How to Manage Chronic Pain
Which drug? What dose? These are the questions we focus on when we interact with a chronic pain patient. Certainly, we believe, there must be a magic pill or patch that will erase our patient's pain and (within the 15 minutes allowed by payers) send him or her out of our office eternally grateful and forever smiling. Are we really that dumb?
In my experience, the majority of success in treating chronic pain is attributable to the patient learning methods to reduce anxiety, reduce depression and improve mood. Anxiety, depression, mood and chronic pain create a cycle of disease where each exacerbates the other. When I conduct a chronic pain consultation/education, I explain to the patient that any medication I recommend will fail if they do not take an active role in reducing their anxiety and improving their mood. I do provide some simple tools and advice they can use to start improving mood and reducing anxiety, but I stress the importance of seeking a professional who has the knowledge and training to assist them further in this endeavour.
Recently, a psychologist friend from the Netherlands told me that in his country they do not treat chronic pain with medication. They advise patients to stay active and provide counselling to assist patients in improving their mood and reducing their stress. While a medication-free treatment may not fit the American mindset, the importance of stress reduction and mood improvement must be our first concern. I am a firm believer that short-acting opioids have no role in the treatment of chronic mu receptor pain. Patients almost always fail chronic mu receptor pain treatment when short-acting opioids are included.
Many practitioners and pharmacists disagree with this, stating the need to use short-acting opioids to address "breakthrough" pain. I have found that when a patient has been stabilized on a long-acting opioid, the appearance of breakthrough pain almost always represents a failure of mood, not of medication. I want the patient to contact me if they experience breakthrough pain so I can evaluate the cause.
I realized practitioners do not usually have the luxury of spending an hour with a patient during an initial chronic mu receptor pain consult. But pharmacists who have been specifically trained to conduct a chronic mu receptor pain consult/education/follow-up and provide the practitioner with recommendations and a plan for treatment can be effective in this role. I am currently developing a program to provide this training and create reimbursement models so these patients will experience an improved quality of life. Pharmacists and other healthcare providers must understand the importance of addressing anxiety, mood and depression in the chronic pain patient. They must be prepared to provide tools and help patients find suitable counsellors, psychologists or psychiatrists who can provide additional help. If we engage in appropriate treatment for patients with chronic pain, the majority of the opioid crisis will be resolved.
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