Rights continues (Table 2).5
My message is straightforward. After you have described (or identified) the cause of pain (neuropathic, nociceptive, centralized, etc.), make a determination as to whether the patient does or doesn’t have an intractable (incurable) pain. Document this fact in the patients chart in clear language that even a 5th grader can interpret. Every prescription, report, and prior authorization should have IP noted on it, if applicable, to educate all concerned parties that the patient being treated is special and unique. Intractability and curability are far more important to patients, families, and regulators than to know if hyperalgesia or neuropathy is present.