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 many unpleasant side effects. Even nondrug 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 significantly. 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. 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.