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Lest We Forget Pain Treatment Is a Stepladder Approach

Editor's Memo from September 2012

Lately, I’ve spent a lot of time with laboratories that want to perform genetic and endocrine testing on patients taking pain medications. A rather amazing realization has dawned on me during these discussions. Most laboratories seem to have the false belief that pain treatment is a one-way, one-therapy endeavor that can be identified by a single laboratory test. In other words, they think, for example, that a specific cytochrome P450 defect or an abnormal serum corticotropin level calls for the selection of a single therapeutic agent. Incredibly, there is apparently a belief in some circles that pain practitioners have a long menu of therapies, and we just arbitrarily select a single treatment, such as an opioid or neuropathic agent, on a biased whim.

Let’s hope I’m exaggerating, but if I’m not, we need to put an abrupt stop to these false beliefs. Certainly, it appears to me we need to recall that pain treatment has always, when practiced appropriately, been a stepladder approach. Fundamentally, the system is one in which the least dangerous and safest treatments are used first and the treatment agents with known side effects, such as potent opioids, are used as a last resort. Apparently, there are practitioners who aren’t following this age-old system or there is the perception that some practitioners are not practicing a stepladder approach.1 For example, the Physicians for Responsible Opioid Prescribing (PROP) has been making the point that opioids aren’t being used as a last resort but as a first-line treatment.1 These critics have a point. The undersigned has just completed a review of some of the opioid prescribing guidelines published by various organizations in recent years.2 They are long on recommending how to use opioids but essentially fail to mention that they are a last-resort treatment to be used after all else has failed. Package inserts and the Physician’s Desk Reference state that opioids are to be used for moderate to severe pain, but these government-approved documents don’t mention that opioids are the last step in the system. Even the new FDA Risk Evaluation and Mitigation Strategy for long-acting opioids doesn’t mention that they are to be a last-resort treatment.3

The oldest protocol document that I recall was the World Health Organization’s guidelines for cancer pain. It was simple, but still generally applicable today. The first rung in the stepladder approach was anti-inflammatory agents followed by weak opioids. Only if these measures did not work did one go to the last step, which are potent opioids. Also, lost in the movement are the spirit and intent of intractable pain laws and guidelines adopted by many states. Fundamentally, the definition of intractable pain is “a pain that is incurable by any known means.” The spirit and intent of these laws were to document that some set of treatments were attempted and failed before opioids were prescribed.

It may be that the stepladder system has been somewhat forgotten due to all of our new treatment agents and modalities. For example, the entire concept of neuropathic agents, which are neither opioids nor anti-inflammatory agents, is only about a decade old. We’ve also had a lot of corticosteroid injections and electromagnetic innovations. All these new modalities are terrific but you don’t hear much call to use them before opioids are tried.

It is hoped that all who read this memo would attempt to re-instill the age-old practice of a stepladder approach in pain treatment. Every pain practice needs to develop a formal or informal protocol so that the safest, effective pain treatment measures are used before treatment agents and modalities with clear complications are considered. Look for Practical Pain Management to recommend some protocols in future issues. One last point: stepladder protocols are not intended to withhold treatment or make any patient suffer. On the contrary, we clearly know that severe pain has serious and life-threatening complications on its own, so pain must be controlled. And it just so happens that some patients will go through the entire stepladder system and need all the help our most potent treatment agents, including opioids and despite their complications, can render. Our job is to relieve pain and suffering and let an informed patient decide whether benefits of a treatment agent outweigh the risks.

Last updated on: October 4, 2012
First published on: September 1, 2012