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While the standards outlined in the CDC Opioid Prescribing Guideline will improve patient care, they don’t go far enough.
A recent letter from the US Surgeon General made a direct plea to physicians to help solve an urgent health crisis - now commonly referred to as "the opioid epidemic" - in America. A copy of the letter is at http://turnthetiderx.org/.
A few startling facts have no doubt played a role in this unprecedented plea for help:
• The Centers for Disease Control and Prevention (CDC) reports that, since 1999, the number of opioid (hydrocodone and oxycodone) prescriptions in the US has increased by 300%.
• The CDC has also found that, while the use of prescribed opioids to treat chronic pain is skyrocketing, diagnoses of chronic pain conditions have declined by 0%.
• Since 1999, there have been over 165,000 prescription opioid-related deaths in the US, with 14,000 (or 38 deaths per day) in 2014 alone.
• Every day, over 1,000 people end up in US emergency rooms because of opioid misuse.
It is important to understand that one of the biggest challenges in diagnosing and managing chronic pain is the fact that physicians have to rely almost exclusively on the individual’s description of their pain and the disability it causes. There is no biomarker, blood test, or imaging study that can objectively detect the presence and severity of pain. However, a growing body of medical research is shedding new light on the processes in our brains and nervous systems that initiate and sustain severe chronic pain. These studies point to the same conclusion - that chronic pain, in and of itself, is not the problem to be treated. Instead, chronic pain should be seen as a symptom of an underlying medical problem, and it is to this underlying problem that treatment must be targeted.
Specifically, chronic pain is a symptom of inflammation in the brain, or what I call “a brain on fire”. This inflammation is triggered by the body’s own immune system, which is designed to respond to any kind of assault. For example, physical injury, infections (such as Lyme disease and viruses), exposure to environmental toxins, concussions, celiac disease, loss of oxygen to the brain caused by sleep apnea, and even long-term emotional trauma can set off an inflammatory response in the brain and central nervous system. Identifying the source(s) of inflammation is critical to breaking the cycle of chronic pain, and frequently, the sources are multiple, compounding, and cumulative.
In order to accurately diagnose and treat the causes of neuroinflammation that manifest as chronic pain, physicians must:
Take a comprehensive medical history of each individual
Work to correctly identify and treat the underlying root cause(s) of chronic pain
Address the complication that once the brain becomes inflamed, it can burn like a wild fire. (Although the research linking chronic pain syndromes to brain inflammation is clear, our understanding of how to quiet the fire once it starts is still, sadly, incomplete.)
Educate people about their relationship with chronic pain. Like all relationships, how this is managed can make life substantially better or worse.
Intensive pain management programs involve a daily treatment schedule that spans several weeks, during which time attendees are typically seen by a team of healthcare providers with a variety of specialties.
Although programs vary somewhat from one to another, each is likely to include: Behavioral health techniques, such as meditation and relaxation therapies; Movement therapies, such as yoga (especially restorative yoga and yogic philosophy training), and physical therapy, including core strengthening and biomechanics; Nutritional intervention, including anti-inflammatory elimination diets and consultations with nutrition experts and specialized, individual sessions with pain-management experts
The goal of this type of intense programming with an emphasis on education is to help individuals to think differently about their pain, while providing them with new tools to manage their pain and re-engage in their lives.
The bottom line is this:
1. Chronic pain is not a disease but a symptom.
2. The way we treat pain now has, for the most part, been a costly, abysmal failure. Opioids are the most pressing issue but there are also serious concerns about the number of unsuccessful and unnecessary procedures (surgeries in particular) and the proliferation of the use of dorsal column stimulators (implanted electronic devices placed near the spinal cord to treat chronic pain), and the over utilization of spinal blocks (injections of anesthetic into the spine). The research evidence for these approaches for the treatment of chronic pain ranges from fair to poor. 1,2,3,4,5
3. Behavioral health programs have some of the strongest data and greatest success in treating chronic pain conditions. And, more importantly, when these programs are not successful they don’t make the situation worse (unlike surgery and other invasive procedures).
What Needs to Happen Now
Individuals suffering with chronic pain must, in every single case, be offered a comprehensive work-up with an individualized treatment approach.
We need to continue with research into the causes of inflammation in the brain, while also working on developing treatment for brain inflammation that leads to chronic pain.
We also need to develop testing that will provide us with an objective indicator of the chronic pain/underlying disease and its response to treatment.
In the interim, we should focus on improving the lives of our patients by using targeted therapies that address the biology of the pain, rather than its symptoms. There is a place for chronic opioid use in treating pain, but only as a last resort. The re-emergence of interdisciplinary pain-management programs is a step in the right direction.
About Dr. Kaplan
Dr. Kaplan is one of only 19 physicians in the country to be board-certified in both Family Medicine and Pain Medicine. A pioneer and leader in the field of integrative medicine, he is a Clinical Associate Professor of Family Medicine at Georgetown University School of Medicine and serves on the Advisory Committee to Health and Human Services for Chronic Fatigue Syndrome. As the founder and medical director of the Kaplan Center for Integrative Medicine, Dr. Kaplan’s strategy has always been to treat the whole person through a coordinated, multidisciplinary approach.
He explores the root causes of chronic pain, and a revolutionary new medical approach to ending suffering in his book, Total Recovery: A Revolutionary New Approach to Breaking the Cycle of Pain and Depression (Rodale, 2015).