According to recent commentary, a regrettable reality is that currently available treatments for chronic noncancer pain are unable to alleviate pain or restore functioning in a majority of patients. Those observations, from a new series on pain appearing in The Lancet, highlight large gaps in the evidence base and call for more research to assess the effectiveness of combination therapies to relieve chronic pain, while ensuring that patients have realistic expectations about pain relief.
Dennis C. Turk and colleagues from the University of Washington, Seattle, observe that 20% of all persons worldwide have some degree of chronic pain, imposing a total economic burden of $210 billion in the United State alone each year [Turk et al. 2011]. They briefly review evidence for the effectiveness of the most commonly used modalities to treat chronic pain during the past decade, covering a broad spectrum: pharmacologic, surgical, interventional, physical rehabilitation, psychological, and CAM (complementary and alternative medicine).
The authors conclude that, despite important advances in understandings of the mechanisms underlying pain and a growing range of treatment options, overall effectiveness remains inconsistent and poor. Even when statistically significant effect sizes are reported in research, “the clinical meaningfulness of the outcomes is not always clear,” they state. “Of all treatment modalities reviewed, the best evidence for pain reduction averages roughly 30% in about half of treated patients, and these pain reductions do not always occur with concurrent improvement in function.”
According to the authors, because current treatments by themselves provide only modest improvements in pain and physical and emotional functioning, future research should focus on the effectiveness of combining various treatments; such as, combinations of several drugs, combining drugs with physical treatments, and pharmacological combined with psychological treatments. To date few trials have assessed combinations of therapies, and there is little clear evidence as yet for the beneficial effect of any particular combination.
For the foreseeable future, they note, “people with chronic pain will continue to live with some level of pain irrespective of the treatment or treatments they receive.” Therefore, chronic pain management should include a “dialogue with the patient about realistic expectations of pain relief, and bring focus to improvement of function.”
Key recommendations from the authors stress the need for a multifaceted approach to pain treatment that involves the whole person, and for treatment effectiveness to include measures of physical and emotional functioning, patient ratings of improvements, and adverse events, rather than just assessing pain duration, frequency, and/or severity. The authors urge: “A great need exists for research that goes beyond asking the questions of whether a particular treatment is effective, to addressing what treatment is effective, for which patients, on what outcomes, under what circumstances, and at what cost.”
A companion editorial to The Lancet series on pain reminds healthcare providers of their ongoing obligation to manage pain more effectively and states the following…
In 1931, physician and philosopher Albert Schweitzer said: “We must all die. But if I can save [patients] from days of torture, that is what I feel is my great and ever new privilege. Pain is a more terrible lord of mankind than even death itself.” To help eliminate or mitigate an individual’s pain is a privilege that clinicians must neither forget nor neglect.
REFERENCE: Turk DC, Wilson HD, Cahana A. Treatment of Chronic Non-Cancer Pain. The Lancet. 2011(Jun 25);377:2226-2235 [abstract here].
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12 comments:
My use of oxycontin may only provide one third relief to my pain but this equates to my being able to participate one third in everyday activities.
Take it away and I have ?
I have been dealing with debilitating Chronic Pain in mt left knee for over 2 years. Oxycontin, fentanyl 150 mcg/hr, and yet no relief. Specialist after specialist and no diagnosis except Chronic Pain.
Also, SS Disability does not like chronic pain with no definite cause. Stuck not moving and needing a firm diagnosis.
If the doctors would titrate opioids to therapeutic effect, they could get rid of the pain in the vast majority of patients, and by definition, restore function. They wont titrate because to do so would get them arrested and/or put them at risk of losing their license. We know this from the crackdown that occurred in the early-mid 2000's. Hogwash, on these findings. I have seen hundreds of people saved, albiet temporarily by titrated opioids. Shame on these "researchers." They are merely buskers for the alternative therapies they tout...
Siobhan Reynolds
I have been enduring pain from fractures of my lower spine which led to diskectomies and fusion at L4,5 and S1 in 1966 followed by 3 additional surgeries on my cervical spine with disc removal and fusions of C5,6 and 7 along with titanium plate and screws. In 2010 I had additional surgery placing 2 steel rods and a basket around L4,5 and S1 with screws. I have been fighting this fight regarding titration of opioids for years. NO ONE will prescribe the level of opioid relief that I need! Not only that, the MDs won't even prescribe the most effective medicine (from my personal experience - i.e., fentanyl patch plus Actiq lollipops)for me! One other issue: why are the MDs so reluctant to prescribe effective muscle relaxants? They often help relieve my pain better than opioids! I have facet joint syndrome and the muscle relaxant really helps but the MDs wont prescribe the most effective relaxants for this condition.
