The “right” goal when managing pain

Robert R. Edwards, Ph.D.
Robert R. Edwards, Ph.D., Contributing Editor

It makes sense that the primary goal of pain treatment should be to reduce pain. However, a recent editorial in The New England Journal of Medicine makes a strong case for looking beyond pain intensity when evaluating what is “successful” pain management.

The “balancing act” of managing chronic pain

Here is the problem: For people with chronic pain, the pain affects nearly all aspects of their lives. But at the same time, treatments to relieve chronic pain also have the potential to influence many aspects of a person’s life. Our best pain-relieving drugs have lots of unpleasant side effects. Even non-drug interventions (like physical therapy) and complementary therapies (such as acupuncture) usually don’t have just one single effect.

This means that, if we prioritize pain reduction over every other outcome, we may wind up doing as much harm as we do good. In particular, the authors of the editorial suggest that focusing only on lowering pain intensity, and creating a moral mandate to relieve pain, have contributed to the opioid crisis in this country. Over the past few decades, we have seen steady increases in opioid prescriptions, cases of opioid misuse and abuse, and related overdose deaths.

Patient surveys also show that people with chronic pain care about more than just experiencing less pain. They care about enjoying life more, having a strong sense of emotional well-being, increasing their physical activity, improving sleep and reducing fatigue, and participating in social and recreational activities. These goals need to be balanced against the downsides of pain treatment.

For example, opioid medications like oxycodone (Oxycontin) may reduce pain intensity and make it easier to fall asleep. But they also make people tired, cause constipation and memory problems, and carry the risk of abuse and overdose. How the benefits and harms stack up is entirely personal and will vary from patient to patient. For some people, the risk of abuse is small, the side effects are minor, and the drug reduces their pain by a lot. For others, these drugs reduce pain only a little, while the fatigue and cognitive side effects are so bad that it is hard to carry out routine activities like driving or going to work.

The future of pain management

The editorial’s authors also suggest that pain-management treatments that are not just individualized but also multimodal (that is, they combine several different therapies) may produce the largest benefits with the fewest harms. A strong foundation of scientific research supports this position. For example, a person with chronic low back pain, a recent history of alcohol abuse, and depression and insomnia might do best with a combination of non-opioid pain relievers, cognitive behavioral therapy, and an antidepressant, while another person, also with chronic low back pain, may get the best results with a combination of daily low-dose opioids and weekly acupuncture. Dr. Robert Jamison at Harvard-affiliated Brigham and Women’s Hospital showed that a behavioral treatment to improve opioid adherence among chronic pain patients actually reduced rates of medication misuse among patients most likely to misuse these drugs.

The “success” of pain treatment is very individual. So you can’t assume that what you read online or hear from other people (for example, “drug X is great, you should try it” or “drug Y is terrible, why would anyone prescribe this”) will represent how a drug will work for you. The field of pain management needs a lot more research to determine which patients are more likely to benefit from a given treatment. Perhaps, for example, younger patients with migraine headaches may get more benefit from drug A, while older patients with tension-type headaches may do best with drug B. This kind of categorizing, known as “phenotyping,” would provide a foundation for personalized pain management that, ideally, would improve the clinical care of people with pain and minimize treatment-related harms.

Over all, I believe that combined therapies that not only reduce pain but help meet quality-of-life goals—along with a renewed focus on individualized treatment—represent important advances for the field of pain management and are critical steps toward more effectively fulfilling our duties to suffering patients.


