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Intractable Pain

Protocols for a lifetime of pain management for patients suffering constant, incurable, excrutiating, unrelenting pain
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Goals Of Treatment

Once the diagnosis of IP is established, both immediate and short-term treatment goals should be quickly established. Often, the undiagnosed or under-treated IP patient is so ill and bed-or chair-bound that diet, ambulation, and hygiene have been severely neglected. Some uncontrolled IP patients make frequent visits to an emergency room just to obtain a modicum of relief. Physicians should initially attempt to determine one opioid that family and patient report to be effective and prescribe this opioid in a dosage and frequency adequate enough to stop emergency room visits and allow the patient to ambulate, begin a proper diet, and attempt to return to normal activities of daily living. Physiologic abnormalities such as tachycardia, hypertension, and altered adrenal hormone concentrations should be identified and serve as biologic markers to gauge treatment effectiveness. Pain monitoring utilizing a pain scale noting severity from 0 (no pain) to 10 (severest pain) should be used to help control pain. The long-term goals are to help the IP patient become ambulatory and be able to leave home to shop, socialize, and possibly work. Psychiatric conditions, particularly depression and suicidal tendency should be treated. A good quality of life, to the extent possible with medication, is the goal — rather than an impractical one, such as withdrawal from all medication or seeking a “miracle” treatment or the elusive cure. Life extension and improved quality of life is clearly possible if IP is controlled.

The long-term goals are to help the IP patient become ambulatory and be able to leave home to shop, socialize, and possibly work.

Management of Baseline and Breakthrough Pain

Baseline pain is the constant, ever-present pain that is consciously perceived be the IP patient. A long-acting opioid is used to suppress baseline pain.4 The following medications are available for this task: methadone, sustained-release morphine and oxycodone preparations, and transdermal fentanyl (see Table 3). Long-acting opioid therapy is initiated at a low dose and titrated upward to achieve maximal pain suppression without sedation, bradycardia, and hypertension.

Opioid Therapy of IP

Long-acting opioids for baseline pain

  • Methadone
  • Transdermal fentanyl
  • Morphine — sustained release
  • Oxycodone — Sustained release

Short-acting opioids for breakthrough pain

  • Codeine with acetaminophen or plain
  • Hyrocodone with acetaminophen
  • Oxycodone with acetaminophen or plain
  • Hydromorphone
  • Morphine
  • Meperidine

Ultra-fast acting opioids for emergency flares

  • Oral transmucosal fentanyl
  • Morphine suppository
  • Opium-Belladona suppository
  • Hydromorphone suppository

Table 3.

Despite the administration of a long-acting opioid, there may be breakthrough pain, which is temporary and has excruciating intensity above the baseline pain. Breakthrough pain is treated with a short-acting opioid such as hydromorphone, hydrocodone, meperidine, or oral transmucosal fentanyl (see Table 3). Sometimes breakthrough pain is so intense that it may force the suffering patient to seek emergency room treatment. Emergency, breakthrough treatment is best treated by oral transmucosal fentanyl or an opioid suppository. These preparations provide ultra-rapid breakthrough pain relief within 5 to 10 minutes and prevent emergency pain situations. Monitoring and management of opioid therapy routinely requires a monthly clinic visit. Tolerance may occur to either long- or short-acting opioids. When this occurs, a rotation to a different opioid is necessary. Opioid therapy should be continued indefinitely, including a lifetime — unless the underlying cause of IP can be markedly reduced or eliminated. Detoxification or withdrawal should not be attempted unless IP is permanently and markedly reduced, otherwise IP will simply re-emerge following detoxification and force the patient to return to a bed- or house-bound, vegetative state.

Physical Therapy and Exercise

Once opioids control IP, the patient can begin measures to strengthen his/her musculo-skeletal system and hopefully reduce pain on a permanent basis. Stretching exercises involving the afflicted anatomical structures that produce IP are essential. Patients should be taught stretching and strengthening exercises that they can practically accomplish each day for their lifetime. Weak or degenerative anatomic structures may benefit from a prosthesis, specially-fitted shoes, or walking stabilization with a cane or walker.

Family and Community Support

Patients may enter IP treatment after they have been medically and socially isolated for many months or years. The authors require a family member or caretaker to accompany the patient until the patient can mentally and physically function well enough to comply with the treatment program. Community resources should be greatly utilized. These may include psychological therapy, religious participation, vocational rehabilitation, and transportation. Local mental health resources can be invaluable. A pharmacist who is familiar with IP is essential to supply medications for lifetime management.

Weight Reduction

Considerable weight gain is a major clinical problem among many IP patients. In some, excess weight is a major, contributing factor to spinal and skeletal degeneration. Once IP develops, patients are unable to move and ambulate in a normal manner, so weight gain ensues. IP patients eat little protein in favor of sugars and starches, since pain and opioid drugs apparently alter insulin and blood glucose concentrations and cause “carbohydrate craving.” Treatment includes teaching the patient to follow a diet that maximizes protein and minimizes carbohydrate intake. Exercise must be tailored to each IP patient’s ability to ambulate and mobilize extremities. Anorexiants and other metabolism-enhancing compounds should be attempted in severe cases.

The challenge to pain practitioners is to establish outpatient, clinical settings which can provide lifetime medical management of IP.

Adjuvant Medication

In addition to opioids, IP patients will invariably require some adjuvant medication for such problems as insomnia, muscle spasm, depression, and attention deficit. Topical analgesics are also especially helpful — with the following providing satisfactory outcomes: morphine, carisoprodal, aspirin, and dehydroepian-drosterone (DHEA).

Last updated on: August 10, 2017
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