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CRITICAL COMMENTARY

Commentary: Empower and Educate Patients Diagnosed WithChronic Nonmalignant Pain

Sridhar V. Vasudevan

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ullivan and Ferrell,1 in their provocative and inter-esting article, raise several important and relevantissues and provide the treating physician with ethi-

al guidelines and a new paradigm to address individualsith chronic nonmalignant pain (CNMP). This informa-

ion should be of particular benefit to primary care pro-iders, who are becoming the major caregivers for thoseith CNMP.Although emphasizing that untreated pain is recog-ized as a public health concern, the authors present aase history and discuss ethical ways of addressing anndividual’s pain and related problems.

Although this case presentation is helpful for the dis-ussion, the fact that the patient is elderly and has historyf breast cancer clouds the issue. More typical for therimary care physician is a relatively young individual inhe 30s or 40s with complaints of musculoskeletal painocalized to the lumbosacral region, so-called “whiplashnjuries,” or complaints of diffuse body ache usually di-gnosed as “fibromyalgia syndrome.”The authors clearly recognize the different approacheshysicians take to address individuals with “malignantain”—that is, pain associated with cancer—and thoseith CNMP. With regard to the majority of individualsith CNMP, the authors cite studies and surveys indicat-

ng that the pain is not proportional to objective disease,uch as back pain and headaches. However, these indi-iduals describe significant limitations with regard toheir ability to function.The authors correctly note a significant shift in the pastecade toward recommendations to treat nonmalignantain with opioids for analgesia. Select patients withhronic noncancer pain can have sustained analgesia andan function better with opioids, without becoming ad-icted.The authors identify several concerns in the use of opi-ids in patients with CNMP. These include the following:

. The focus has been solely on the harm of opioid treat-ment without clarifying goals for treating individuals

rom the Center for Pain and Work Rehabilitation, St Nicholas Hospital,heboygan, Wisconsin.ddress reprint requests to Sridhar V. Vasudevan, MD, Center for Painnd Work Rehabilitation, St Nicholas Hospital, Sheboygan, WI 53224.-mail: drvasudevan@usa.com526-5900/$30.002005 by the American Pain Society

oi:10.1016/j.jpain.2004.10.007

0 The Journal of Pain, Vol 6, No 1

with CNMP. Opioids provide about 30% relief andoften do not improve physical function, the authorsnote.

. Although the initial low estimates of iatrogenic addic-tion were based on patients with cancer pain, theauthors state a current estimate indicating that 3% to19% of patients with chronic pain may be abusing oraddicted to opioids. Iatrogenic addiction is a seriouspotential harm for some patients and should beweighed and understood in light of potential benefitsof chronic opioid treatment, they note.

. Although efforts to improve treatment of CNMP havefocused on increasing access to opioids, this move-ment has not been matched by attempts to increaseaccess to other effective treatments, such as behav-ioral, cognitive behavioral, and multidisciplinarytreatments.

In addition to these issues, in my experience, opioidreatment for noncancer pain raises other issues worthonsideration. These include the following:

. It increases patients’ beliefs that they have an unusualand significant condition that requires opioid analge-sia, thus reinforcing illness behavior and disabilityconviction.

. Although opioids do not produce end-organ damagecompared with other analgesics, they lead individualsto become dependent on the health care system,which can be as problematic as the physical depen-dence on opioids.

. Chronic opioid therapy, while perceived as cheaperand easier to implement than pain rehabilitation, pre-vents patients from taking responsibility and controlfor the pain and their lives.

. Limited practical access to physicians, within commu-nities, who prescribe these medications on a long-term basis, and who will be the provider of opioidsindefinitely.

. Perception within the family, who may continue toreinforce the pain behaviors becaise chronic opioiduse convinces them of the patient’s significant medi-cal illness.

. Many individuals with structural conditions (failedback syndromes, arthritis, etc) function fully, withoutthe need or use of opioids.

. Opioids seem to induce personality changes, as noted

by some patients and many family members.

(January), 2005: pp 10-11

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11CRITICAL COMMENTARY/Vasudevan

The authors correctly emphasize the need to breakway from the dichotomy of real versus unreal pain.lthough medical education centers on defining theathologic bases for subjective pain and the need forssigning objective correlates, it is well recognized thatain is a biopsychosocial phenomenon and is modifiedy several legal and environmental issues. An extensive

iterature exists to show a lack of one-to-one correlationetween pathologic/objective abnormalities that areeen on examination or radiologic studies with symp-oms of pain. There is also a very poor correlation be-ween the severity of pain reported and the resultantegree of disability. Numerous issues such as satisfaction

n life and at work, psychological factors, economics, andocial status all play a role in perception and reaction toain.In concluding their discussion, the authors note that

he physical and psychologic dimensions of CNMP arentertwined. They emphasize the need to treat both theain and suffering of the patient.In emphasizing the ethical guidelines, the authors note

he importance of the clinician to “believe the patient’seport of pain, but negotiate about the treatment indi-ated.” In more than 28 years of pain medicine experi-nce, I have applied the rule that I would not judge thexistence of someone’s pain but would judge the under-ying cause, if it can be found, and consider the appro-riate combination of treatment to address the “personnd the pain.”The authors recommend that physicians listen to and

alidate the patient’s pain report without conceding tonappropriate demands for test or treatment. This pointhould be strongly emphasized.In stressing treatment goals, I agree with the authors’

iew to negotiate a plan of care because “cure is rarely n

he cloud of doubt. J Pain 6: 2-9, 2005

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ossible.” In doing this, the physician and the patienthould agree on Specific, Measurable, Achievable, Real-stic, and Time oriented goals (SMART goals). Patient ed-cation should underscore the tradeoff between com-ort, vitality, and mental clarity with shared decisionaking.The first responsibility to the patient is to avoid harm,

he authors conclude. In addition to the surgeries, re-eated invasive procedures, and overuse of medications,strongly suggest that giving patients limited informa-ion without clarification can also lead to harm.The authors should be commended for addressingany unrecognized and underemphasized problems re-

ated to using chronic opioids, including relatively mini-al pain reduction, hormonal changes and alteration of

mmune function, pharmacologic tolerance, and opioid-nduced abnormal pain sensitivity.

Finally, pain clinicians may wish to borrow from theiterature on chronic headaches. An example is the well-eceived concept and entity of “analgesic rebound head-che.” One accepted characteristic of this condition ishe use of opioids at least 2 days per week. It is very likelyhat a certain portion of patients with CNMP may haverebound pain.” Elimination of the medication causingebound headache is the hallmark of treatment. Anec-otally, many clinicians and patients have observed thatlimination of opioids—in some patients with CNMP—ctually eliminates the pain.I hope readers of the article will come to appreciate theeed to listen and validate the patient pain complaints,ducate patients about their conditions, and set specificong-term goals for improved function on the basis ofhared decision making. Empowering patients shouldreate a balanced approach to managing the complex

eeds of individuals with CNMP.

eference

. Sullivan M, Ferrell B: Ethical challenges in the manage-ent of chronic non-malignant pain: negotiating through

ecommended Reading

ask Force of the Wisconsin Medical Society: Guidelines for thessessment and management of chronic pain. Wis Med J 103,

004. Available from: www.wisconsinmedicalsociety.org