  1. Rusty

    Your post is a timely coirtibutnon to the debate

    • Comprehensive Medical Center

      I always believe that the primary goal of pain treatment should be to reduce pain. Once you have accomplish that you can move on to treat the main problem

  2. Lori A. Woody

    I’m looking for some logical answers please? I went 8+ months with high blood pressure for eight plus months, and was given the two medications that wasn’t even to treat the blood pressure. I had my pressure checked every month the average was 180 over 100+ to 240 over 120. I was told “Oh it’s just a little high” . In April 2015 I had received a very traumatic call involving my mother. I was in my kitchen I blanked out to the point fifteen minutes later I was now sitting on the floor in my hallway. I started having what I thought was flu type symptoms at first that progressed into odd symptoms like Vision Change, Speech, and Numbness. This all took about a week plus, and went to an ER. My BP was 220 over 110, and Hemoglobin was at 7. My past history of Headaches increased with age to full blown Migraines. My MRI showed I had a stroke. With the correct medication mostly all symptoms went away. However I found that the Headaches, and Migraines I have daily. From morning till night OTC, and RX drugs so far seem to dull it down from a 10 to a 5. The only time it seems to be gone is while sleeping. I take medications now for that. I have been seen by a neurologist, and was told I now have Chronic Migraines. With the history of high BP untreated, and Stroke cause the Chronic Migraines & Headaches daily? Can it be cured ? Could it just be permanent damage at this point? I’m at the stage of still trying different types of medications to rid them if only for a few days a week. Any help or input would be amazing. Please & Thank you.

  3. Rebecca Smith

    Pain and addiction are two different animals all the way. I understand what addiction is and it really kills me to see that we are not using the things we have to help those people get better if they want to. We do not have that choice with pain and for me to think i would abuse the medications is a laugh considering one of my family members was addicted to drugs both prescribed and illegal. It killed me to see the system failed him miserably when he needed more help than he was given. Yet if we take medication on time jump through the hoops given to us who have the adherence with the medications get looked at like a drug addict. Addicts are aware of what they are doing, but cannot stop getting high. We look for pain relief and that is it. I am one fo the ones who if it is less it is better. I can deal with some of the pain. I also think if we go in talking pain then the doc should open the ears more instead of shutting down. We may have something wrong with us and when we go in it is imperative that the docs hear everything and finally give tests that are within the pain problem to make sure we are not gonna get hurt more by something. The other which is in here is how everyone takes medications. I can some meds and most of the rest are off limits. My liver is going to look like i drank alcohol nonstop and it is not true. I havent had a sip to drink since I got married about 8 years ago. in fact alcohol will be expelled from me as soon as i drink it no mater what the proof. I just cant take things that will hurt me. I have a genetic condition that actually is something to help understand the why to most of my med intolerance or side effects. it depends on the doc i guess. Poor metabolizing is hard to deal with and when it come to pain meds i am screwed with what I can take. i want to be seen as respected and to know I understand what is going on with the epidemic. I lived and breathed this persons addiction til i could not take it anymore, and yet because i cared i tried to help him on and off. What the docs are doing is letting one go while the other pays the price for the one who was not cared for. Why was he let off to get in more trouble and to keep taking the meds. He almost killed himself to get away from what he is doing to himself. thank you for letting me have the pain relief to try to be there for him and have the strength to do it. he needed the help more than me.

    Alternatives are good with both being the play as well. It is true if you want us to do more give us the minor relief to move and get to the other modalities.

    This is long, and i have been bottling up my disdain for the medical community because i was treated very badly to the point I am dealing with it and will for more years now. I am not an addict I am not so mentally ill i cannot understand the uses of medicine. There are many people who feel the same as i do and we all just want one thing. To have QOL. Period . Why cant we all work together and not penalize those who do follow the guidelines that were there , which we had to go through hoops for as well. the hoops are getting to small to go through please consider this if it is addiction then help those people do not just throw them away. You will spend less money to figure out a problem t hen to use the things we had or just making them some better or instead of jail give them alternatives as well. Addiction has been around for too long, and they are the ones who need the help. I am intelligent, but have mental health and physical problems that no one can just fix. Stop making people like me feel horrible because of your fears.

  4. Chris greene

    The evidence shows that a Mediterranean diet may fetch with inflammation. As usual weather also has it’s own impact on Arthritis pain.

