The Use of Opioids for the Treatment of Chronic Pain These publications, which have been endorsed by AAPM and APS, state that opioids, sometimes called "narcotic analgesics," are an essential part of a pain management plan. There is currently no nationally accepted consensus for the treatment of chronic pain not due to cancer, yet the economic and social costs of chronic pain are substantial, with estimates ranging in the tens of billions of dollars annually.
Pain Can Kill "...he and his team demonstrated that pain repressed the body's immune system and could indirectly promote tumor growth, or in Liebeskind's stark phrase, "Pain can kill!"
A Position Statement from the American Pain Society
1. We recognize that the current debate over physician-assisted suicide and euthanasia reflects a broad public concern that terminal illness is often accompanied by severe pain and other symptoms that make death seem preferable.
2. Pain and other symptoms at the end of life can usually be relieved if clinicians have the training and resources to focus on this goal, but current treatment often falls short. Well-trained clinicians can provide adequate pain relief for more than 90% of dying cancer patients. Patients can be reassured that in the occasional case where the best treatments cannot allow the patient to be alert and relatively comfortable, intravenous sedatives can relieve all symptoms in the last days of life. However, a substantial proportion of patients, particularly those in minority groups, receive inadequate analgesic treatment (Cleeland et al., 1994). Suicidal wishes in patients with advanced disease are closely linked to unrelieved pain and to mood alterations such as depression and anxiety, which like pain, frequently respond to clinician treatment if the clinician identifies and addresses them (Foley, 1995).
3. Despite the best intentions of clinicians, pain and symptom control is often suboptimal because the entire healthcare system has been designed around cure of disease rather than palliation (Max, 1990). There have been many demonstrations of major improvements in pain treatment within a healthcare organization, but programs that do this must redesign many aspects of the way care is delivered (Jacox et al., 1994; American Pain Society Quality of Care Committee, 1995). Essential ingredients in such programs include the following:
4. Policies to ensure adequate treatment of symptoms should take precedence over legalization of physician-assisted suicide and euthanasia. This position statement seeks to improve symptom relief for all dying patients within the next 5-10 years, not just for the few patients who may request assisted suicide. As discussed in the preceding point, this is a challenging task, requiring considerable effort throughout the healthcare system. Experience in The Netherlands, where there has been relatively little effort to improve pain and symptom treatment, suggests that legalization of physician-assisted suicide might weaken society's resolve to expand services and resources aimed at caring for the dying patient (Foley, 1995; Hendin, 1994). For this reason, the American Pain Society opposes the legalization of physician-assisted suicide and euthanasia at this time.
5. Laws and regulations must provide protection for health professionals to aggressively treat pain with analgesic drugs, and when needed, with terminal sedation, even if these treatments hasten death. At present, physicians and nurses are often reluctant to give large doses of analgesics to dying patients, fearing that they will be subject to prosecution if the drugs contribute to a respiratory arrest. Regulations must specify that an intent to relieve pain, supported by documentation of the patient's report of pain or behaviors that suggest pain (e.g., grimacing or moaning), can justify the use of high doses of analgesics or sedatives, even if these treatments also depress respiration or hasten death in some other way. Such treatment is based on ethical principles that are widely accepted by health professionals and ethicists (Emanuel, 1988) and should not be considered an act of assisted suicide or euthanasia.
6. We must encourage basic and applied research related to the mechanisms and treatment of symptoms of disease. Medical research has traditionally focused on curing disease, with relatively few resources devoted to improving symptomatic treatment. Over the past 20 years, a small group of basic neuroscientists and clinical researchers have focused on the study of pain. The achievements of this research, including the development of spinal opioid treatment, patient-controlled analgesia, sustained-release opioid compounds, and effective new treatments for pain related to nerve injury and migraine, illustrate the dramatic results that biomedical research can produce when applied to symptom research. Now that treatments exist for many types of pain, a crucial research question is how to ensure their broad application. Many other symptoms of advanced illness have had relatively little basic or clinical research, including poor appetite, fatigue, shortness of breath, constipation, and pain related to the heart, gastrointestinal tract, urinary tract, and female reproductive organs. Governmental and private foundations should encourage the development of research in these areas, with particular attention to training young investigators in specialty areas where there is currently little symptom research.
American Pain Society Quality of Care Committee. (1995).
Quality improvement guidelines for the treatment of acute pain and cancer pain. Journal of the American Medical Association, 274, 1874-1880. Cleeland, C.S., Gonin, R., Hatfield, A.K., Edmondson J.H., Blum, R.H., Stewart, J.A., et al. (1994).
