Chronic Pain Patients Who Fail Standard Treatment
Patients who fail, or receive minimal relief from, standard pain treatment represent a unmet medical need.1 Despite receiving standard treatment for moderate-to-severe pain, as outlined by the World Health Organization, some patients are unable to adequately function, carry on activities of daily living, or have a decent quality of life. As a consequence, such patients often seek treatment alternatives, higher opioid dosages, and/or remain reclusive at home and in bed. A recent survey of 40 consecutive patients referred to the author due to failure of standard treatment, including potent opioids, found that the patients collectively had consulted 461 physicians, 172 pain specialists, 104 psychologists or psychiatrists, and 23 university centers without finding any sustained pain relief.2
Fortunately, new diagnostic tools that recently have become available to objectively study patients with chronic pain might help practitioners develop effective treatment strategies for these patients. Part 1 of this 2-part series will describe the author’s protocol for the diagnosis and evaluation of patients who have failed standard pain regimens and the therapeutic strategies he has used to help a great majority of them regain a better quality of life.
Although the diagnostic evaluation and treatment strategies presented here are in a very early stage of development and undoubtedly will improve, the need to address failing patients is urgent. Consequently, this report describes the author’s attempts to deal with this problem. Part 2 of this series will outline the treatment strategies that have been developed to assist them.
What Is Standard Treatment?
The long-standing standard of pain treatment is the 3-step analgesic ladder developed in 1982 and adopted in 1986 by the World Health Organization (WHO).3 Although originally adopted for cancer pain, and despite many new treatments, approaches, and suggestions to modify the 3-step ladder, it remains the standard treatment approach for treating chronic pain, including cancer-related pain.4 The WHO pain ladder (Figure 1) describes pain in terms of intensity and recommends that analgesics be prescribed starting at Step 1 (nonopioid analgesics, such as acetaminophen or nonsteroidal anti-inflammatory drugs [NSAIDs] with or without adjuvant therapy). If the pain persists or worsens, the clinician prescribes pain relievers from Step 2, described as “weak opioids,” with or without a nonopioid and with or without adjuvant therapy. At this point, if pain persists or worsens, the patient is administered a “strong opioid,” with or without a nonopioid and with or without adjuvant therapy (Step 3). Thus, pain therapy is based on pain intensity and patients progress through the steps one by one, from lowest to highest, until pain relief is obtained. The terms “weak” and “strong” opioid are rarely used today. The WHO pain ladder lists codeine, hydrocodone, and tramadol as “weak opioids,” and morphine, oxycodone, methadone, hydromorphone, and fentanyl as “strong opioids.”4
Pain treatment failure occurs when the third step of the treatment ladder is not enough to adequately control pain. For the purposes of this paper and the patients described here, I provide a more detailed description of the WHO third step: “A prior and/or current regimen of nonpharmacologic measures such as physical therapy, electromagnetic, or psychotherapy and multiple pharmacologic therapies that may include anti-inflammatories, antidepressants, neuropathic (antiseizure) therapies, topical analgesics, corticosteroid injections, and a daily opioid dosage of 100 mg or more of morphine equivalents.”3
Recognition of Failing Patient
The physical, emotional, and economic impact of poorly controlled pain is well documented.5-12 Patients with inadequately managed centralized (neuropathic) pain often exhibit a common behavior pattern (Table 1). They complain of inadequate pain relief and demand more medication. This sometimes causes the pain practitioner and his or her staff to label such patients as “drug seekers,” “addicts,” or “difficult.”1 In reality, these patients might actually need more medication (or a change in medications). Patients with chronic pain who are not receiving adequate pain control often will present ahead of their scheduled appointments, frequent emergency rooms, and see more than one physician.2 These patients often lose their jobs, social contacts, and former way of life.5-12 They usually become reclusive and are housebound or bedbound. Proper hygiene, nutrition, and social contacts diminish, and patients and their families might develop hostile, angry demeanors, often directed at the pain practitioner.1 Severe uncontrolled pain can seriously impair attention span and memory, so patients might miss appointments or other instructions, causing them to be labeled as “non-compliant.” Rather than pejoratively labeling these patients, practitioners should consider them treatment failures and evaluate them accordingly.
New Diagnostic Developments
Several scientific developments recently have occurred that make it possible to objectively evaluate the chronic pain patient who is failing standard treatment. The first is the understanding of pain centralization.13-16 Referred to by various names, including neuropathic pain, central pain syndrome, central sensitization, or chronic pain syndrome, the basic pathology is the same—microglial cell activation, neuroinflammation, cellular destruction, and implantation of pain sensation in the cells of the central nervous system (CNS).13-16 Centralization of pain can occur from:
- direct injury to the brain, such as trauma, infection, or stroke,
- disease processes, such as fibromyalgia, multiple sclerosis, migraine, etc.
- peripheral nerve injury or disease that activates both a CNS and peripheral disease process.13
Regardless of the initial cause of the injury (pain event), microglial cells in the spinal cord and brain become activated, resulting in neuroinflammation, metabolic disturbances, and tissue destruction by phagocytosis.12-14 Typical clinical manifestations are constant pain, insomnia, fatigue, depression, mental impairment, allodynia, hyperalgesia, and excess sympathetic discharge.13,15 These manifestations make it possible to clinically determine if centralization has occurred, as has been seen through recent magnetic resonance imaging (MRI) imaging of the brain.15