Why Untreated Chronic Pain is a Medical Emergency

Why Untreated Chronic Pain is a Medical Emergency

https://edsinfo.wordpress.com/2015/04/15/why-untreated-chronic-pain-is-a-medical-emergency/

Alex DeLuca, M.D., FASAM, MPH;Written testimony submitted to the Senate Subcommittee on Crime and Drugs regarding the “Gen Rx: Abuse of Prescription and OTC Drugs” hearing; 2008–03–08.

Untreated Chronic Pain is Acute Pain

The physiological changes associated with acute pain, and their intimate neurological relationship with brain centers controlling emotion, and the evolutionary purpose of these normal bodily responses, are classically understood as the “Fight or Flight” reaction,

When these adaptive physiologic responses outlive their usefulness the fight or flight response becomes pathological, leading to chronic cardiovascular stress, hyperglycemia which both predisposes to and worsens diabetes, splanchnic vasoconstriction leading to impaired digestive function and potentially to catastrophic consequences such as mesenteric insufficiency. 

Unrelieved pain can be accurately thought of as the “universal complicator” which worsens all co-existing medical or psychiatric problems through the stress mechanisms reviewed above, and by inducing cognitive and behavioral changes in the sufferer that can interfere with obtaining needed medical care

Dr. Daniel Carr, director of the New England Medical Center, put it this way:

Chronic pain is like water damage to a house – if it goes on long enough, the house collapses,” [sighs Dr. Carr] “By the time most patients make their way to a pain clinic, it’s very late. What the majority of doctors see in a chronic-pain patient is an overwhelming, off-putting ruin: a ruined body and a ruined life.”

Dr. Carr is exactly right, and the relentless presence of pain has more than immediate effects. The duration of pain, especially when never interrupted by truly pain-free times, creates a cumulative impact on our lives.

Consequences of Untreated and Inadequately-treated Pain

we must also consider often profound decrements in family and occupational functioning, and iatrogenic morbidity consequent to the very common mis-identification of pain patient as drug seeker.

The overall deleterious effect of chronic pain on an individual’s existence and outlook is so overwhelming that it cannot be overstated. The risk of death by suicide is more than doubled in chronic pain patients, relative to national rates.

What happens to patients denied needed pharmacological pain relief is well documented. For example, morbidity and mortality resulting from the high incidence of moderate to severe postoperative pain continues to be a major problem despite an array of available advanced analgesic technology

Patients who received less than 10 mg of parenteral morphine sulfate equivalents per day were more likely to develop delirium than patients who received more analgesia (RR 5.4, 95% CI 2.4–12.3)… Avoiding opioids or using very low doses of opioids increased the risk of delirium. Cognitively intact patients with undertreated pain were nine times more likely to develop delirium than patients whose pain was adequately treated. Undertreated pain and inadequate analgesia appear to be risk factors for delirium in frail older adults. [7]

Pain Sufferers are Medically Discriminated Against

Chronic pain patients are routinely treated as a special class of patient, often with severely restricted liberties – prevented from consulting multiple physicians and using multiple pharmacies as they might please, for example, and in many cases have little say in what treatment modalities or which medications will be used. These are basic liberties unquestioned in a free society for every other class of sufferer

chronic pain patients are often seen by medical professionals primarily as prescription or medication problems, rather than as whole individuals who very often present an array of complex comorbid medical, psychological, and social problems

Instead these complex general medical patients are ‘cared for’ as if their primary and only medical problem was taking prescribed analgesic medication.

This attitude explains why most so-called Pain Treatment Centers have reshaped themselves into Addiction Treatment Centers.  Even with a documented cause for pain, the primary goal of these programs, whether stated or not, is to coerce patients to stop taking their pain medications.

This may work for a small number of pain patients who may not really need opioids in the first place, but is a “cruel and unusual” punishment for those of us with serious, documented, pain-causing illnesses.

The published success rate of these programs has nothing to do with pain – it is measured by how many people leave the program taking no pain medication, but there is no data about the aftermath, how many manage to stay off their medication long-term.

their obvious primary medical need is for medical stabilization, not knee-jerk detoxification

Chronic Pain is a Legitimate Medical Disease

Chronic pain is probably the most disabling, and most preventable, sequelae to untreated, and inadequately treated, severe pain.

Following a painful trauma or disease, chronicity of pain may develop in the absence of effective relief. A continuous flow of pain signals into the pain mediating pathways of the dorsal horn of the spinal cord alters those pathways through physiological processes known as central sensitization, and neuroplasticity. The end result is the disease of chronic pain in which a damaged nervous system becomes the pain source generator separated from whatever the initial pain source was.

