Our clinical focus on pain scores began in the 1980s when underutilization of opioids to treat pain in patients dying of cancer was first acknowledged and addressed. For a number of different reasons – sometimes fear of prescribing because of drug regulations, sometimes lack of availability because of restrictions on production, importation and sales, sometimes stigma – opioids were underused. People in many countries were dying with unbearable pain that could have been relieved by opioids. In 1985, the World Health Organization (WHO) tried to remove the concerns related to opioids through a simple paradigm intended to encourage doctors to use opioids to relieve pain at the end of life when other analgesics did not work. This was the WHO stepladder that suggested a step-wise approach, starting with mild analgesics and progressing to strong analgesics (opioids) given in increasing doses until pain was under control. It was stated that analgesics should be given at regular intervals and not on demand, and that dose increases should occur according to the level of pain reported (titration-to-effect).[1,2]
This was the first time that people thought about treating a measured pain score instead of a description of pain or suffering. Rather than respond to a level of distress, the stepladder approach taught us to respond to a stated pain level, and to respond in a linear fashion – a high pain score needed to be reduced. The sentiments of the time were captured in a 1989 New England Journal of Medicine article by Wanzer et al: “The proper dose of pain medication is the dose that is sufficient to relieve pain and suffering … To allow a patient to experience unbearable pain or suffering is unethical medical practice”.[3] That this way of thinking came about as recently as the 1980s seems hard to believe now that the 0-10 pain scale has entered our language, and become our chosen way to express pain and the need for pain treatment.
If pain is occurring after surgery, or when dying, it tends to progress in a fairly linear fashion, either improving or worsening over time. The stated pain level is a fair reflection of the underlying pain-producing process, and the pain usually responds well to opioids in dose-dependent manner. What then if the pain is chronic? Chronic pain tends not to be excruciating in the way that pain after surgery or pain due to advanced cancer is excruciating. But it can produce overwhelming suffering, and that suffering may be reflected in a report of high pain intensity. This intensity is related to pain’s relentlessness, its unclear meaning, or the threat it poses to the enjoyment of life, and maybe to life itself. There is no end in sight, and no good purpose to the pain. Perplexingly, the degree of pain may bear no relationship to the degree of tissue damage or an appearance on imaging. This pain does not behave in a predictable or linear fashion, and it is conspicuously influenced by emotional and psychosocial factors.[4,5]
The question is, when pain is chronic, does high intensity pain benefit from opioids in the same way as when it is short-lived? Chronic pain patients that report the highest pain intensity are often completely overwhelmed, and may be burdened by substance abuse or other mental health conditions. Studies have shown that they are the most likely patients to stay on opioids long-term and to dose-escalate, and the least likely to be able to avoid opioid complications including tolerance (loss of efficacy), dependence and abuse. We have termed this self-selection to unhelpful and unsafe regimes ‘adverse selection’.[6] Studies have also shown that prolonged opioid therapy in general tends to be associated with higher doses, more toxicity, more complications, and modest pain relief at best. What we have seen is that attempts to reduce pain scores in chronic pain patients have led inevitably to greater use of opioids at higher doses and with greater adverse effects than ever before. This is because there is no other treatment that can reduce a pain score rapidly enough to satisfy the needs of the titrate-to-effect principle. We are responding to a pain score that is an oversimplification of a complex problem, and is an unclear reflection of the suffering that is causing and being caused by the pain. And we are responding with a treatment that may not, in the long term, help that suffering. Yes, opioids can rapidly reduce pain scores, at least with each dose escalation, but does this necessarily improve function and reduce distress and suffering for the chronic pain patient?
What really matters to most people with chronic pain is that they can live, work and enjoy life. If opioids help to do that in an enduring and comprehensive way, then they may be the right choice. But if they only reduce pain’s intensity, and don’t help improve a life, or worse, if they cause deterioration in function and quality of life, then they are certainly the wrong choice. Too much focus on pain’s intensity has distracted us from what needs to be done to improve the lives of many chronic pain patients. It puts the focus on a medical solution, when there may not be one. Instead of being empowered to manage their own pain, patients become dependent on pills they must obtain from clinicians.
The titrate-to-effect principle has value when treating acute and end-of-life pain where pain is predictable, short lived, and responds well to opioids. But applying this principle to chronic pain has led to unrealistic and potentially damaging expectations for patients, and therapeutic disappointment for clinicians. It is time to abandon the idea that every high pain score needs to be reduced, and that clinicians are failing in their duty or practicing unethically if they don’t respond to every high pain score with an opioid.
About Jane C Ballantyne MD FRCA
Dr Ballantyne trained in Anaesthesia in Oxford, England, before moving to the Massachusetts General Hospital (MGH), Harvard University, Boston in 1990. She became Chief of the Division of Pain Medicine in MGH in 1999. She moved to the University of Washington in 2011 as UW Medicine Professor of Anesthesiology and Pain Medicine. She has editorial roles in several leading journals and textbooks, is a widely published author and researcher.
About Mark D. Sullivan, MD, PhD
Dr Sullivan received his M.D. and his Ph.D. in Philosophy from Vanderbilt University. After completing an internship in Family Medicine at University of Missouri, he completed a residency in Psychiatry at the University of Washington in 1988. He is now Professor of Psychiatry and Behavioral Sciences as well as Adjunct Professor of Anesthesiology and Pain Medicine and Adjunct Professor of Bioethics and Humanities at the University of Washington. He has served as attending physician in the UW Center for Pain Relief for over 25 years, where he is Co-Director of Behavioral Health Services. He has published over 230 peer-reviewed articles, many on chronic pain. He is currently participating in NIMH, NIDA, CDC, PCORI and VA-funded studies on opioid therapy for chronic pain. He has been chair of the Ethics Committee of the American Pain Society and on the editorial board of Pain. He has just completed a book titled, The Patient as Agent of Health and Health Care. He has developed a webtraining concerning opioid therapy of chronic pain, which is available at www.coperems.org
References
- Ventafridda V, Saita L, Ripamonti C, De Conno F. WHO guidelines for the use of analgesics in cancer pain. International journal of tissue reactions 1985;7:93-6.
- Ballantyne JC, Kalso E, Stannard C. WHO analgesic ladder: a good concept gone astray. Bmj 2016;352:i20.
- Wanzer SH, Federman DD, Adelstein SJ, et al. The physician’s responsibility toward hopelessly ill patients. A second look. N Engl J Med 1989;320:844-9.
- Sullivan MD, Ballantyne JC. Must we reduce pain intensity to treat chronic pain? Pain 2016;157:65-9.
- Ballantyne JC, Sullivan MD. Intensity of Chronic Pain-The Wrong Metric? N Engl J Med 2015;373:2098-9.
- Sullivan MD, Edlund MJ, Zhang L, Unutzer J, Wells KB. Association between mental health disorders, problem drug use, and regular prescription opioid use. Arch Intern Med 2006;166:2087-93.