In defense of pain management

Well this seems to be coming up a lot lately. One of the things about working in a hospital is you get to see a lot of different opinions and cases from doctors from all areas of expertise. It gives everyone a well rounded education and frankly no matter where you are in your career it’s always good to keep up with the state of the art in your field and adjacent fields. I’m in the neurosurgery department so we get to talk a lot about the brain and spinal cord, which means pain is a frequent topic.

Now recently I discussed the whole pain issue, how 1 in 5 people are dealing with chronic pain, and how to treat it is not clear cut (more). It’s tough on both sides of the equation frankly because treatment for pain is tricky and the best tools we have for pain relief just happen to be addictive. The issue becomes, is the person using these addictive medications addicted to them or just in chronic pain? The answer is most likely the latter, but this puts doctors in a tough spot and patients who rely on these medications for relief in an even tougher spot.

The frustrating part about the whole situation is that most doctors will never have to experience chronic pain. Or if they do it will be much later in life, well after decades of treating it. In most cases anyway, I’m sure there are exceptions, just like there are exceptions to any rule. However, for the most part the people treating chronic pain only have second hand knowledge of what it’s like living with it. To say this is not sufficient is an understatement.

Today we heard about several cases of people needing spinal decompression surgery and one of the cases presented, anonymous of course, had a note that the patient was addicted to opioids. Now to be fair I do not know the full story. That could have very well been the case, but I’m always hesitant to use the word addicted when you’re dealing with pain. For example, you wouldn’t suggest a person who needs insulin is addicted to it.

Yes, a person could very well deal with withdrawal symptoms if they came off the medications, just like someone can go through withdrawal symptoms if they came off antidepressants or other medicines. That doesn’t mean a person is addicted. So you can see my frustration when we stick a label on patents that are merely using these, yes additive, medications long-term. Until there is a more effective way to treat them, the rule should be do the least amount of harm and if that involves keeping someone on a medication long-term that shouldn’t really be used long-term (if it can be helped) then so be it.

From my experience seeing people with chronic pain, it’s not a matter of being drug seeking, it’s a matter of being relief seeking. Most don’t want to be on the medications and only do it because the alternative is to live with the pain and trust me when I say chronic pain isn’t something you “just live with.” Chronic pain isn’t like a cut or even like sawing through a limb. There are mechanisms in place that will literally make the pain of cutting a limb off less painful, unfortunately those mechanisms aren’t active when you’re dealing with neuropathic pain. I say neuropathic because that’s the technical term for the pain I’m describing and its definition is almost literally, “we have no idea what’s causing this pain.”

Now this is probably redundant from the last post on this topic, but the pain pathways from the spinal cord are… well let’s just say not exactly direct. They are convoluted, complex, and in a lot of ways redundant. Pain is important for survival so it makes sense that these pathways would be robust to just about everything. That unfortunately means they are incredibly complex. Complex enough that treating them directly is, for the moment anyway, not possible.

Spinal cord stimulation is a promising alternative, but that doesn’t treat the cause, instead it’s a shotgun blast to the area which removes the pain signals, for most people anyway, but the application is broad across most of the spinal cord. This is why people who use this approach often will deal with paresthesia, or tingling in the extremities until the device is adjusted properly. What’s proper? Well just like pain, that is very dependent on the person. Even placement of the stimulating paddle, which requires surgery, is different depending on the patient and where the pain is located.

Between the high cost and high risks involving surgery, it’s no surprise that opioids are the first and basically only line of defense against chronic pain. Yes, pain medication can be addictive and I’m certain that there are cases of people who live with chronic pain becoming addicted to the medication and thus doing things that are detrimental to their lives to get more medication. However, I would wager that for the bulk of the people who use these medications to treat their chronic pain, relief is enough to make sure they don’t fall into behaviors that would affect their life.

So once again, I’m left to scream at the top of my lungs that most patients aren’t drug seeking, they are simply relief seeking. If more doctors knew first hand what living with chronic pain was like I think they too would be more conservative with slapping an addiction label on a person. If by some chance you’re a doctor or medical professional who stumbles upon this, please keep in mind you (probably) have no clue just how painful chronic pain really can be.