Aggressive treatment of severe pain, capable of protecting these critical spinal pain tracts, is the standard care recommended in order to achieve satisfactory relief and prevention of intractable chronic pain

Medications represent the mainstay therapeutic approach to patients with acute or chronic pain syndromes… aimed at controlling the mechanisms of nociception, [the] complex biochemical activity [occurring] along and within the pain pathways of the peripheral and central nervous system (CNS)… Aggressive treatment of severe pain is recommended in order to achieve satisfactory relief and prevention of intractable chronic pain.

we are seeing ominous scientific evidence in modern imaging studies of a maladaptive and abnormal persistence of brain activity associated with loss of brain mass in the chronic pain population

Atrophy is most advanced in the areas of the brain that process pain and emotions. In a 2006 news article, a researcher into the pathophysiological effects of chronic pain on brain anatomy and cognitive/emotional functioning, explained:

This constant firing of neurons in these regions of the brain could cause permanent damage, Chialvo said. “We know when neurons fire too much they may change their connections with other neurons or even die because they can’t sustain high activity for so long,” he explained

It is well known that chronic pain can result in anxiety, depression and reduced quality of life

Recent evidence indicates that chronic pain is associated with a specific cognitive deficit, which may impact everyday behavior especially in risky, emotionally laden, situations.

The areas involved include the prefrontal cortex and the thalamus, the part of the brain especially involved with cognition and emotions

The magnitude of this decrease is equivalent to the gray matter volume lost in 10–20 years of normal aging. The decreased volume was related to pain duration, indicating a 1.3 cm3 loss of gray matter for every year of chronic pain

clinicians have used opioid preparations to good analgesic effect since recorded history.

No newer medications will ever be as thoroughly proven safe as opioids, which have been used and studied for generations.  We know exactly what side effects there are, and they are fewer than most new drugs, with less than a 5% chance of becoming addicted if taken for pain.

In fields of medicine involving controlled substances, especially addiction medicine and pain medicine, the doctor-patient relationship has become grossly distorted.

doctors-in-good-standing who, faced with a patient in pain and therefore at risk of triggering an investigation, modify their treatment in an attempt to avoid regulatory attention

Examples include a blanket refusal to prescribe controlled substances even when clearly indicated, or selecting less effective and more toxic non-controlled medications when a trial of opioid analgesics would be in the best interests of a particular patient. At the very least, some degree of suspicion and mistrust will surely arise in any medical relationship involving controlled substances.

the quality of care most physicians provide is fairly close to the medical standard of care which is what the textbooks say one should do, and which is generally in line with core medical ethical obligations

For example, modern pain management textbooks universally recommend ‘titration to effect’ (simplistically: gradually increasing the opioid dose until the pain is relieved or until untreatable side effects prevent further dosage increase) as the procedure by which one properly treats chronic pain with opioid medications. Yet the overwhelmingly physicians in America do not practice titration to effect, or anything even vaguely resembling it, for fear of becoming ‘high dose prescriber’ targets of federal or state law enforcement.

It is a foundation of medicine back to ancient times that a primary obligation of a physician is to relieve suffering. A physician also has a fiduciary duty to act in the best interests of the individual patient at all times, and that the interests of the patient are to be held above all others, including those of family or the state.[23] These ethical obligations incumbent on all individual physicians extend to state licensing and regulatory boards which are composed of physicians monitoring and regulating themselves. [24]

A number of barriers to effective pain relief have been identified and include:

  1. The failure of clinicians to identify pain relief as a priority in patient care;
  2. Fear of regulatory scrutiny of prescribing practices for opioid analgesics;
  3. The persistence of irrational beliefs and unsubstantiated fears about addiction, tolerance, dependence, and adverse side effects of opioid analgesics.

A rift has developed between the usual custom and practice standard of care (the medical community norm – what most reputable physicians do) and the reasonable physician standard of care (what the textbooks say to do – the medical standard of care), and this raises very serious and difficult dilemma for both individual physicians and medical board

Research into pathophysiology and natural history of chronic pain have dramatically altered our understanding of what chronic pain is, what causes it, and the changes in spinal cord and brain structure and function that mediate the disease process of chronic pain, which is generally progressive and neurodegenerative

This understanding explains many clinical observations in chronic pain patients, such as phantom limb syndrome, that the pain spreads to new areas of the body not involved in the initiating injury, and that it generally worsens if not aggressively treated. The progressive, neurodegenerational nature of chronic pain was recently shown in several imaging studies showing significant losses of neocortical grey matter in the prefrontal lobes and thalamus

Regarding the standard of care for pain management:

1) Delaying aggressive opioid therapy in favor of trying everything else first is not rational based on a modern, scientific understanding of the pathophysiology of chronic pain, and is therefore not the standard of care. Delaying opioid therapy could result in the disease of chronic pain.

2) Opioid titration to analgesic effect represents near ideal treatment for persistent pain, providing both quick relief of acute suffering and possible prevention of neurological damage known to underlie chronic pain.

