Chronic Pain Treatment Approaches

I write for a couple of medical sites– not the ones I have mentioned here, but sites where they actually allow doctors to identify themselves so that the person asking the question knows the credentials of the person providing the reply.  Oh, what the heck– I think it is OK to name them…  I answer questions ‘formally’ for MedHelp.com and for DoctorsLounge.com.  Go ahead and check them out if you like– if you do, be sure to give me good feedback!!  They are unpaid positions–  as I have whined about many times, I cannot find a way to make money as a doctor on the internet!  But I do them for the publicity– although what the publicity does for me, I’m not really sure…

Here is something I wrote recently about chronic pain;  I figure that the readers of this blog might find my basic approach useful.  The question was a generic request for help with chronic pain in a family member.

My Reply:

When treating pain, physicians generally separate acute pain from chronic pain in order to decide upon proper strategies for treatment.  We then tend to separate cancer pain from non-cancer pain; perhaps a more useful approach is to separate pain in the presence of limited life expectancy vs pain in a person with years of life ahead.  The reason for these distinctions relates to the problems with narcotic pain medications, namely tolerance, physical dependence, and addiction.  If a person has pain but has only months to life, the tolerance and addiction issues are unimportant;  the person can be treated with narcotics without much concern about addiction.  Likewise, ‘acute’ pain is pain that is time-limited;  narcotics can be used without a great deal of concern, providing the patient is monitored for signs of developing an addiction to the medications, and provided that the medications are discontinued as soon as possible.

The big challenge is dealing with chronic, nonmalignant pain.  I recommend anyone with this type of pain do an internet search using the terms ‘chronic’ and ‘nonmalignant pain’ and read up on the concerns and options.

The problem with any narcotic, including morphine, is tolerance and dependence.  The dose that works today will be ineffective in a month or two.  If the doctor or patient keeps increasing the dose, eventually there will be significant problems related to dependence and withdrawal– the patient will be on a huge dose of narcotic that no longer works.  So caution must be taken to prevent dose escalation;  many doctors are guilty of giving in to requests for ‘more, more, more’ until they eventually get scared of the dose, throw up their hands and say ‘I can’t treat you anymore’.  Ouch!    It is a difficult spot for the doctor, but of course worse for the patient–  it seems that more medication is the answer… but it simply isn’t.  There MUST be a reasonable limit.

OK, back to the question… there are many alternatives to morphine; some narcotic, some non-narcotic.  For narcotic medications, the general approach is to combine a long-acting narcotic, say a once per day or twice per day medication, with a short-acting medication for ‘breakthrough pain’.  There are many long-acting narcotics out there– oxycontin, opana ER, the fentanyl patch, once-per-day morphine preparations… but again, they all have the danger of tolerance and dependence.

Non-narcotic options require an understanding of the cause of the pain;  pain from nerves (damaged or compressed nerves) will often respond to anticonvulsant-related meds like gabapentin, tegretol, or lyrica; inflammation-related pain responds to NSAIDS like ibuprofen or naprosyn; and acetominophen often adds some relief to any other medication.  Depression makes pain worse, and antidepressants that might help include mainly the SNRI’s like Cymbalta, Effexor, and Pristiq.  The older tricyclics like amitriptyline, in small doses, have proven helpful– particularly taken at night, as they are quite sedating.

For many patients, non-narcotic medications don’t seem to be enough, and there is strong temptation to take narcotics.  That is a huge step;  once a person moves to narcotics for chronic pain it is VERY difficult to ever go back to life without them.  Narcotics usually affect the personality over time;  the person taking them becomes more and more focused on the pain, and on the narcotic, until both become the center of the person’s life.  Hobbies disappear.  Relationships suffer.  Through ‘denial’, the patient doesn’t see this happen, but simply thinks that more medication is the answer.

Because of this problem, there is growing attention to the use of buprenorphine for chronic pain.  The medication has been around for 30 years, but more recently has been developed as an oral preparation used to treat opiate dependence, called Suboxone.  A search for buprenorphine at clinicaltrials.gov will show the growing interest in the medication for pain.  I talk about buprenorphine extensively on my blog Suboxone Talk so I won’t go on and on here, but basically buprenorphine is a ‘partial agonist’ that has strong opiate properties– as potent as about 60 mg of oxycodone– but it has a completely different effect on the patient’s psyche.  When given to opiate addicts, the medication virtually eliminates interest in opiates;  when taken by pain patients there is much less desire or urge to take more than prescribed.  The medication has a ‘ceiling effect’ that helps reduce (but not eliminate!) the risk of overdose.

As I guessed would happen, other companies are jumping onto the R and D bandwagon;  I wrote about a couple other meds in testing in one of my last posts.  Time will tell which meds will make it all the way to the market– a very long trip in the US.