1. Why is there/why do we need a specialty of pain management?
Katrina: That’s a great question, and I think any meaningful answer has multiple facets or perhaps layers. At one level, we have this interesting juxtaposition of people living longer lifespans owing primarily to technology, and at the same time experiencing the consequences of personal and environmental factors that don’t seem to be trending in a healthy direction. So we have people surviving infections, cardiovascular diseases and cancer, now dealing with inflammatory conditions and musculoskeletal breakdown that parallels the accelerating effects of the post-industrial era on top of the normal aging process.
Heath: At another level, along with whirlwind advances (I resonate with your Jetson’s reference!) there’s been a profound shift in cultural values over the past half-century, with different expectations and in my opinion, interpretation of what “life, liberty and the pursuit of happiness” means. Expectation of a suffering-free existence (a philosophy fairly unique to the modern affluent West) has been cultivated by TV and movies, and the ubiquitous Big Pharma advertisements, etc.
Katrina: For a lot of people, the term “pain management” is synonymous with “narcotics” (opioids), but we, as a modern Western society, are starting to realize a shift from treatment to prevention. The current opioid crisis has been the impetus, or even a silver lining, if you will, for searching out alternative ways of dealing with chronic pain and lessening the use of traditional allopathic medications. Sometimes a lifestyle or dietary adjustment, or complementary treatment, may very well be a better solution and less injurious to the patient. As we look forward for new ways to manage and treat painful conditions, we have begun to look back to theories and viewpoints held by the ancients and realize that they might have had it right all along.
Heath: For me, the opioid crisis sort of ties together many of the threads we’re trying to highlight here. Many states have recently passed legislation requiring that legitimate pain specialists be consulted or even assume management of the prescription of opioids; something that primary care providers and surgeons have done for centuries but which has spiraled out of control obviously over the past 2 decades. That’s not to say that pain physicians get it right all the time by any means – the news is replete with stories of terrible failures. Anyhow, there’s this bewildering, exponentially-increasing array of diagnostic and treatment options across the board in every specialty, and no generalist can stay on top of all of them. In fact, no specialist can either, which has led to the recognition of the need for a multidisciplinary team approach in treating chronic pain at least – something we’re championing and constantly refining at NAPM. Hence my colleague, here!
2. The topic of opioids has come up quite a bit already in this discussion. What is their role, and the role of drugs in general in pain management?
Heath: So, any therapy – really any decision in life – boils down to a risk:benefit ratio analysis, and generally with an eye toward alternatives. In the case of medicine, we’re blessed in this country with an FDA that does its best to evaluate the risk:benefit part of that equation. However, the prescriber still has to make sound decisions based on much more than generalizations from small and often idealized sample populations involved in clinical trials. Mrs. Jones or Mr. Smith often have heart or lung, kidney or liver, or behavioral health issues that tip the scales out-of-favor for therapy X, Y or Z and this requires a careful process of ongoing assessment of that personalized risk: benefit ratio. That ongoing assessment is also carried out by the FDA (as well as professional societies and scientific organizations) and in the case of opioids, we’re increasingly understanding that outside of the context of terminal cancer and other rare exceptions, chronic and continuous use of opioids does not have a positive outcome. Opioids have their time and place, perhaps like a glass of champagne on New Year’s Eve, but in general, continuous use leads to more harm than good.
A big part of the reason for that is the phenomenon of tolerance, which plagues many drugs (including that example of alcohol) and which really is a protective mechanism of the human body. We are designed to try to maintain homeostasis, and the physiology behind that is incredibly complex, involving almost every organ system in every situation. In the case of opioids, like most derived or synthetic drugs, there’s an underlying natural system within our bodies that we are trying to mimic with these compounds. However, we lack the comprehensive understanding of the innate balance that our bodies possess, which exists partially to mitigate the negative effects of our own endorphins and such, and the table turns over. Along those lines, one thing we are starting to understand better is the phenomenon of opioid-induced hyperalgesia, which basically means that being exposed to these drugs for too long actually increases pain sensitivity. Again, not dissimilar to chronic alcohol exposure increasing anxiety.
Anyhow, along those lines we favor as natural and as preventive an approach as possible, and I’ll defer expounding on that to Katrina.
Finally, I would just say that what we call “multimodal” approaches, involving a little of this, and a little of that are generally a whole lot safer than too much of any one component.