Pain and its treatment in outpatients with metastatic cancer. New England Journal of Medicine, 330, 592-596. Emanuel E.J. (1988).
A review of ethical and legal aspects of terminating medical care. American Journal of Medicine, 84, 291-301. Foley, K.M. (1995).
Pain, physician-assisted suicide, and euthanasia. Pain Forum, 4, 163-178. Hendin H. (1994).
Seduced by death: Doctors, patients, and the Dutch cure. Issues in Law Medicine, 10, 123-168. Jacox, A., Carr, D.B., Payne, R., Berde, C.B., Brietbart, W., & Cain, J., et al. (1994).
Management of cancer pain. Clinical practice guideline No. 9. Rockville, MD: U.S. Public Health Service, Agency for Health Care Policy and Research. (AHCPR No. 94-0592.) Max, M.B. (1990).
Improving outcomes of analgesic treatment: Is education enough? Annals of Internal Medicine, 113, 885-889
APS Task Force on Pain, Symptoms, and End of Life Care: Mitchell Max, MD, Chair; James Cleary, MD; Betty Ferrell, PhD FAAN; Kathleen Foley, MD; Richard Payne, MD; Barbara Shapiro, MD
The American Pain Society is the U.S. chapter of the International Association for the Study of Pain. Its 3,000 members include many of the leading basic and clinical researchers in the epidemiology, mechanisms, and treatment of acute and chronic pain caused by the range of human diseases. The following position statement has been prepared by the society's Task Force on Pain, Symptoms, and End of Life Care and has been approved by the board of directors.
A consensus statement from American Academy of Pain Medicine and American Pain Society
In the last several years, health-policymakers, health professionals, regulators, and the public have become increasingly interested in the provision of better pain therapies. This is evidenced, in part, by the U.S. Department of Health and Human Services' dissemination of Clinical Practice Guidelines for the management of acute pain and cancer pain.
These publications, which have been endorsed by AAPM and APS, state that opioids, sometimes called "narcotic analgesics," are an essential part of a pain management plan. There is currently no nationally accepted consensus for the treatment of chronic pain not due to cancer, yet the economic and social costs of chronic pain are substantial, with estimates ranging in the tens of billions of dollars annually.
AAPM and APS believe that the United States is in a critical phase of state-level policy development with respect to the use of opioids in pain treatment. In this regard, there has been recent activity in state legislatures (i.e., intractable pain treatment acts and the establishment of pain commissions) and at the regulatory level (statements of policy from state boards of medical examiners). In response to inquiries from concerned boards, AAPM and APS wish to encourage a dialogue with regulators about the appropriate relation between law and the practice of pain medicine. The purpose of laws that govern controlled substances and professional conduct is to protect the public. Our objective is for state policies to recognize but not interfere with the medical use of opioids for pain relief, while continuing to address the issue of prescribing that may contribute to drug abuse and diversion.
It is imperative that this statement not be misconstrued as advocating the imprudent use of opioids. Rather, if a practitioner decides to treat chronic pain with opioids, this document should serve as a guide for both the practitioner and regulators with regard to the judicious use of these drugs in the course of medical practice.
Many strategies and options exist to treat chronic noncancer pain. Since chronic pain is not a single entity but may have myriad causes and perpetuating factors, these strategies and options vary from behavioral methods and rehabilitation approaches to the use of a number of different medications, including opioids.
Pain is one of the most common reasons people consult a physician, yet it frequently is inadequately treated, leading to enormous social cost in the form of lost productivity, needless suffering, and excessive healthcare expenditures.
Impediments to the use of opioids include concerns about addiction, respiratory depression and other side effects, tolerance, diversion, and fear of regulatory action.
Addiction: Misunderstanding of addiction and mislabeling of patients as addicts result in unnecessary withholding of opioid medications. Addiction is a compulsive disorder in which an individual becomes preoccupied with obtaining and using a substance, the continued use of which results in a decreased quality of life. Studies indicate that the de novo development of addiction when opioids are used for the relief of pain is low. Furthermore, experience has shown that known addicts can benefit from the carefully supervised, judicious use of opioids for the treatment of pain due to cancer, surgery, or recurrent painful illnesses such as sickle cell disease.
Respiratory depression and other side effects: Fear of inducing respiratory depression is often cited as a factor that limits the use of opioids in pain management. It is now accepted by practitioners of the specialty of pain medicine that respiratory depression induced by opioids tends to be a short-lived phenomenon, generally occurs only in the opioid-naive patient, and is antagonized by pain. Therefore, withholding the appropriate use of opioids from a patient who is experiencing pain on the basis of respiratory concerns is unwarranted. Other side effects, such as constipation, can usually be managed by attention to diet, along with the regular use of stool softeners and laxatives. Sedation and nausea, possible early side effects, usually dissipate with continued use.
