The Challenges of Chronic Pain
There was an uplifting article about “A Soldier’s War on Pain” in last Sunday’s New York Times, written by Barry Meier. In 2010, Sargent Shane Savage was on patrol in Afghanistan when a roadside bomb exploded, crushing 24 bones in his left foot and causing a severe concussion.
He was sent home a week later, and joined a legion of young men in the military who suffer from Post Traumatic Stress Disorder, head injury, and now, chronic pain. In order to ease his pain, he was prescribed strong narcotic painkillers.
“What followed was a familiar arc of abuse and dependence and despair. At one point, Sargent Savage was so desperate that he went into the bathroom and began swallowing narcotic tablets. He would have died had his wife, Hilary, not burst through the door”.
Sadly, chronic pain affects millions of Americans. The attitudes about using narcotics to treat chronic pain have swung back and forth in the last twenty years. Two decades ago medical ethicists viewed pain levels as the “fifth vital sign” and encouraged doctors to more aggressively treat pain. Around the same time, longer acting narcotic’s were developed, most notably, OxyContin, which was liberally prescribed to patients with a wide range of chronic pain conditions.
But, in the last ten years, physicians have recognized that there are no “free lunches” with these medications. These drugs have resulted in over 16,000 deaths a year, mostly from accidental overdoses. While they blunt the sensation of pain, they can depress an adult’s central nervous system. With a high enough dose, the individual just stops breathing.
How does this happen? Higher and higher doses are often required because our bodies become habituated to the dose level of narcotics and they no longer work at the lower doses. The patient takes more of the drug, forgets when they took the last dose, but swallows more pills in search of pain relief.
The net result of these deaths has caused the medical community to become far more conservative in using these medications for the treatment of chronic pain. Many studies have shown that the treatment of chronic pain with narcotics does not improve a patient’s function or quality of life. Other studies which evaluate the use of non-narcotic approaches, such as yoga, acupuncture, cognitive behavioral therapy, and physical therapy have demonstrated that patients can improve the quality of their life with a comprehensive non-narcotic approach to pain management.
At the same time, health insurance pays liberally for narcotic medications, but often does not pay for these alternative approaches. This puts patients and providers alike between a rock and hard place. The patient wants relief from her pain, but all their provider has it his disposal is a prescription pad. The net result can be an adult who becomes addicted to pain medications that continue to be less and less effective over time. It’s a vicious cycle.
Not surprisingly, five years ago 80% of the injured soldiers at Walter Reed Army Medical Center were treated with narcotics. Today, only about 10% of these soldiers receive chronic opioid therapy. Walter Reed physicians note that patients are recovering more quickly.
The treatment of chronic pain is complex, and there isn’t a one size fits all. We live in a world where patients want a “quick fix” for their pain, which can be debilitating and terrifying. There are often many factors that contribute to the subjective experience of pain—emotional, psychological, and physical. It is very difficult for patients and providers to sort out what factors are at play and what treatment to provide.
Like Sargent Savage, I have seen many chronic pain patients on high doses of these medications throw away these pills after becoming addicted and disabled by their side effects. After they were weaned off of the pills, they could focus and function better, and didn’t experience worse pain. But I have also seen others who feel that their life would be over if they didn’t have these medications.
Last week’s article resulted in scores of emails to the New York Times about this complex subject. The wide range of responses, both positive and negative, testifies to the complexity of this problem.
What do you think? Have you had personal experience with chronic pain? What has worked for you?