The medical lexicon is filled with the term failure. We have heart, renal, pituitary, and liver “failure.” The triage treatment system recognizes “failure.” For example, coronary stents, insulin, and organ transplants are not used until there is openly acknowledged failure of a standard medical treatment.
For opioid addiction, Federal regulations require written documentation of two detoxification “failures” before a patient can go on daily methadone maintenance. I initiate this year’s first Editor’s Memo with the realization that today, despite our many advances in pain management, we find that our standard treatment regimen fails to control pain in many patients with chronic pain.
Failure or minimal results from standard treatment of chronic pain disorders is one of our major unmet, clinical needs. The just-published and widely used Lange Current Medical Diagnosis and Treatment 2015, sums it up1:
“Clinicians have difficulty treating the patient with a chronic pain disorder. This type of patient frequently takes too many medications, stays in bed a great deal, has seen many clinicians, has lost skills, and experiences little joy in either work or play. All relationships suffer (including those with clinicians), and life becomes a constant search for relief. The search results in complex clinician-patient relationships that usually include many drug trials, particularly sedatives, with adverse consequences (eg, irritability, depressed mood) related to long-term use. Treatment failures provoke angry responses and depression from both the patient and the clinician, and the pain syndrome is exacerbated.”
The first step to resolving the unmet needs of chronic pain patients is to admit we are not succeeding with every patient and that we need diagnostic tools to understand these patients and strategies to help them.
For starters, I submit my definition of standard pain treatment. It is a set of nonpharmacologic measures (physical therapy, dietary guidelines, psychotherapy, electromagnetic treatments), and pharmacologic therapies that include antiinflammatories, antidepressants, muscle relaxants, neuropathic (“anti-seizure”) agents, topical analgesics, corticosteroid injections, and a daily opioid dosage below about 80 to 100 mg of morphine equivalents.
Failure is when this treatment regimen doesn’t keep the pain patient physically and mentally functional, such that they are able to carry on activities of daily living, achieve some quality of life, and, perhaps above all, stop doctor shopping. You may have a different view of what constitutes standard pain treatment and its failure, and I ask that you send me your differing approaches. Please note my daily maximum opioid level, which I consider “standard.” This level of opioids can and should be safely administered in the primary care setting. (Click here to read more on the Rationale for Medical Management).
With some basic idea as to what constitutes standard treatment and its failure, all pain practitioners—medical and psychological—should make sure that every pain patient is given the benefit of a standard treatment regimen, which consists of a wide variety of non-pharmacologic and pharmacologic therapies including low-dose opioids. The just published 2015 Conn’s Current Therapy has an excellent pain section on standard treatments, authored by Steven House, MD, of the University of Kentucky.2 He recommends opioids plus adjunctive medications to insure that patients get a good, basic, standard treatment regimen.
Too often chronic pain patients are labeled erroneously as “drug seekers,” unmotivated, or psychologically disturbed, when they haven’t even been given the benefit of standard treatment. When a patient has received standard treatment and it fails to control their pain, practitioners should acknowledge this development in the patient’s chart and attempt to seek specialty care to, hopefully, find effective, non-standard therapy.
I highly support the Lange Medical Diagnosis and Treatment recommendation in dealing with chronic pain disorders. To prevent failure and a poor outcome they make the following statement: “A single clinician in charge of the comprehensive treatment approach is the highest priority.”1
My other high priority is to promote improved family involvement. It is my opinion that any clinician who has a patient on long-term opioid therapy, regardless of dosage, needs to insure that the patient’s family is aware and supportive of the treatment.
My next belief in preventing or dealing with patients who fail treatment is that they have regular, scheduled clinic visits and that some goals and limits are established as soon as treatment is initiated. In my practice, patients who require opioid dosages over 80 to 100 mg of morphine equivalents a day have a diagnostic workup that may include opioid serum levels, psychological testing, genetic testing, a hormone profile, assessment of neuroinflammatory biomarkers and viral titers, and an evaluation for malabsorption.
Such a diagnostic workup usually will provide a strategy for treatment success in pain treatment failures, as with other medical disorders.
This issue of PPM also introduces a new series developed by Mary Lynn McPherson, PharmD, an Editorial Board Member and Professor and Vice Chair in the Department of Pharmacy Practice and Science at the University of Maryland School of Pharmacy, Baltimore. This two-page “hand-out” provides a comprehensive, easy-to-read summary of one pain medication each month. These are designed to be clipped out of the journal or downloaded from our Web site (practicalpainmanagement.com) and distributed to your patients to help better educate them about commonly used medications. This month’s column features Acetaminophen.