History of Pain: The Treatment of Pain
“The stronger person is not the one making the most noise but the one who can quietly direct the conversation toward defining and solving problems.”
—Aaron T. Beck, MD (1921- ), Founder of Cognitive Behavioral Therapy
I have a strong conviction that the best treatment of chronic pain encompasses a multidisciplinary approach—not an either/or option. Clinicians should not treat chronic pain just medically and then only refer the patient for psychological treatment if medical treatment fails. This is the worst-case scenario for the patient because the patient will interpret that scenario to mean, “my pain must be all in my head.”
This conviction evolved over my 25 years of practice, during which time I have been fortunate to work with excellent surgeons and pain management physicians.1-4 Twenty years ago, I was invited to join a small, select group of spine surgeons to form a website. At that time, the World Wide Web was just beginning and we had no idea where this endeavor would go. Today, SpineUniverse.com, a sister website to Practical Pain Management, has over 200 distinguished faculty members as contributing editors and receives over 5 million visits per year.
My experience as a pain psychologist at the Oregon Health & Science University (OHSU) Multidisciplinary Pain Program also taught me to appreciate how various disciplines can work together to provide optimal pain treatment. While at OHSU, I was appointed to sit on the Institutional Review Board (IRB) for 6 years. Because the IRB is responsible for evaluating and approving every research protocol involving human subjects within the medical school, this experience was extremely valuable in honing my critical thinking skills needed to evaluate research methodologies. And perhaps most importantly, I have acquired critical knowledge from my many patients as to what treatments have been helpful. These experiences inspire me to share my thoughts and opinions on the treatment of pain.
The Scope of Pain Treatment
Because the scope of pain treatment is so extensive, I have divided this review into 2 major sections:
I have omitted many adjunctive and alternative therapies that are equally important in the overall treatment of pain. The most notable omissions are physical and occupational therapies. The value of both of these therapies from a multidisciplinary approach is well documented and I highly recommend them.
When I discuss treatment options with patients, I use the metaphor of a toolbox. I explain that each provider will offer pain management tools for the patient’s toolbox. These tools are not mutually exclusive; they are additive. The more tools in your toolbox, the more effective you will be in managing your pain. Some tools may be invasive, pharmacological, or behavioral, and they all are equally important. I point out that there are no “silver bullets.” These therapies are not necessarily curative, but if the patient is willing to work hard, they will achieve more control over their chronic pain and an improved quality of life.
We begin with the World Health Organization (WHO) pain ladder, which was first published in 1986 (Figure 1).5 This widely accepted approach to medication management has 3 successive rungs (steps), from Step 1 to Step 3. The ladder describes pain in terms of intensity and recommends that an analgesic be prescribed starting at Step 1 (non-opioid analgesics including non-steroidal anti-inflammatory drugs [NSAIDS] and aspirin). If the pain persists or worsens, the physician should prescribe analgesics from Step 2, including “weak” opioids, including schedule II opioids such as codeine, with or without a nonopioid or adjuvant therapy. Step 3, reserved for patients with moderate to severe pain, calls for the use of “strong” opioids.
In my opinion, pharmacological approaches to pain treatment can be appropriate adjunctive tools if the prescribing physician is familiar with the patient’s history of pain, type of pain, pain medications, and contraindications related to the patient’s pathology.
I have worked with many prescribing pain physicians who feel that schedule III opioids are not appropriate for long-term care. One pain physician I work with requires a psychosocial evaluation before prescribing opioids long-term. As a practicing pain psychologist who provides adjunctive behavioral treatment, the requirement of a psychosocial assessment appears prudent, but it is not a universally accepted approach. From a practical treatment approach, it makes sense if you know your patient’s psychological profile before you enter into a long-term relationship of opioid prescribing. On the other hand, it may not be feasible in rural areas where pain psychologists are scarce. As pain psychology matures and more pain psychologists become available, I can foresee a requirement of a psychosocial evaluation becoming the rule and not the exception.
Aspirin (salicylate), acetaminophen (Tylenol, others), and NSAIDS are the most common analgesics represented in Step 1 of the WHO analgesic ladder. NSAIDs yield pain relief by reducing the excitation of the peripheral nociceptors by reducing synthesis of prostaglandins, chemical lipid mediators associated with cell membranes that are synthesized in most tissues. According to Marchand, “the reduction of postaglandin synthesis will decrease the inflammatory response by blocking the accumulation of substances such as bradykinin and histamine which activate or sensitize the peripheral nociceptors.”6
Therefore, NSAIDs work directly at the site of a lesion. Unfortunately, there are well-documented adverse reactions associated with the use of NSAIDs. They may cause gastrointestinal upset, bleeding issues, and neurological problems. Some patients may experience an allergic response, and these risks increase in the elderly population. If the forgoing risks are an issue, then the use of acetaminophen is a safer alternative because it does not have an anti-inflammatory effect, although at higher doses it can impact the liver.