Tolerance: It was previously thought that the development of analgesic tolerance limited the ability to use opioids efficaciously on a long-term basis for pain management. Tolerance, or decreasing pain relief with the same dosage over time, has not proven to be a prevalent limitation to long-term opioid use. Experience with treating cancer pain has shown that what initially appears to be tolerance is usually progression of the disease. Furthermore, for most opioids, there does not appear to be an arbitrary upper dosage limit, as was previously thought.
Diversion: Diversion of controlled substances should be a concern of every health professional, but efforts to stop diversion should not interfere with prescribing opioids for pain management. Attention to patterns of prescription requests and the prescribing of opioids as part of an ongoing relationship between a patient and a healthcare provider can decrease the risk of diversion.
State law and policy about opioid use are currently undergoing revision. The trend is to adopt laws or guidelines that specifically recognize the use of opioids to treat intractable pain. These statements serve as indicators of increased public awareness of the sequelae of undertreated pain and help clarify that the use of opioids for the relief of chronic pain is a legitimate medical practice.
Due to concerns about regulatory scrutiny, physicians need guidance as to what principles should generally be followed when prescribing opioids for chronic or recurrent pain states. Regulators have also expressed a need for guidelines to help them to distinguish legitimate medical practice from questionable practice and to allow them to appropriately concentrate investigative, educational, and disciplinary efforts, while not interfering with legitimate medical care.
AAPM and APS believe that guidelines for prescribing opioids should be an extension of the basic principles of good professional practice.
Evaluation of the patient: Evaluation should initially include a pain history and assessment of the impact of pain on the patient, a directed physical examination, a review of previous diagnostic studies, a review of previous interventions, a drug history, and an assessment of coexisting diseases or conditions.
Treatment plan: Treatment planning should be tailored to both the individual and the presenting problem. Consideration should be given to different treatment modalities, such as a formal pain rehabilitation program, the use of behavioral strategies, the use of noninvasive techniques, or the use of medications, depending upon the physical and psychosocial impairment related to the pain. If a trial of opioids is selected, the physician should ensure that the patient or the patient's guardian is informed of the risks and benefits of opioid use and the conditions under which opioids will be prescribed. Some practitioners find a written agreement specifying these conditions to be useful.
An opioid trial should not be done in the absence of a complete assessment of the pain complaint.
Consultation as needed: Consultation with a specialist in pain medicine or with a psychologist may be warranted, depending on the expertise of the practitioner and the complexity of the presenting problem. The management of pain in patients with a history of addiction or a comorbid psychiatric disorder requires special consideration, but does not necessarily contraindicate the use of opioids.
Periodic review of treatment efficacy: Review of treatment efficacy should occur periodically to assess the functional status of the patient, continued analgesia, opioid side effects, quality of life, and indications of medication misuse. Periodic reexamination is warranted to assess the nature of the pain complaint and to ensure that opioid therapy is still indicated. Attention should be given to the possibility of a decrease in global function or quality of life as a result of opioid use.
Documentation: Documentation is essential for supporting the evaluation, the reason for opioid prescribing, the overall pain management treatment plan, any consultations received, and periodic review of the status of the patient.
The American Academy of Pain Medicine is the AMA-recognized specialty society of physicians who practice pain medicine. The American Pain Society is the national chapter of the International Association for the Study of Pain and is composed of physicians, nurses, psychologists, scientists, and members of other disciplines who have an interest in the study and treatment of pain.
The mission of the American Academy of Pain Medicine is to enhance pain medicine practice in this country by promoting a socioeconomic and political climate conducive to the effective and efficient practice of pain medicine and by ensuring quality medical care by physicians specializing in pain medicine, for patients in need of such services.
The mission of the American Pain Society is to serve people in pain by advancing research, education, treatment, and professional practice. The undertreatment of pain in today's society is not justified. This joint consensus statement has been produced pursuant to the missions of both organizations, to help foster a practice environment in which opioids may be used appropriately to reduce needless suffering from pain.
The statement was prepared by the following committee members: J. David Haddox, DDS MD (Chair); David Joranson, MSSW (Vice Chairman); Robert T. Angarola, Esq.; Albert Brady, MD; Daniel B. Carr, MD; E. Richard Blonsky, MD; Kim Burchiel, MD; Melvin Gitlin, MD; Matthew Midcap, MD; Richard Payne, MD; Dana Simon, MD; Sridhar Vasudevan, MD; Peter Wilson, MBBS, PhD. Consultant: Russell K. Portnenoy, MD.