I'm a retired physician with disc degeneration in my neck, causing pain throughout my thoracic cavity, even into peripheral neuropathy in both feet. After scores of tests, MRI's, CT's, and three years of agony, I finally found a treatment that works. It's Buprenorphine, the active ingredient in Subutex, and one of the two in Suboxone, which is primarily used for opiate addiction. It binds to the same receptors in the brain as do the regular agonist opiates, but has antagonist properties as well. In April, 2011 Purdue Pharma came out with BuTrans, a transdermal patch worn for 7 days at a clip, in three strengths. With that, and the sublingual generic buprenorphine, I have FINALLY gotten to where I have not only achieved a 50% pain reduction, but a 75% function INCREASE! I have to say, that it's been a miracle for me, to be able to walk to the store, go out with my dog, sleep through the night. Not to say that there haven't been roadblocks. My Medicare Part D insurance would pay for the Suboxone, at nearly $6.00 a pill, but not the generic Buprenorphine at less than a buck. Why? Who knows. I had to file a written appeal, which I had countersigned by both my neurologist and pain specialist, and they finally gave in. But I had to fight for it, and educate myself on something that I was totally unfamiliar with. More than more the trouble.
I've been a chronic pain patient for 28 YEARS. The only way a statement like this could be made is because a correct titration to a correct dose is almost NEVER done. I've had it done three times now, to the point where I was recovering, gaining function, and looking into returning to work or going to school - at which point someone panicked and the opioids that had allowed me my life back were taken and I was crippled again. This is a lying, horribly damaging CROCK written to push an agenda other than correct CP treatment.
And how much is "not enough" return of function or lessening of pain? WHY is that NEVER up to the patient?? America has become a medically savage, pitiless and uncompromising place. When people have no choice to get away from their pain other than suicide - like 20,000 Americans every year - there are monsters in charge and their goals have nothing to do with healing or amelioration of suffering. NOTHING.
Ian MacLeod
I have been an RSD patient for 20 years and
have lost enough function that I require a walker at all times. Even if I got adequate
pain relief now, I would not regain function, but I cannot even get pain relief. The
pain care specialists in my little town refuse
to take Medicare patients and my internist will
not prescribe the meds I need out of fear of
the government. I live in constant pain with
no hope of relief in the future. Suicide?
When I can't stand the pain any longer that is
the only option I see. The government can make
all the rules it wants, but they are not at all
interested in relieving the pain of one single
person. They are into control only.
To see a loved one who has exhausted all the medical world has to offer including unbelievably clueless psychologists to seriously consider suicide as an option is utterly and profoundly sad but at the same time rationally understandable.
One pain management doctor of high acclaim told him to wait until he was 40 when at that time the pain would magically disappear! ( He is in his 20's)
Any ideas of how to emotionally support some in this kind of hell which I know many of you suffer in?
If I have learned anything from chronic pain, it's that most people don't realize the torture element.
I tried for awhile to explain my injuries and pain to people when they asked me, but I stopped. The best way to get it is to spend time with me. It is also helpful to describe the impact of it and not get into the pain itself or how it feels. One friend said it hit home for her when I mentioned cooking dinner at the stove while sitting on a bar stool because it was too painful to stand for that long.
I have also been a chronic pain patient for over 20 years due to a minor back injury. It has been hell all of these years to get any opiod relief from MD's, because of fear of addiction, scrutiny from whichever uncaring overseer was dominating at the moment for less used of opiates, the latest celebrity overdose creating an uproar , etc. I finally found a doctor that would listen, and over 5 years we worked with physical therapy, opiates and NSAID's and therapy to get my apin to a livable level. We are now being told in WA state that no matter what the case other than cancer pain, you can have a certain amount of opiates, period. This will, and is cutting my dose in half. When the spin-down is ended, I will be back to a sniveling wreck of pain. How can they do this in modern society? why all of this uproar about opiates? Sure, some people will abuse them but why does that mean that real sufferers of chronic pain must live a sub-par life? I will never understand this. I signed a pain contract and have never broken it. Of course the wealthy will never suffer for a moment. It is torture to have the main element of your pain control plan always under fire for the panic-of-the-moment's decree's. There has to be a better way.
After learning what I have in the past few days, via internet, I am pretty proud of myself for the way I have "handled" mental, emotional and physical pain these many years. JUST learned bipolar depression, Dysphoria, is different from other depressions and treatment is slightly but importantly different (you need the mood stablizer!), IBS and bipolar often go hand in hand, the chronic pain I suffer could be help by better medical care. I am 72 and it took many calls before I could find a psychiatrist who would accept any kind of Medicare. Being an evangelist at heart I want to spread the good news of hope and help if we keep searching and helping each other!
I was at my Drs office and was told I have to now reduce my dose. I have been living fairly comfortably at this dose for several years. I dont ask for early refills and I take my meds as I should according to my pain contract. All of a sudden I'm told that no one should be on over the equivelent of 200mg of morphine unless they have significant structural damage. Apparently herniated discs and disc degeneration dont count. This comes just a few months after being told by two different surgeons that I needed a fusion surgery which I declined. Now I am being told that I dont have anything significant enough wrong with me to warrant the need for the pain medication that I've been taking for over 4 years-the same dose. This is pain politics at work. It is much easier to go after pain patients than it is the illegal drug trade!
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