16 Responses

  1. I may print this out & take it to the Oregon “We’re going to ban ALL pain meds for ALL conditions, no exceptions” meeting on August 9th. tho the analogy “Chronic pain is like water damage to a house – if it goes on long enough, the house collapses” hits a bit too close to home, as my house is killing me with toxic mold resulting from a flood to the floorboards 3 years ago (it’s also collapsing). Guess me & the house will go down together.

  2. Thank you.

  3. I have taken this opportunity to share my heartbreaking story in hopes these witch hunting Opiate ill informed skeptics will read and understand that I would have no life without Medically prescribed Opiates by a physicians care and strictly monitored monthly urine and blood test. Please remember that An Opinion Before A Thorough Investigation Is The Epitome Of Ignorance! And that a little more compassion from the Medical Field and its representatives could have saved my beautiful Stepdaughters life. Let me say this! A person who has a addictive personality will abuse anything that helps them feel better. I have taken Oxycontin for 14 years , I have had 25 major surgery’s in 14 years. I have so much physical pain I can not even get out of bed with out Medically Prescribed Pain meds and when I run out I run out and just lay in bed praying the Lord relieve me of this horrible condition and I pray God that pain med skeptics never go through what I go through everyday of my life when the only thing you have to do is threaten what help I get, Shame on them! There will always be drug abuse and as the so called war on drugs has failed all this will! All that these witch hunters are doing is stoking and aiding the Illegal Heroin Dealers business to knew heights in the Black Market of Heroin while trying to deprive folks as me to this horrible movement! My Stepdaughter committed suicide 6 years ago because of being treated like a drug addict by some of her family and doctors when all along she suffered from Lupus and Fibromyalgia which I believe was brought on by a deadly car crash at her age of 18 , she told me between that which I was being put through and what they were putting her through she was not going to live her life in such a hell brought on by people like these Opiate Ill-Informed Skeptics that are on a witch hunt to out law Opiates and pain meds that give us some sort of a life . I will send you a last picture of me and my precious Stepdaughter a year before she committed suicide so you can see a face on our story. As a retired Police officer and worked indirectly close to the DEA, some of these people do not have a clue how thrilled they are making the illegal Heroin trade and think of my Late Stepdaughter as they continue on with this 2017 Version of the ( 1940s Propaganda Film named (REEFER MADNESS )movement to outlaw opiates! Just like the slaughter of children at Sandy Hook Elementary School if there would have just been gun laws , my God they were Gun Laws , the guns that murdered all those 20 children were all registered and owned by a school teacher! You fight Drug Addiction in Elementary education by teaching all children the dangers of Booze and Tobacco which if these witch hunters want for us to know the real truth but they do not. I miss my Stepdaughter so much and some of us will continue on the fight to protect our right to feel better and function without fear of these witch hunters trying to convince us to commit suicide . And they are doughtily wanting us Chronic Pain Sufferers to do exactly that as horrifying as it sounds to do exactly THAT!( SUICIDE)!
    The under line real truth is THESE witch hunters would rather us Chronic Pain sufferers commit suicide are and DRINK all the BOOZE we can drink! The Federals legalized it ( ALCOHOL) knowing its a more deadly drug than Strychnine. And just because the DEA has miserably failed with their witch hunt type movement on drugs why do they so desperately launch all this propaganda to compare us that have legitimate Chronic Pain try to compare us with Heroin Addicts? And attempt to deprive us sick people of our Constitutional Rights to be Happy in that pursuit of with Professional Physicians care and monitoring of Opiate Pain Medications taking Legally Prescribed medications that give us relief of this horrible malady of Chronic Pain ! May God have mercy on their miserable souls they that seek to destroy us Chronic Pain Sufferers only and little hope of temporary relief of this horrible sickness.

  4. This article is based on testimony from 2008. Obviously no one listened. Now that there are so many regulations and laws in place it’s highly unlikely that anyone with the power to do anything to help us is going to save us now. While reading I felt some hope that someone finally gets it and pretty much lost all hope when I realized when it was actually written.

    • Me too. Been told that there are so many more studies since then, that they know so much more now etc. etc. as I am again reduced. Asked how far I have to go and not looking forward to it. Since beginning, I was undertreated, never brought up to where it would have made a great difference and now, after years, being brought down. Glad now I didn’t start too high, was told it was very minimal. Still above the 90 mme so will be dropped. Yes, I have to go down further than guidelines. I have spent years doing alternate therapies and believe me, pain does not get better without opioids like they try to tell you. Pain does not adjust to amount of medication etc. The stories I hear.