Approved by the AAPM Board of Directors on June 29, 1996:
American Academy of Pain Medicine
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Glenview, IL 60025-1485
Approved by the APS Executive Committee on August 20, 1996:
American Pain Society
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Editor's note: I have taken only the final contribution, General Discussion, to this lengthy and scholarly article Psychological Aspects of Persistent Pain: Current State of the Science, and have excluded all REFERENCE entered at end of article. For the full article go to Psychological Aspects of Persistent Pain: Current State of the Science. The online article is has bookmarked all chapters and is easily accessed for research.Psychological Aspects of Persistent Pain: Current State of the Science
An overview of current research, this article by Dr. Francis J. Keefe et al includes a review of recent findings addressing psychological factors associated with poor or improved adjustment to pain. Another section of the review looks at behavioral and psychosocial interventions for persistent pain. The review ends with a discussion of how to advance this area of research.
Psychological Aspects of Persistent Pain: Current State of the Science Francis J. Keefe, Meredith E. Rumble, Cindy D. Scipio, Louis A. Giordano, and LisaCaitlin M. Perri
As we have seen, recent studies clearly indicate that there are a number of psychological factors that are associated with good and poor adjustment to persistent pain. The consistency of research findings for a number of the psychological factors depicted in Fig 1 is impressive. In particular, there is strong evidence from multiple studies to support the conclusion that pain catastrophizing and pain-related anxiety and fear are related to poor adjustment to pain and that higher self-efficacy and adaptive pain coping are related to improved adjustment to pain.
The studies cited in this article also clearly document that psychological treatment interventions can reduce pain and improve functioning in patients with persistent pain. Programmatic research testing the efficacy of psychological interventions is being carried out by a number of research groups. Increasingly, treatment outcome studies incorporate methodologic refinements including random assignment to treatment and control conditions, the use of psychometrically strong measures, assessments across important domains of adjustment (eg, pain, psychological distress, and physical disability), and sophisticated data analytic methods.
What is needed to advance this field? First, there is clear need to develop new conceptual models that attempt to integrate findings from studies in this area into a more comprehensive theory of adjustment to pain. There appears to be overlap among a number of the psychological concepts that are the focal points of current research. For example, patients who engage in pain catastrophizing might exhibit high levels of pain-related anxiety and fear and also report low self-efficacy and few coping efforts. In a given patient (or a given research study), which of these factors is likely to be most important? What is the temporal relationship among these factors? New theoretical models could guide clinicians and researchers in answering these questions.
To our knowledge, several theorists and research programs are currently working on such models, and their efforts could be especially helpful in integrating knowledge in this area. In the interim, researchers need to be careful to provide a clear conceptual rationale for the concepts they are examining. Furthermore, whenever possible, investigators should measure potential overlapping psychological factors to determine the unique explanatory nature of the target factor they are studying. Second, to foster better communication there is a need to develop clear and understandable definitions of psychological concepts.
We recommend that a task force or working group be convened by one or more of the major scientific organizations to develop a taxonomy of commonly used psychological concepts such as catastrophizing, fear of pain, anxiety, and neuroticism. Such a taxonomy would have several benefits. First, it would foster the use of a common language among pain researchers and clinicians from varied disciplines. Second, it would improve understanding of psychological concepts and theories among nonpsychologists. Finally, it could encourage greater collaboration between psychologists and other pain specialists. A third strategy for advancing this field is to conduct more research examining how psychological factors relate to the social context of persistent pain.
Given the importance of the social context in behavioral24 and psychological theories of pain,80,81 it is surprising that this area has received relatively little research attention. There is growing evidence that social factors can influence and be influenced by pain. Paulsen and Altmaier89 examined the relationship of social support to pain behavior in patients with chronic lower back pain. Contrary to social support theory, but consistent with operant behavioral theory, they found that patients who reported that their spouses provided higher levels of social support displayed more pain behaviors while completing assigned tasks than did those patients reporting lower social support. These findings suggest that, in some patients, spousal social support might reinforce the display of pain behavior. The broader social context of pain, including cultural perceptions and assumptions about the pain experience, is also receiving increased research attention.
