Negotiate with patients on treatment of pain

What are the professional responsibilities that go along with prescribing powerful pain killers? What is the conversation and possibly the contract the physician has with the patient? How can the physician learn to understand the duties that arise in cases of long-term pain therapy?

Reply:

Pain treatment decisions require an examination of a patient's case history. Molly Thomas (name changed to protect the patient's identity) was diagnosed three years ago with stage II breast cancer. After a mastectomy, she was treated with chemotherapy. During this time, she had moderate auxiliary pain successfully managed with oxycodone. She has no evidence of recurrent cancer but has reported moderate to severe pain for three months. Her pain is multifocal, occurring in her lower back, joints and right lower thorax. Physical examination and diagnostic studies, including a thoracic CT scan, are unremarkable.

Thomas is a divorced woman of 57 with four adult children, including a son with a history of chronic depression and a daughter also recently diagnosed with breast cancer. Thomas' pain has been unsuccessfully treated with nonsteroidal anti-inflammatory drugs and physical therapy. She is requesting oxycodone because this worked so well for her previous pain.

The clinic nurse believes Thomas is not really having severe pain, because she does not appear to be in acute distress. The nurse believes, perhaps, Thomas is anxious about recurrence of her breast cancer, given her daughter's recent diagnosis. The medicine resident also is reluctant to refill the oxycodone, because no cause has been identified for the pain. The previous resident attempted to refer Thomas to the university pain clinic, but her insurance provider denied this request.

Case discussion

In recent years, there has been a moral crusade for aggressive treatment of cancer pain, with the World Health Organization declaring undertreated cancer pain a top priority. Efforts to increase opioid availability have been made by international, national and state cancer treatment advocates. Pain relief is considered "basic and standard therapy" in the care of patients with incurable and terminal diseases, but it is not clear what role it plays in the care of chronic pain without identifiable disease.

Pain intensity and associated distress in patients with nonmalignant pain is at least as high as it is in patients with cancer pain. A recent WHO survey of primary care patients in 15 countries reported 22% had pain for at least six months that required medical attention or medication, or interfered significantly with daily activities. The vast majority of these patients had pain not proportional to objective disease, such as back pain and headache. Yet 13% of headache patients and 18% of back pain patients in the United States report they have been unable to work full time because of their pain. The social burden of chronic noncancer pain is large, because in contrast to cancer pain, it occurs in the midst of life, not at the end.

Over the past decade, physicians have urged a response to this epidemic of chronic noncancer pain parallel to that previously urged for cancer pain, focusing specifically on the broader use of opioid analgesics. Both use and abuse of prescribed opioids have increased dramatically in the past two decades. Yet there is still widespread disagreement about the safety and efficacy of long-term opioid therapy for chronic noncancer pain.

Most of the debate has centered on concern over iatrogenic addiction and the abuse of opioid medications. While it is important not to harm patients with treatments we prescribe, this focus distorts the debate about the long-term use of opioids in a number of ways.

First, to focus solely on the harms of opioid treatment does nothing to clarify the goals for treatment of chronic noncancer pain and how they might be different from those for treatment of cancer pain. Pain relief in chronic noncancer pain must be balanced with the capacity for physical, psychological and social functioning over many years of treatment. The best evidence available indicates chronic opioids provide a 30% decrease in pain and less often improve physical function.

Second, the risks of iatrogenic addiction are not unique to the population with chronic noncancer pain. It is estimated 3% to 19% of patients with chronic pain might be abusing or addicted to opioids. This prevalence must be understood in light of the independent observation that there is a 10% to 16% rate of substance abuse and addiction in medical outpatients and the general population. Completely new iatrogenic addiction is most likely a rare event, with opioid misuse most common in patients with a history of substance abuse.

Third, perhaps due to its roots in cancer pain initiatives, the effort to improve chronic noncancer pain management has focused on increasing access to opioids. This effort has not been matched by an increase in access to other treatments proven effective for chronic noncancer pain, such as behavioral, cognitive-behavioral and multidisciplinary treatments. After rapid growth through the 1990s, the number of inpatient or intensive outpatient chronic pain management programs accredited by the Commission on Accreditation of Rehabilitation Facilities has declined since 1999. Interest might be shifting to opioid therapy, because it is perceived as cheaper and easier to implement than pain rehabilitation and more often covered by patient health benefit plans. In fact, chronic opioid therapy done properly requires significant time on the part of the prescribing physician both before and after the prescribing. Recent data suggest opioids are more likely to be prescribed to patients with depression, anxiety and problem drug use, but these are precisely the patients who have been excluded from randomized trials of opioids for chronic noncancer pain.

Despite these complexities, we cannot dismiss the pain and the suffering of patients like Thomas. In 1992, the Agency for Health Care Policy and Research stated "the ethical obligation to manage pain and relieve the patient's suffering is at the core of the health professional's commitment."

My primary recommendation concerning the treatment of chronic noncancer pain is: Believe the patient's report of pain, but negotiate about the treatment indicated.

Physicians can replace suspicion about pain with negotiation about treatment goals. No pain should be dismissed as unreal or unworthy of medical attention. But physicians need to learn how to listen to and validate patients' pain reports without acceding to inappropriate demands for tests or treatments.

Prescribers inappropriately escalate opioid doses when treatment goals are not achieved, rather than questioning the appropriateness of opioid treatment. It is always important to consider nonopioid treatments such as active physical therapy, because opioids alone often do not increase functional status, and antidepressants, given the high rates of depression and anxiety disorders in candidates for opioid therapy.

Treatment goals for chronic noncancer pain need to be negotiated at the outset of care, because cure is rarely possible. Chronic noncancer pain treatment often involves complex trade-offs between comfort, vitality, physical functional capacity and mental clarity. The physician should make clear the goal of treatment is to maximize the patient's quality of life. Reducing pain intensity is only one aspect. The focus should be on improving the patient's life rather than eliminating his or her pain. Opioid contracts are a common strategy in chronic noncancer pain management. Though often used to set limits on patients, they could be adapted for the purpose of collaborative goal-setting.

Case resolution

The resolution of this case might be: After speaking to Thomas about her treatment goals, the medicine resident identifies that walking to the park with her grandchildren is a top priority. Together they develop a treatment plan involving both time-contingent oxycodone and physical therapy. In addition to problems with mobility, Thomas reports she has been sleeping poorly and unable to enjoy her favorite grandchild, so the medicine resident suggests they include an antidepressant medication in her treatment plan.

The resident asks Thomas to keep track of her mood and daily walking time for her next visit in a month. He also asks if her son or daughter would come with her, so they could be included in her treatment and evaluation of its outcome.

A cloud of doubt hangs over the care of patients with chronic noncancer pain that has been largely banished from the care of patients with cancer pain. The patient in our case history has reported both kinds of pain and received different responses from health professionals. This difference is based not on the intensity of the pain or its degree of interference with her life, but on its association with a potentially lethal disease.

Whether pain is proportional to objective disease does not determine whether it is worthy of relief. Physicians have interpreted their duties concerning the relief of chronic noncancer pain through the confused concepts of real versus unreal pain, or somatogenic versus psychogenic pain. Doubts about the reality of patients' pain have distorted decision-making about chronic noncancer pain care, bringing too much critical attention to the risks of opioid treatment and too little attention to its benefits.

The core issue is not whether chronic noncancer pain is real, but how it should be managed so that the patient's quality of life is optimized.

Mark D. Sullivan, MD, PhD, professor of psychiatry and behavioral sciences, University of Washington, Seattle