  5. Cheryl D

    Why should chronic pain patients be denied opiates if they have proven to work to control the pain & addicts be coddled?? Oh he/she is an addict, let’s put legislation in place & help them! Oh he/she is in horrible life altering pain, let’s deny them a medication because some choose to abuse opiates that are not prescribed to them & then decide to use heroin.

    And what’s worse is treating chronic pain patients like drug seekers. Or keep on giving those expensive injections that have warning labels from the manufacturer NOT to inject into the spine. Yet none tell the patient they’re using the steroid off label and the risks of life long horrible pain that they will have to just live with….how many suicides from lack of care for pain patients have to happen before pain doctors realize the majority are not abusing, selling or giving away their medication?

  6. Michael Wagner

    I have been using oxycontin for arachnoiditis pain for many years, before they changed the formula so people couldn’t tamper with it.
    With the old oxycontin I don’t have the problem with it as I do with Purdu’s new formula , it causes me to sweat day and night, I have complained to Purdue several times, what I get out of them is it must be in the hypthamulas gland. I had low testosterone levels and , I have had that taken care of, which was to help correct those problems.

    Has anyone else had these problems with any of the time released pain medicines?


  7. Holly K

    I was functioning when I had pain control with a combination that worked, and a doctor who listened. That suddenly changed thanks to the anti-opioid hysteria. Other therapies make my condition, Tarlov cyst, much worse by altering the spinal fluid pressure. I’ve been bounced around like a ping-pong ball for over 3 years now, at an enormous physical, financial (both to me and insurance) and psychological cost (doctors are verbally abusive and write derogatory comments in your chart if you say the word pain), and the only thing prescribed regularly is blood pressure medicine, since my blood pressure spikes to stroke and hypertensive crisis levels, rather than treat my uncontrolled pain! I’ve also had new diagnoses of occipital neuralgia, dural ectasia, multiple sclerosis, cervical spondylosis, osteoarthritis of the spine, adhesive capsulitis, along with the previous C5-6, T6-7 herniated discs, and a lumbar herniation and disc bulges, etc.

    I now have overwhelming exhaustion, weakness, and pain. The only side effect I experienced with pain medicine was pain relief and a semblance of a life. I was able to to clean my body, get a meal, enjoy my family, tinker in my yard, etc.

    Doctors now constantly trivialize and ignore the Tarlov cyst glaring at them on the MRI, as well as the reversal of my C4-5 vertebrae, or claim there is no MS, and ignore every one of my painful conditions and then write that I was “non-compliant” or “refused treatment” when I am physically too exhausted and often in too much pain to get to an appointment. Before the anti-opioid hysteria, they’d say “Wow, you’ve got a lot going on” and understand why PT never helped, and listen when I explained how Epidural Steroid Injections make Tarlov cysts worse, and the research on them. They seemed to care more about helping, rather than gleefully and almost sadistically insisting on inflicting more harm, which seems to be the new trend these past several years.

    I had a better quality of life with the pain medicine I was on because it lowered my pain. Why force me into therapies that have already inflicted damage on me, sending me to the emergency room because it aggravated the occipital neuralgia, and increased the spinal fluid pressure causing severe head pain, only to be treated as “drug seeking” by the very people from whom I seek help?

    Where is the morality in inflicting more pain, suffering and harm on patients like me merely because some people have a propensity for addiction? Leave me alone. I will never be cured. Let me have the medicine and regimen that works for me. Why is my health and well being too much to ask for?

