Chronic pain and opiate management

The words chronic pain and opiates are too often spoken in the same context; almost to infer a symbiotic relationship between the two, as if opiates are the answer to chronic pain and chronic pain commands the use of opiates.

How did we get here in this epidemic of “prescription opioid abuse, overdoses, and death?”¹ How did we as a nation that makes up 5% of the world population come to consume 80% of the world’s opiates?² And most importantly, has this consumption positively impacted our overall function and pain?

A review of our nation’s history on pain management will help providers to understand better and to respond to the mixed messages that are being conveyed as “proper management of opiates in chronic pain.” All of our actions and responses have shaped us into the providers we are today. And though there exists a constant flux of changes to the opioid-prescribing guidelines presented to us, a common thread can be seen. That more is no longer always the solution, and that in fact, the previously taught principle of “titrate to effect: the correct dose of an opioid was whatever dose provided pain relief as measured by a pain intensity scale”¹ was flawed when expanding tenets previously originating from the treatment of pain in cancer patients to this new medically diverse and complex population of chronic non-cancer-related pain patients.

When the Joint Commission introduced a mandate that the pain be recognized and treated, the American Pain Society began in 1996 the promotion and push for Pain as the “fifth vital sign.” Dr. James Campbell, in his November 1996 Presidential Address for the American Pain Society noted, “vital signs are taken seriously. If pain were assessed with the same zeal as other vital signs are, it would have a much better chance of being treated properly. We need to train doctors and nurses to treat pain as a vital sign. Quality care means that pain is measured and treated.”³ The VA went on to establish a toolkit designed to promote “Pain as the 5th Vital Sign” and to offer guidelines for the completion of comprehensive pain assessments. Many other pain organizations followed suit and universally, healthcare providers were pushed to inquire about and directly address and treat patient’s pain.

Mistakenly, information was also conveyed to practitioners that by prescribing opiate medications, the risk for adverse outcomes such as addiction and misuse were low, thus liberating prescribers to feel a false sense of safety. Unfortunately, studies up until that point had focused primarily on studying the use of opiates in cancer pain patients and not in chronic non-cancer (or non-malignant) related pain. These non-cancer-related pain patients exposed to chronic opiate therapies proved to be a completely unique subset of patients with pain originating from multifactorial contributions. The complexity of their disease combined with significant socioeconomic stressors and psychiatric/psychological overlay led to much higher rates of addiction and misuse than previously seen in the cancer pain population.

In 1982, the World Health Organization (WHO) brought together a group of cancer pain consultants to develop a practice regimen for global education and dissemination. This set of guidelines recommended that a physician prescribe analgesics on a regular schedule and titrate dosage to the patient’s pain at each of the three steps.⁴ These guidelines completed in 1996 now remain the conceptual framework for the management of pain. The ladder system directs pharmacological treatment of pain based on subjective pain reports of patients using the numeric rating scale 0–10. Based upon the numeric rating, patients are categorized to have mild (1–3), moderate (4–6), or severe (7–10) pain.

In step 1 (mild pain, 1–3) of the ladder, non-opiate pain medications such as aspirin, acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), and adjuvant analgesics are recommended. In step 2 (moderate pain, 4–6) of the ladder, certain opiate pain medications such as hydrocodone, oxycodone, codeine, and tramadol were recommended in addition to all drugs in step 1. In step 3 (severe pain, 7–10) of the ladder, more potent opiates such as morphine, hydromorphone, methadone, and fentanyl were added in addition to all drugs in steps 1 and 2. This ladder was developed with the intention of serving as a guide for prescribers to be used in conjunction with clinical judgment and experience.⁵

With the publication of studies reporting the safety and efficacy of opioids prescribed to a small number of patients with chronic non-malignant pain combined with the publication of a seminal article entitled “The Tragedy of Needless Pain”⁶ and the push for “Pain as the 5th vital sign,” the use of opioids to treat chronic non-cancer-related pain (non-malignant pain) became more widely practiced and incorporated into clinical guidelines.⁷