Katrina: As Heath stated, the measure of any treatment modality, allopathic or complementary, can be judged based on risk as compared to benefit. While we have all been recently educated on the negative effects of the inappropriate and chronic use of opioids for treating pain across the board, we are less likely to be as educated on the assortment of alternative and complementary treatments available that present less risk and high efficacy. While opioids certainly have their place, they are not intended for long term use, as previously stated. While these substances attempt to mimic what the body already has an ability to do, acupuncture taps into the body’s own natural ability to heal itself, to come back to balance, without pharmacotherapy.
A basic premise of eastern medicine is that without balance, there is disease. Acupuncture attempts to bring balance to the organs and channels to either treat an existing imbalance (disease) or prevent a new one; it is drug-free, low risk, and, quite frankly, just feels really good. Acupuncture can cause the body to release endorphins, those brain chemicals that are responsible for a “runner’s high”, which can bring a feeling of euphoria, relaxation, and well-being; this may facilitate the healing process and can also be used to treat the symptoms of addiction and withdrawal. Going further with this statement, the attempt to achieve balance can either bring us back to health or it can lead to more imbalance or disease, depending on treatment modality. For example, if we are attempting to bring ourselves back to balance, or achieve pain relief, as the case may be, by using opioids and/ or narcotics, we are providing a solution that will, in turn, set ourselves up for a potentially long-term problem, using an imbalanced method to treat an imbalance. Conversely, if we instead choose to use complementary treatments, such as acupuncture, tai chi, qi gong, massage, we are, in fact, empowering our body to heal itself.
Do we sometimes need to supplement with allopathic medication? Absolutely! Again, that is part of the balance in a modern world and it would be foolish to ignore and not try to incorporate, to a certain extent, what is available to us.
3. So, what should the next decade look like in terms of pain management?
Katrina: Pain management, in the future, should be a model of pain prevention, a model that looks at the individual prior to serious health concerns and formulates a plan to mitigate risk factors as well as promote optimum health. As a result of increased education, both on the patient’s as well as the practitioner’s part, patients are becoming more savvy when it comes to their health and appreciate having a voice when it comes to their care; patients are reaching out and asking for alternatives, and practitioners are starting to echo and respond to this desire. If this trend continues, in concert with increased healthcare options and education, I believe we will see longer life expectancies, due to not only medical and technological advances, but also the interest in self-care and prevention of disease, versus a response to something which may have been preventable. Pain prevention will address all aspects of a patient’s life in order to find the best fit for treatment and identify areas which need attention, in order to best tailor a treatment to the individual, not a one-size-fits-all approach.
Heath: Another great question. As with most areas of medicine today, we’re starting to develop what we call Clinical Practice Guidelines, based on the best evidence we have from the scientific literature. These aren’t cookbooks of course, and sometimes a little deviation from the recipe is called for but overall this is a good thing, as Martha would say. And of course, the government is here to help too. In all seriousness, I’m a big fan/proponent of the National Pain Strategy that came out in 2016, and not just because it reflects what we’ve been trying to do here at NAPM for nearly a decade. It [National Pain Strategy, or NPS] highlights some fundamental issues that we all need to stay true to, such as education not only of practitioners but also patients, multidisciplinary care, what’s called a biopsychosocial focus, and also a strong emphasis on healthy lifestyle and prevention.
Technology will advance, bringing welcome relief to many. But as UCLA’s Coach Wooden taught, fundamentals are everything. The [NPS] recognizes that, with a back-to-basics approach focusing on pursuing physical health – that means getting rid of toxins (alcohol, tobacco, a lot of the food and medicine we consume), improving our sleep (maybe the most important intervention!) and exercise. But its scope extends far beyond that, as we humans are far more than flesh and blood. The pursuit of psychological/emotional and relational, and ultimately spiritual health are of the essence in managing pain, and in helping us grow in our capacity to handle it. Buzzwords like “mindfulness” and the new Acceptance-Commitment Therapy approach are actually long-overdue in our society, and the healing of relational sickness and spiritual bankruptcy are absolutely critical.
That’s not to say that medication and procedural/surgical interventions don’t have their place; I’d be out of a job if that were true! But as Dr. William Osler, the Father of American medicine reportedly said 200 years ago, the job of the physician is to reassure the patient that 85% of the time everything will be just fine, but to recognize the 15% that isn’t. Less is usually more in pain management – in terms of less intervention. More prevention is the key!