Editor's Memo: Care With Caution
Two recent reports tell us a lot about the status of pain management today—especially about the use of opioids. The first report, entitled “Prevalence of Persistent Pain in the US Adult Population: New Data from the 2010 National Health Interview Survey,” is the very best assessment done to date on the prevalence of severe chronic pain and the need for medical pain treatment.1
The researchers, from Washington State University College of Nursing, in Spokane, reported that approximately 39.4 million people in the United States have persistent pain. This represents 19% of the population. The critical number for physicians who treat chronic pain is that 67.7% of that number, or 26.5 million people, said their pain was “constant” and 50.5%, or 20.9 million people, said their pain was sometimes “unbearable and excruciating.”
Readers of this teaching journal will recognize that constant pain, with episodes or flares that are “unbearable” or “excruciating,” usually indicates that persistent pain has become centralized in the central nervous system. With this type of pain, simple non-medical, peripherally-oriented treatments are not likely to be effective by themselves, and long-term medical management will be required.
The second recent report provides a welcome reprieve from the opioid bashing of the last couple of years. In September, the National Institutes of Health (NIH) convened a consensus conference entitled “The Role of Opioids in the Treatment of Chronic Pain.”2 Although the invited attendees were, for the most part, known to be opponents of opioids, their preliminary executive report has this supportive statement: “Patients, providers, and advocates all agree there is a subset of patients for whom opioid treatment is an effective method for their chronic pain, and limiting or denying access to opioids for these patients can be harmful.”
Hallelujah! Someone besides the practitioners on the frontlines of treating chronic pain are starting to get it!
Considering that about 20 million Americans need aggressive medical pain management, the attack on opioids needs to be tempered. Fortunately, the message of the anti-opioid crowd is starting to grow stale. The vast majority of chronic pain patients take their medications as prescribed. Although opioid overdoses are tragic, even the most uninformed observer is starting to understand that such overdoses are self-inflicted by drug abusers, and do not reflect bad drugs or prescribers. If someone wants to take a prescription drug that has not been specifically prescribed for them, or take a drug other than prescribed, the doctor or pharmacists should not be to blame.
The real tragedy of the anti-opioid rhetoric, and many guidelines to restrict opioid access, is that the propagators offer no alternative to opioids. Once our menu of nonopioid drugs and measures are exhausted, what is the alternative? One would logically think that condemnation would be accompanied by alternatives. We are waiting.
In other medical conditions that require a prescription drug with known complications, usually there is an objective discussion of risks and benefits. Can you imagine anyone not discussing the risks and benefits of drugs in pregnancy, cancer, or diabetes? With pain it’s different. According to those opposed to opioids, these agents have all risk and no apparent benefit. Severe chronic pain is a disastrous condition that has too many cardiac, endocrine, neurologic, immunologic, and mental complications to even list in this short memo. Even the NIH consensus report has a long list of opioid complications but hardly mentions the physiologic risks of uncontrolled pain.
Practical Pain Management always has taken the position that opioids are to be used only after other measures fail. Potent opioids (eg, Schedule II, long-acting) are only for patients who fail all other options. We believe there is “no bad pain treatment,” and we have and will continue to welcome, support, and publish teaching articles on psychological, rehabilitative, nutritional, electromagnetic, surgical, topical, interventional, and homeopathic therapies, as well as prolotherapy and non-opioid pharmacologic approaches.
As we approach the holiday season, we can be thankful that the pain treatment movement of the past 2 decades has brought humanitarian care and relief to millions of suffering people. For the last several years, every concerned pain practitioner has studied and learned that many pain treatments, particularly opioids and sedatives, can be hazardous if caution is not exercised. We need to carry this knowledge forward because many more people need our help. If opioids are needed, we know to be cautious and not to let caution keep us from caring.
Wishing everyone a Happy and Healthy Holiday and New Year !
Forest Tennant, MD, DrPH
Editor in Chief