Ng et al83 investigated the relationship between a person’s ethnicity and the prescribing of patient- controlled analgesia for postoperative pain. Data analyses showed that ethnic background was significantly related to the amount of medication prescribed, with physicians prescribing significantly higher levels of narcotic for blacks than Hispanics and significantly higher levels for whites than Hispanics. It is interesting that ethnic background related to physician prescribing of analgesic but not to the total amount of narcotic that was actually self-administered. There is also evidence that psychological factors known to be important in understanding pain might be linked to social factors. For example, does pain catastrophizing have important interpersonal correlates? We examined this possibility in a recent study of 70 patients with pain caused by gastrointestinal cancer.50 Data analyses showed that there was a significant relationship between pain catastrophizing and patients’ ratings of instrumental support. Specifically, patients who engaged in higher levels of pain catastrophizing reported higher levels of instrumental support from their caregivers. These findings fit with a communal model of catastrophizing that maintains that catastrophizing represents an interpersonal form of coping whose aim is to maintain proximity to and support from others.119
Interestingly, although patients who catastrophized reported higher instrumental support, they also experienced higher pain, and their caregivers reported higher levels of caregiver strain. This suggests that, although catastrophizing is a coping strategy that might address certain social needs, it is related to negative outcomes for both patients and their caregivers. A fourth way to advance the field is to examine how psychological factors important in understanding persistent pain are linked to biological processes such as painrelated brain activation patterns. Developments in neuroimaging methodology have enabled researchers to study how cognitive factors such as attention and mood are related to neural activation.99,139
Neural imaging has also been used to study the anticipation of pain. Porro et al95 conducted a functional magnetic resonance imaging study that showed that both pain and the anticipation of pain produced changes in a number of brain areas including the contralateral S1 and bilaterally in the anterior cingulate cortex (ACC), anterior insula, and medial prefrontal cortex. The changes in brain activation were similar for both pain and pain anticipation, except that the magnitude of changes was 30% to 40% lower during the anticipation of pain. Hsieh et al36 have reported that brain activation during the anticipation of pain might depend on experience. Subjects who had participated in multiple practice sessions in which a pain stimulus was delivered showed decreased activity in the caudal ACC and subgenual ACC while waiting to receive the stimulus, whereas those who had not had this experience showed increased activity in the same areas. Emotional states such as anxiety can increase pain. Is the effect of anxiety on pain evident in different patterns of brain activation? Ploghaus et al94 used functional magnetic resonance imaging to investigate brain activation responses to pain experiences that were increased by an anxiety manipulation (warning of a highly noxious stimulus). Results indicated that activation in the entorhinal cortex of the hippocampal formation differed depending on whether pain intensity was increased by the anxiety manipulation.
Given evidence that cognitive and emotional factors can influence neural brain activation, it is likely that neural imaging techniques can be used to study the influence of psychological factors such as pain catastrophizing or self-efficacy. One of the most important avenues for neural imaging research is to examine the effects of psychological interventions on brain activation. Rainville et al100 conducted an interesting neural imaging study in which they used hypnotic suggestions to selectively reduce the unpleasantness of pain, but not its sensory intensity. Results indicated that the hypnotic intervention altered activity in the ACC, suggesting that this brain area might be particularly important in influencing the emotional component of pain. A final way to advance this field is to conduct more research on the mechanisms underlying the efficacy of psychological treatments for persistent pain. At this point there is evidence that psychological interventions can be effective, but why they work is not fully understood. Many of these treatments target the psychological factors listed in Fig 1. More research needs to be done to analyze how changes in these factors occurring during the course of psychological treatments are related to short- and long-term outcomes. Changes in certain psychological factors (eg, self-efficacy) could be much more important than changes in other factors (eg, acceptance.)
This information is important because it could be used to tailor treatments so as to address more directly the key psychological changes that underlie treatment improvements. Psychological treatments for persistent pain also might work via behavioral mechanisms (eg, increasing activity level or changing interaction patterns between individuals and their social environment) or biological mechanisms (eg, altering descending pain control pathways). If we are to better understand how psychological treatments work, attention needs to be given not only to underlying psychological mechanisms but also to underlying behavioral and biological mechanisms. 27,33,40,43,88
SOURCE General Discussion "Acknowledgments The authors wish to thank Karen Cooper..." have been omitted from this page.
Liebeskind's lab remained in the forefront of the field for more than twenty
years. In the 1980s, he and his team demonstrated that pain repressed the
body's immune system and could indirectly promote tumor growth, or in
Liebeskind's stark phrase, "Pain can kill!"
Liebeskind's editorial in Pain (1990) was a forceful expression of his lifelong view that the ultimate purpose of pain research was to provide better care for pain patients and to ensure that no patient should have to suffer the debilitating and dangerous condition of chronic pain.
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