A Few Words on the Treatment of Chronic Pain

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I treat addiction.  Also, I have treated chronic pain.  What I have found is that it is hard to find doctors who are aware of the clinical issues where these two disciplines intersect. 

On one hand, the addiction professionals are not often involved with pain management (although this is changing) and they are hesitant to trust the patients.  Most pain physicians want to do invasive medical procedures since that is where the money is.  They vary with willingness to prescribe opiate medication.
  They do not want to spend time talking about the pain medication.

Unfortunately, if a patient has trouble following the directions, the pain doctor may not have the knowledge, time or inclination to identify the roots of a problem.  Problems become the fault of a patient, who is identified as an ADDICT, rather than the fault of an incomplete treatment approach.  It is no wonder the patients become distrustful of the medical establishment and even distrustful of themselves.  Many turn outside of standard medical care to obtain what they think they need.

20 years ago, researchers such as Dr. Russell Portnoy of Beth Israel Medical Center and others reported that opiate pain medications could be safely given to many people in chronic pain without the emergence of addictive behavior.  In many cases this is true.  Many doctors, including myself, believe chronic opioid therapy works for a lot of patients.  

 

However, in many cases, problems do arise.  These drugs are habit forming and can cause long term physiologic changes and behavioral problems.  You can’t just throw opiates at everyone in pain and ignore the consequences.  Therefore, even when pain is real, pain medication use has to be closely monitored, adjusted when necessary or even discontinued when the overall affect of the treatment is negative.  Many patients, even those with true pain, will do better when their pain medications are discontinued.

 

In my own practice, I have seen many people come off of medication with good outcomes.  These are people whose injuries had occurred some time in the past and who are stable on medication regimens.  They made a voluntary decision to stop the medication.  During a careful weaning process, they did not experience long-term or severe exacerbations in pain.  As the doses became lower, the person became more active in their work and family.  It was as if the drug took an edge off their ambition and caused a state of decreased motivation.  
 

Other patients responded badly to weaning.  They experienced increased levels of pain, decreased ability to participate in work and other activities.  They did better remaining on the pain medication. 

I found no reliable way to differentiate who would do better with weaning from who would not.  There is one factor that is partially helpful.  I look at a person’s daily activities.  Persons who were active and significantly involved with work were more like to do poorly with weaning.  Persons who remain at home and are relatively inactive were more likely to be better off medications. 

 

I do not mean to suggest that people who do not work should not be treated with pain medications: they are often more disabled and in more pain.  However, I feel a greater percentage of this population is not functioning at their top potential and one reason for this may be the opioid use.  A careful inventory of daily activities needs to be considered and an honest appraisal of whether a person’s function has improved with the medication needs to be made.  The subjective level of pain should not be the only determinant. If a person is truly functioning better, they should stay on the medication.  If not, they should attempt to wean. 


I no longer to chronic treatment with opiods unless the opiod used is Suboxone or Subutex.  The regulatory environment means that a bad outcome with a patient will lead to attempts to discredit the physician.  Since I have chosen to embrace the treatment of patients with a history of misuse, I will see bad outcomes more often.

In this website, I have attempted to present the medical science underlying both addiction and chronic pain.  I also present my clinical impressions based on addiction work since 1989 and pain work since 1992.  

  

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