  8. Chrystal Weaver

    I have complex regional pain syndrome type 2 with documented nerve damage and I live my life add a level 6 or 7 every single day. The hysteria that the media has created using statistics that are inaccurate ( nobody knows how many of the 16,000 annual deaths are intentional or unintentional) and simply pointing to increased prescription for opiates without the proper context (people are living longer and baby boomers are hitting their late fifties and early sixties) the government feels pressured by certain anti opiate live in groups to drastically reduce access to these important life enhancing and indeed life-saving pain medications. I would be at a level 10 or higher without the morphine that I receive. The doctor refuses to adjust my dose and I’m basically home bound. He is afraid that the DEA will come knocking on his door and accuse him of over prescribing. Because of the aggressive tactics of law enforcement legitimate chronic pain patients are being under treated for pain or they cannot find a treating physician at all. Pharmacies are afraid to fill the prescriptions and wholesalers are putting artificial quotas on what pharmacies can order for their stock. When you are in that much pain and you can I get any help whatsoever, you may as well not be living. Because every moment you are in agony. No one understands this unless they battled a serious condition for some time and realize that this is the new normal and a new normal is not tolerable. If animals were made to live in this much pain, people would go to jail for cruelty to animals. Yes it’s ok to do that to someone with a debilitating intractable incurable disease that causes excruciating chronic pain. Pain so bad that I would choose amputation of my leg if that would make the pain go away. Your life can change in a blink of an eye. You could be me tomorrow. If you had a hundred people and one of them was guilty of murder you would not think about incarcerating 99 innocent people in order to punish the one person. Neither should you force doctors to follow one-size-fits-all guidelines. The bell shaped curve is real you will always have outliers. We are human beings.

  9. Anne Fuqua

    I understand the point of needing to not medicate a person to the point that they cannot fungus mentally and physically due to sedation. However, it’s also hard to function when you have severe pain. It wrecks your concentration, saps your energy, steals your sleep, and moving itself hurts for many. Clearly these factors do not promote being able to function well. This is why a tolerable pain level is essential for improved function.

    Clinicians need to do what works for the particular patient. It’s helpful to start with what commonly works for a given condition of course, but medicine is both art and science. Sometimes you just have to do what works for THAT PATIENT even if medicine cannot fully explain why. The WHO Ladder for Pain Management is a time-tested tool. Opioids shouldn’t be started when other agents with an acceptable side-effect profile may be efficacious, nor should they be avoided when other measures fail or are intolerable or pose too much risk due to gastrointestinal, cardiovascular, hepatic, or renal , effects. Additionally concerns are emerging regarding the effects gabapentin and pregabalin may have on regeneration in the nervous system. Dose should not be limited if an increased dose improves pain and function. The amounts needed varies widely among patients as a result of genetic factors, tolerance, and absorption issues. In most patients pain must be improved and at least tolerable to see an improvement in function.

    Anne Fuqua, BSN

  10. Kim Miller

    In order to get a patient in chronic pain to a point where they are able to participate in other therapies, it would be helpful, if not essential, for the patient’s pain intensity to be somewhat lessened. If, for this reason alone, easing pain intensity should be a priority, if the medical provider doesn’t find it necessary out of the need to treat patients humanely. It absolutely floors me that the main reason a person sees a doctor, may not be considered important to the doctor!

    For instance, if I’m in the office today with a pain level 8 out of 10, the provider decides I should begin going to the YMCA for swimming therapy. I find a disconnect between the fact that I can’t imagine getting up, taking a shower, putting on swimming clothes under my regular clothes, driving, or riding to the “Y”, taking off my street clothes, spending an hour in the pool. I must then get out of the pool, get into the shower at the “Y”, put my street clothes back on and drive home, all of this at a LEVEL 8!

    Not possible for me, the program has failed before it started because the belief that getting my pain intensity under control was irrelevant. This is the case with any multimodal program. If the patient doesn’t feel good enough to get up, dressed, etc., then you have no patient to participate in the program.

    This disconnect has developed as a result of the development of guidelines or ideas that were contrived without the main ingredient: the pain patient.
    Twitter: @KimmeeKMiller

    I’m a chronic pain patient.

  11. Ritika Sharma

    Pain is a very common event for almost every person, which occurs in any way in his lifetime. but it differs from person to person, as per his health condition. Apart from medicines, few therapies also work for the pain management.