It’s like running a race without a finish line. Why would anyone do that? It seems that if you are a runner starting a race, you want to know where it ends. That is critical information for several reasons. You want to know how to pace yourself. But most of all, you need to know when to stop running!
We have a similar situation in healthcare and it is killing people. The Institute of Medicine tells us that up to 100 million people experience chronic pain in the United States.(IOM, 2011) A small minority of those people have a medical condition that can be cured thus relieving the pain. For the great majority of people with chronic pain their diagnosis is back pain, headaches, fibromyalgia, osteoarthritis, or post-traumatic pain. For these people, there is no cure for their disease and no absolute cure for their pain.
So, for most people with chronic pain, our goal is to reduce their pain. But how much? What is the goal? America is an entitled nation. We all think we should live without pain. So for those in treatment for chronic pain, the goal becomes to reduce pain as much as possible. Is that a problem? Yes, because the final step will almost always be the addition of an opioid pain medication; a step that may slightly improve pain (although that is unproven)(Kissin, 2013) and kills many. Contrary to what some say, opioids are unsafe at any dose and usually result in a bad outcome.
Most guidelines for treatment of chronic pain tell us to use non-opioid treatments and if those are not successful then it is acceptable to use opioids. One state guideline has a typical recommendation: “Alternatives to opioid treatment should be tried, or previous attempts documented, before initiating opioid treatment.” While I agree with that statement, there are no alternatives that will completely stop the pain so opioids become the default final treatment.
What should the goal be? I propose that the goal for chronic non-cancer pain should be maximal improvement with non-opioid treatments and improved quality of life. The addition of chronic opioid therapy is the step in treatment that is unproven, will likely lead to a worse quality of life(Eriksen, Sjøgren, Bruera, Ekholm, & Rasmussen, 2006), and kills tens of thousands every year. Maximal treatment of pain will involve more than medicines. In fact, medicines should have a minor role. This involves behavioral therapy to understand, deal with, and be victorious over the pain. This involves, PT, chiropractic, exercise, acupuncture and other modalities.
We are running a race to infinity. Let’s define a finish line. If we don’t, this race will kill us.
Eriksen, J., Sjøgren, P., Bruera, E., Ekholm, O., & Rasmussen, N. K. (2006). Critical issues on opioids in chronic non-cancer pain: an epidemiological study. Pain, 125(1-2), 172–9. http://doi.org/10.1016/j.pain.2006.06.009
IOM. (2011). Relieving pain in America: A blueprint for transforming prevention, care, education, and research. Journal of Pain and Palliative Care …. Washington D.C. Retrieved from http://informahealthcare.com/doi/pdf/10.3109/15360288.2012.678473
Kissin, I. (2013). Long-term opioid treatment of chronic nonmalignant pain: unproven efficacy and neglected safety? Journal of Pain Research, 6, 513–29. http://doi.org/10.2147/JPR.S47182