The management of chronic pain presents significant problems for both the patients and their physcians. The process of evaluating pain levels, determining the basis for the problem and developing a reasonable plan for management is a serious task.
The patient wonders can the doctor find the true and identifiable source of the pain? Will they consider the options when it comes to relative risks and benefits of treating or foregoing treatment? Will the they understand each other’s goals and expectations?
The doctor wonders: How well will the patient follow through with the treatment plan? And is the best course of treatment here pharmacological, interventional, physiatrics, and/or psychological?
Below are some questions that hit hard on the controversy.
Q: As far as treating my chronic pain, I allow it to go on for several days and then take a narcotic pain killer when I feel like I can’t take it anymore. Is there a daily pain medication I can take to control my symptoms and allow me to continuing enjoying my sex life? With chronic pain, what course of treatment would be the least likely to affect libido?
Dr. Gould: From what is provided, it seems that the current approach to managing pain is similar to one where a person who notices smoke arising from a waste basket of papers chooses to wait to dump a cup of water on a struggling ember until flames have spread to envelop the curtains and reached the ceiling. Solutions at that point are usually more expensive, have greater consequences and are less effective. In deciding what mode of treatment for pain is best for you, it is important to remember that the management of acute pain is distinctly different than the management of chronic pain. Acute pain is usually related to an inciting event, that rapidly escalates maximum intensity levels and then over time returns to baseline. Depending on the intensity of the pain, its duration and frequency, treatment may be given, declined or withheld, but the decision is based on relative need and likelihood of response.
Low grade pains and pain that last only minutes (less time than the expected time needed for drug absorption and effect) may need to be endured and not be treated. Severe pains lasting hours to days are treated as determined based on the perceived intensity and duration of the pain. Routine medications given to cover pain “just in case” are more likely to be detrimental than beneficial. By contrast, chronic or frequently recurring pain, i.e., pain like that associated with migraine headaches that is severe and will predictably occur on a regular or irregular basis or daily pain related to a chronic medical condition, e.g., arthritis, neuropathic conditions, are best treated with the goal of routinely maintaining acceptable pain levels and managing the less frequent exacerbations, rather than treating the pain only when it is intolerable. It is easier to manage a pain intensity of 4-5/10 than one of 7-8/10 intensity. Providing routine dosing of medications is more likely to keep the pain in a manageable range with few side effects while utilizing less medication overall than treating “as needed.” If you can predict when activities are likely to produce increased pain, it is often prudent to treat the predicted pain before it happens to reduce the need for higher doses of analgesics. The medications that are likely to provide benefit with the least side effects would depend on the type of pain, e.g., nociceptive v neuropathic, that is causing the problem. Many medications can cause a decrease in libido either idiosyncratically or predictably as in long-term opioid use. Generally, the problem of decreased libido should be followed when any neuroactive medications are used. Adverse effects including libido occur most often with prolonged use of relatively high daily doses. That said, a good rule to follow is to use the lowest routine dose of an appropriate medication necessary to reasonably control the pain realizing that high pain levels by themselves can decrease one’s interest in pursuing sexual activity. In the event of lowered libido, monitoring for hypogonadism is appropriate and when present consideration of opioid rotation (if opioid drugs are being used) or sex hormone supplementation may be an option.
Q: I’m frightened about how to handle asking my general practitioner about getting a prescription for terrible back pain that comes and goes. Are they allowed to prescribe pain medication to me? Is there any reason why they wouldn’t prescribe it to a patient complaining of pain?
Dr. Gould: Patient fear is one of the major reasons that limit our ability to adequately manage pain. Some of the patient fears that reduce the likelihood of successful pain control include
1) the fear that an underlying disease will not be adequately treated if the doctor’s attention is distracted by the pain complaint,
2) denial that the pain is important for fear that it is associated with a terrible diagnosis and/or mortality,
3) the fear that if medications are used early they won’t be effective at a later time “when I really need them”,
4) the perception that patients that require strong analgesics are going to die,
5) the fear that they will become or will be perceived as having become a drug addict, and
6) that they will not be viewed by their physician as a “good patient.”
Physician fears also contribute to the lack of success in providing pain control. These fears include
1) the lack of experience about how to appropriately evaluate a pain problem,
2) a level of discomfort in using and monitoring the effects of analgesic medications for chronic conditions,
3) a discomfort with using adjuvant medications (medications with analgesic properties designed to treat another condition),
4) the fear that they will be responsible for providing the means by which their patient could become addicted to treatment, and
5) because of the many untoward problems related to the long-term use of strong analgesics, both medical and social, the fear that they may lose their license to practice medicine and earn a living or worse, may be found criminally negligent and incarcerated.
Indeed, the reason many physicians refuse to write prescriptions for controlled medications is that they are inadequately compensated for taking the extraordinary amount of time and effort needed to comply with all of the regulations necessary to provide proper evaluation and follow up and to monitor for the possible misuse, abuse and diversion of prescription medications. In order to achieve a good outcome for pain management, both patient and physician must overcome their fears and be able to discuss possibilities and expectations, decide what is appropriate and reasonable and agree on a path of treatment. General practitioners are allowed to prescribe pain medications, but based on his/her level of training, experience and type of practice he/she may not have the capacity to do what is necessary to provide complete and proper assessment, treatment options and follow up. In that case, it is beneficial for the general practitioner to obtain the advice and counsel of a pain specialist and to work with them to provide the best care for patients in need. Because of the limited number of pain specialists and the overwhelming need of those in pain, the specialists may not be able to be the primary doctor to provide medications, but their expertise and training can be quite valuable in determining and validation treatment plans that can be implemented by primary care physicians and their patients.