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Seeking Relief for Pain

Pain management remains a complex issue for both patients and physicians

An elderly woman experiencing physical pain has a quiet moment at home with her seated husband visible in the background.

by Joseph Shurman, MD

Remember when the “Baby Boomer” generation referred to young professionals and new parents?

Now, the Baby Boomers have grandchildren, are well on their way to retirement and are facing many of the health issues associated with aging — and the pain that may accompany those issues.

In fact, one out of two people over age 50 will experience chronic pain. The most common types include headaches and low back pain, although cancers and degenerative diseases, such as arthritis, play major roles as well.

Pain management as medical issue

In recent years, pain management has become a significant medical issue. Pain is now considered the fifth vital sign, along with blood pressure, temperature, respiratory rate and pulse rate.

Moreover, every physician in the state of California is now required to take at least 12 hours of educational credits in pain management in order to maintain his or her medical license.

The first step in pain management is a diagnostic evaluation to rule out correctable causes of pain; for example, a pinched nerve in the spine or a hormonal imbalance that leads to migraine headaches.

If no cause is found, we move on to treatments, which can range from physical therapy to integrative approaches, such as biofeedback and acupuncture or medication.

Generally, we begin with over-the-counter pain relievers; if those are not helpful, we try prescription medications, starting with the mildest and progressing to stronger drugs as needed. It is those stronger drugs that have become the crux of a crisis.

Pain: a national problem

Back in the early 1980s, powerful pain relief drugs known as opioids were reserved strictly for malignant pain; in other words, pain caused by terminal illnesses like cancer.

Opioids contain natural or synthetic chemicals based on morphine, the active ingredient of opium that mimics the actions of pain-relieving chemicals in the body. Opioids were used to keep terminally ill patients comfortable during their final days.

In the late 1980s and early 1990s we began to see these drugs prescribed for relief of non-malignant pain. Opioids such as codeine and oxycodone hydrochloride (commonly known as OxyContin) were prescribed to help patients with chronic, non-malignant pain feel well enough to return to work and take care of their families.

Problems with pain medicine abuse

Because of the wide availability of opioids, there have been problems with abuse. It has been estimated that 8 to 10% of high school students in some cities have experimented with OxyContin. Radio talk-show host Rush Limbaugh garnered national attention for his use of the drug, and Time Magazine ran a cover story on its prevalence.

It’s important to remember that, when taken exactly as prescribed, opioids are safe, effective and rarely cause addiction.

However, in rare situations, a chronic pain patient can become addicted, and overdoses have occurred in patients who have taken opioids along with other medications.

And as a result, physicians are being blamed, sued, and even sentenced to prison for prescribing them. Although all of these cases are being appealed, it has led to an alarming “chilling effect” among physicians, as many are now afraid to take care of pain patients and, especially, to prescribe opioids.

This has created a national crisis. Chronic pain patients are not only among the most challenging to treat, it is becoming increasingly difficult for them to get the care they need.

A model for pain management

In response to this crisis, a pain management model was started up here at Scripps Memorial Hospital La Jolla to protect patients as well as physicians.

The model mandates that patients with intractable (nonmalignant) pain who need to be placed on opioids first agree to see a psychotherapist.

These patients sometimes have a higher risk of suicide than those with terminal pain, because they may have 30, 40, or 50 more years to live with that pain.

We require psychotherapy not only because of the suicide risk, but also because it is so valuable to pain patients in terms of psychological support, stress reduction and family support.

In addition, we require patients to see an addictionologist at the start of treatment to evaluate their risk for addiction, and recommend a second opinion from another pain specialist.

We make every effort to use pharmacists who attend our meetings and are well-versed in our program. We conduct cognitive testing (for driving) to determine how patients are affected by the medications, and do sleep evaluations; often, if patients can sleep better, they have less pain.

Finally, we incorporate non-drug approaches to pain management, such as exercise, physical therapy, water therapy and integrative mind/body treatments such as those offered through Scripps Center for Integrative Medicine.

It is a lot to ask of the patients, but in the end it is extremely valuable for them, and it protects the physicians as well.

To date, we have introduced the model in 10 of the country’s most troubled areas, including Miami, Las Vegas, Portland, Detroit, and Nashville. In addition, we have developed a “tool kit” for use by physicians in areas that may not have access to the recommended team of professionals.

This Scripps Health and Wellness information was provided by Joseph Shurman, MD, chairman of pain management at Scripps Memorial Hospital La Jolla.