The Pain Mess

Pain rots the soul.  Pain scourges the body.  Sadly, so does the present day treatment of chronic pain.  What was a problem has become a national mess with thousands dying yearly and millions more suffering.

Fashion may be the arbiter in social media, but it is a poor selector for public health trends.  For many years it was fashionable for surgeons to cut off pain medication post surgery in a matter of days – we don’t want to get patients hooked.  Research in the sixties and seventies demonstrated very, very low rates of addiction following surgery.  So surgeons became more liberal in the use of pain medication.

Then people noticed that chronic pain was a huge problem.  Pharmaceutical companies discovered another giant untapped “need.”  Behaviorist approaches to chronic pain treatment were sidelined in favor of higher and higher doses of opiates – preferably patent protected ones like oxycontin, with higher profit margins.  Physicians discovered that long known procedures – like spinal epidural injections – could usefully modify patients’ pain.  Since so few surgical patients got hooked, why worry about chronic pain patients.? Their need was great.  It was best to treat them up to the limit of what diminished pain.

So the specialty of pain medicine took off. And off.

The huge unmet need begin to be met.  People who had writhed in pain for years walked out of their wheelchairs.  Physicians rushed to become pain specialists, particularly anesthesiologists.  People who had known good livings began buying yachts.  But as in the standard American cautionary tale, the profit rush produced corruption.  Companies actively started pushing “off label” their increasingly potent medications.  Pain clinics began pain mills.  And while many were helped, others were destroyed.

People on the street figured out they could take oxycontin tabs (a long acting version of oxycodone, a potent synthetic opiate) crush them and snort them.  Thousands tried and died.  Soon prescription drug abuse was rampant, and deadly.

The response was to “pull in the horns.”  Purdue Pharmaceutical, maker of oxycontin was fined and sanctioned, but the company’s owners did not go to jail.  Prescribers did.  Some were very aware they had crossed a line, giving people medications that made them highly dependent, but quite a few were not.  In clinical practice, the line between sensible treatment and addiction, as in cancer patients, is often anything but clear cut.

As the pendulum swung backward, chronic pain patients discovered their physicians would no longer give them the medications – only pain specialists could.  These specialists made far more money pushing procedures than prescribing pills.  Many pain patients found themselves writhing in agony again.

Pain, like hunger, makes people go to almost any length to assuage it.  Many pain patients found it much cheaper to buy newly inexpensive heroin on the street rather than fight for medications with regulatory shy physicians.  A new spate of deaths from heroin overdose now added to the pain mortality list.

The response of many regulatory bodies has been to push behavioral treatments and non-opiate pain relievers – like Nsaids, non-steroidal anti-inflammatories including ibuprofen and naproxen (advil and aleve.)  But behavioral programs are costly, often unavailable or refused by insurance companies, and not as quickly relieving as drugs.  Now the FDA has declared that Nsaids should not be taken for more than a few days at a time.  (link is external)The risk of increased heart attack and stroke may be an added 10-20% – a big public health risk over a large population.  Yet more upsetting, though the data are inadequate, the FDA claims the cardiovascular risks of chronic opiate use are higher than that of nsaids.

So what do you do?

A Needed Public Health Response

Physicians and the public have a hard time seeing the body as an information system, but that’s what it is.  Pain exemplifies this story well.  People with horrible looking medical and surgical lesions often experience no pain.  Others have horrible pain without any problems or diseases  doctors can physically detect.  Very frequently, the “it must be obvious” relationship between disease and pain does not exist.

For pain itself is an information event.  Like many peripheral and central nervous functions, it is poorly understood.  There are many actors and innumerable variables.  Much of the newer pain research looks at how the brain identifies and classifies pain – thus the emphasis on behavioral approaches.  But such approaches still remain insufficiently effective.

So it’s time for a new look.  The public health risks of addiction and death through overdose must be weighed against the horrible suffering of people with chronic pain syndromes.  Viewing this as a health issue rather than a police issue (as in our national “War on Drugs”) is essential.  Too many of us will experience chronic pain in our lives to leave the field to political sloganeers.

The National Institute of Medicine is one place to look for guidance.  So are many departments within schools of public health.  Treatment, even discussion of pain amongst the public, is a mess.  People who have watched this mess unfold over the decades may be uniquely positioned to provide some wisdom to what is now a political, social and economic disaster.

By Matthew J. Edlund M.D


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