The Problem of Persistent Pain

by Timothy Gieseke MD, CMD

In recent years, I have noticed a dramatic increase in admissions to my PA-LTC (Post Acute-Long Term Care) practice of patients with persistent non-cancer pain managed with high dose opioids .  Despite this intervention, many of these patients still report their pain intensity as a 10.  In fact a pain audit of patients with persistent pain in one of my facilities recently found that 1/3rd of their patients with persistent pain had reported a 10 pain intensity in the prior month.

For this reason, I was drawn to the NEJM Dec 2nd Perspective article on “Intensity of Pain – The Wrong Metric”.  Our emphasis on pain intensity scales and the 5th vital sign grew out of successes in the late 1980’s and early 90’s targeting medications (mainly opioids) for the relief of acute pain and terminal cancer pain, where an immediate medication intervention resulted in a measureable reduction in reported pain that was usually tolerable and safe.   Unfortunately, this model hasn’t worked well for chronic pain which is much more complex with added layers of cognitive and emotional responses to unremitting pain.  In fact functional imaging studies done during reported intense persistent pain reveal that much of the activity is in areas of the brain involved with emotion and reward, rather than the nociceptive sensory “pain matrix” areas.  This may explain why efforts to modulate “10’s” with acute opioids in persistent pain, are seldom effective.  However, as many of us have seen, this approach increases the risk of opioid dose acceleration and addiction as well a reduction of function, quality of life, and increase risk of falls, dehydration, malnutrition, and aspiration pneumonia.

As I wrote last summer in my WAVE article on improving the reliability of the 5th vital sign, we need to add better measures to our care plan for persistent pain.  While these measures are not yet quantified in a standard way like our pain scales, they promote a more realistic and safer approach.  As the NEJM article notes, our ability to rapidly improve a 10 with meds may prove more burdensome than beneficial.  Instead our emphasis needs to be on developing care plans that identify the many potential reasons for persistent pain like mental health issues, coping strategies, and sense of helplessness and hopelessness.  This model requires a shift to one of respectful and compassionate communication with persons with persistent pain that emphasizes a partnership of discovery of what works and doesn’t while setting expectations for a successful long term strategy, rather than current emphasis on a “quick fix”.  This partnership may require new care processes with greater communication amongst rehab, clinical psychologists, activities personnel, social services, and clinicians.  The goal is to develop additional metrics based on a patient’s functional status, quality of life, and self care while reducing the potential burdens of excessive and ineffective opioid dependent care plans.

As we approach this New Year, I recommend reviewing your care practices of persons with non-cancer persistent pain. It would be great to hear of your efforts in this area at our annual meeting. (Visit our Poster Session page.)

Happy New Year! 

New England Journal of Medicine reference:  http://www.nejm.org/doi/full/10.1056/NEJMp1507136