I read with interest and disagreement this article about chronic non-malignant pain. Over the last two decades, chronic pain has been a fascination of mine since it is shielded from the majority of physicians. Physicians and public alike have been dazzled by major breakthroughs in the treatment of hypertension, dislipidemia, etc. , yet in chronic pain there have been few advances.
Dr. David Saul writes that he finds chronic pain patients demand more and more medications. This, in my experience, is not true when the pain is adequately controlled. If there is a demand for more medication, it usually means the pain is not controlled. Many patients are deeply apprehensive of using opioids because they are confused, as are some physicians, by the difference between dependence and addiction. The former is physiological, the latter psychological and street-based.
Pain is intrusive, depressive and invades all aspects of performance and physiology. I truly believe one cannot live with intrusive pain and be normal. I believe chronic pain to be one of the most under-treated illnesses and that is a sad state of affairs.
Dr. Saul is right in being concerned about missing a diagnosis. However, I should point out that in the last 15 years only one case referred by me had a missed diagnosis on the etiology of pain and that was an extremely rare circular lymphoma of the corda equina, and that was before the free availability of CT scan and MRI. With modern technology, a misdiagnosis of a chronic pain condition is extremely rare.
We worry about addiction—tolerance developing. I have as yet not seen more than one case in 15 years of addiction. It is nearly a dogma that patients with chronic pain do not become addicted, though obviously dependent, to opioids. Tolerance occurs, but is rare in my experience, and with opioid rotation, co-analgesics, etc. , it can be dealt with.
I have followed many patients for 10 to 15 years and have found it extremely rare to have to escalate the dose. It is important to be strict with protocol, spot checks, and make sure prescriptions are not easily altered.
I agree with Dr. Saul that “all chronic pain patients are unhappy living with pain. " It is a life sentence we as physicians should do our utmost to treat. One is very grateful for the supportive guidelines by the colleges in Canada, giving recognition, support and guidelines for the use of opioids.
I strongly disagree with Dr. Saul that chronic pain patients become addicts. The work of Russell Portenoy and others has shown this to be not true. Once the pain is controlled, many of my patients start a new life, often returning to work, stopping the search for a magic bullet or an etiology to their pain. Not only do they benefit, but the health-care system benefits as they stop searching for a cause that does not exist and a magic bullet treatment.
I would strongly agree with Dr. Saul that in the field of chronic pain management there have been few new products in the last 50 years compared to hypertension, diabetes, etc. , but quoting the great British physician Thomas Sydenham: “Among the remedies which it has pleased Almighty God to give to man to relieve his suffering, none is so universal and so efficacious as opium. " The poppy has been used for the last 4,000 years for pain control. However, it is only in the last two decades that it has been used in chronic, non-malignant pain. It may be a gift of the gods, since morphine is receptor specific.
One important point overlooked by Dr. Saul is that the great majority of patients believe pain means ongoing illness and is a symptom, and therefore this should be defined and dealt with. My philosophy is that chronic pain is an illness due to physiological changes and it is important to explain this concept to patients. As Epictetus wrote, “Men are disturbed not by things but the views which they take of them. " Bright words for a man born a slave.
I find selecting the right chronic pain patient for opioid therapy and turning their life around is like diagnosing a severe diabetic or other illness. The world is changed, the patient is seen once a month, often returns to work, saving the economic cost to the health-care system, and the intrusiveness of pain is blocked.
Although there have been no more breakthroughs in medication for chronic pain control, we could help a great deal by re-honing our skills of using the opioids and their derivatives to better effect.
—Dr. Alan Russell, Brampton, Ont.
Dr. Russell earned his B. Sc. Hons. M. B. , B. S Hons, M. R. C. P.degrees from the University of London and continued his post-graduate training at St. Bartholomew’s Hospital where he was Honorary Assistant in the Department of Neurology. He has also been a medical guest panelist for numerous seminars; has lectured in Europe, China and North America; has published over 300 articles on TENS, Patient Guides to Chronic Pain, Non-steroidals, the use of Narcotics in chronic pain. He also helped develop topical NSAIDs, discovering the topical analgesic effect on oral pain. His professional memberships include the International Association for the Study of Pain, Canadian Pain Society, American Academy of Pain Management, International Headache Society. He can be reached through Coach Picasso at http://www.coachpicasso.com .