  5. Thank you for a sensible,accurate,article.But I need to add,SO WHAT.The idiots that keep passing the laws that put doctors in fear to do their jobs,ARE NOT LISTENING TO US! They’ve declared war against chronic pain patients,and they don’t give a damn how much suffering their intrusion and ignorance is causing.So what good is it to keep repeating the same things to idiots that refuse to listen? People are suffering,and committing suicide because of all this hysteria,red tape,fearmongering.Politicians playing doctor.Do I sound fed up? You bet I do,because I am.Every Gd month,month after month,in horrible pain,I have to crawl to a doctors office,to get a piece of Gd paper,in order to get the same medicine that I’ve used for 7 years.
    Every month ,month after month,I have to pee in a Gd cup,like some freaking criminal,in order to get the only medicine that helps me get through another depressing day of pain.They haven’t increased the dosage in three years because of all this idiotic hysteria of politicians.I make due with the same dosage only because of the pain relieving herb kratom.Without the combination of the two,I can not function.Every month,month after month,I have the concern that maybe this will be the month they may say they won’t help me anymore.I am fed up,as are millions of others who are unable to put into writing,what I am saying.
    How much longer will this bs continue? Get a copy of this article into Chris Christies hand.Get a copy of this article into the hands of congress and senate,and local politicians who play doctor.Get a copy of this article into the hands of every doctor in the land,that is intimated by the DEA and the ama.HOW MUCH LONGER?

  6. I almost choked up when reading to my husband what you said about “a ruined body and a ruined life”. I told him, someone really understands. He understands as much as he can living with me but only someone constantly dealing with unrelenting pain knows how it is truly. I sometimes think he gets tired of listening to me tell him about all that is going on out there (probably because he doesn’t know how to “fix it’). I am new at reading all these sites and I feel like I am not alone anymore.

  7. Thank you Dr. Daniel Carr, and PHARMACIST STEVE, as I begin my inhumane & UNNECESSARY withdrawal from my very much needed fentanyl (prescribed by pain mgt 15yrs ago) this obviously hit home for me & many others. Knowing where I’m headed without it is even worse. Don’t Quit please, I can promise you that I will support, and help all in any way possible, I’ll continue to educate til we raise our arms together with changes being made.
    Honestly I feel like dying right now but will personally rebuke any thought of suicide, I refuse to die in vain. So many of these providers denying us also watched us struggle & fight for the little quality of life we had before now…
    OH NO even if struggling in pain, I will not sit idly by while they (CDC, DEA, & government too) decide to rip it away and send us packing, cold turkey for many. (Hmm, if I were from the street, I’d have the endless help with my withdrawal and financial support (that we will help pay for) to boot ! OH Hell NO, NOT I !! Please reach out if we can assist you in any way. In the end we will all need to unite and speak as ONE, it is the only way.

  8. I see in my life how my anxiety has gotten worse the longer I am in pain. I am sent to Mental Health time and time again for my anxiety. I have been in counseling almost all my life. My anxiety will only get so much better as long as I live with high pain in my body. Its the same with my depression. Its horrible to be disabled by pain and anxiety and depression. If only my pain was better in control and i could have a somewhat normal life will my anxiety and depression improve. It seems so simple to me I dont understand why the Dr.s dont understand it. Maybe because they themselves dont have chronic pain. When will this end? Im doing my best to hang in there, but its looking more and more like its getting close to checking out. I see no alternative.

  9. Perfectly said. Thank you for this well written, thoughtful and compassionate article supporting chronic pain patients.

  10. Perfect!! Thank you for this well written, thoughtful and on-target article supporting chronic pain patients.

  11. I agree completely with your comments.

    Re: “The duration of pain, especially when never interrupted by truly pain-free times, creates a cumulative impact on our lives.”

    This is exactly what makes chronic pain so debilitating, yet few seem willing to acknowledge the devastating effect of accumulated pain. For me, the relentless presence of pain can be crazy-making after months and years without a true break.

    It’s unusual for a person without chronic pain to have such a good understanding of it, so I appreciate your insight.

    • Thank you Dr. Daniel Carr, and PHARMACIST STEVE, as I begin my inhumane & UNNECESSARY withdrawal from my very much needed fentanyl (prescribed by pain mgt 15yrs ago) this obviously hit home for me & many others. Knowing where I’m headed without it is even worse. Don’t Quit please, I can promise you that I will support, and help all in any way possible, I’ll continue to educate til we raise our arms together with changes being made.
      Honestly I feel like dying right now but will personally rebuke any thought of suicide, I refuse to die in vain. So many of these providers denying us also watched us struggle & fight for the little quality of life we had before now…
      OH NO I will not sit idly by while they (CDC, DEA, & government too) decide to rip it away and send us packing, cold turkey for many. (Hmm, if I were from the street, I’d have the endless help with my withdrawal and financial support (that we will help pay for) to boot ! OH Hell NO, NOT I !! Please reach out if we can assist you in any way. In the end we will all need to unite and speak as ONE, it is the only way.

  12. Amen,,,bringing this into all my Doc’s,, great article,,truthful article,,,,,maryw

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