Sunday, October 6, 2019

Part 5 - Why Do We Lump the Non-Cancer Pain Syndromes Together?

by Drew Rosielle (@drosielle)

A Series of Observations on Opioids By a Palliative Doc Who Prescribes A Lot of Opioids But Also Has Questions.

This is the 5th post in a series about opioids, with a focus on how my thinking about opioids has changed over the years. See also:
Part 1 – Introduction, General Disclaimers, Hand-Wringing, and a Hand-Crafted Graph.

Part 2 – We Were Wrong 20 years Ago, Our Current Response to the Opioid Crisis is Wrong, But We Should Still Be Helping Most of our Long-Term Patients Reduce Their Opioid Doses

Part 3 – Opioids Have Ceiling Effects, High-Doses are Rarely Therapeutic, and Another Hand-Crafted Graph

Part 4 – Everything We Were Taught About High Doses Was Wrong, And The Same Hand-Crafted Graph

This is Part 5 – Why Do We Lump The Non-Cancer Pain Syndromes Together? Part 6 is heavily related to Part 5, and will ask the sort of inverse to Part 5 – Why Is Cancer Pain So Special?

The language we use to categorize pain and talk about pain is inadequate, dangerous, and unfair.

In particular what I mean here are the distinctions made between ‘chronic pain’ and ‘cancer pain.’

What is actually meant by chronic pain? In the very important CDC opioid guidelines, they use this definition: “Chronic pain has been variably defined but is defined within this guideline as pain that typically lasts at least 3 months or past the time of normal tissue healing.” Most definitions use something like that. Note that the definition really focuses on the temporality of the pain, which is of course important, but really makes no proposal otherwise on what the pain syndrome is, what its course is, what causes it, what the patient’s prognosis is, whether or not it involves a primary ongoing lesion of the nervous system or ongoing active tissue inflammation and damage (eg, chronic rheumatoid arthritis pain, chronic sickle cell pain, etc, which can continue for years), etc.

What this leads to is a broad lumping together of dozens of different pain syndromes into a single category: ‘chronic pain,’ or ‘chronic non-cancer pain’ (I’ll just say CNCP here for brevity).

Reading guidelines like the CDC’s, they basically apply themselves to all CNCP, with a brief, unexplained exception for patients with cancer pain, or who are receiving palliative care, whatthehellever that means.

Which essentially means in those guidelines, and in all the policy responses to them (by payors, state medical and pharmacy boards, local health organizations implementing new policies, etc), all CNCP syndromes are lumped together.

Think about this. From a policy standpoint it treats chronic pain from fibromyalgia, work-related back injuries, chronic headaches, severe inflammatory arthritidies, poorly defined chronic abdominal and pelvic pain syndromes, moderate degenerative arthritis, bone on bone deforming degenerative arthritis, sickle cell disease, congenital spine deformities like severe scoliosis, spasticity syndromes like multiple sclerosis or cerebral palsy, chronic bone diseases like osteonecrosis, chronic ischemic limb pain, chronic wound pain, post-surgical neuralgias, complex regional pain syndrome, the dozens of types of axonal neuropathies, etc., as the same thing (from a policy standpoint).

You get my point, I hope, which is to argue that many of these are very different pain syndromes, which have different prognoses and ranges/types of treatments, and regardless of anything else, should not be lumped together without qualification with the couple syndromes that we do in fact have half-way decent-ish research data showing that opioids aren’t effective (for most patients), (long-term), (eg, chronic back pain, fibromyalgia, chronic headache syndromes). This is not me arguing that opioids are the best or first-line analgesic for many of the other pain syndromes (!), but more to point out that highly influential guidelines or organizational/public policies which do not differentiate between, say, the patient lacking cartilage in most of their weight-bearing large joints who has trouble taking the dog out to pee without a few hydrocodone a day (who’s tried many other modalities also), and the depressed, unemployed patient with a work-related back injury who drinks to intoxication most days a week and is on long-term opioid therapy (which has not been successful to restore function), is a shit guideline/policy.

I can’t see a clinically coherent or fair reason to do this lumping, except that these things aren’t ‘cancer pain’ (see the next post on this). Like everything, it’s complex, and what we need are thoughtful, skilled clinicians who are knowledgeable and who can perform individualized assessments and treatment planning with patients, not one-size-fits-all lumping, but these policies and guidelines discourage that, regardless of their authors stated intentions (I don’t care what their intentions were), and that’s crap.


Part 1 – Introduction, General Disclaimers, Hand-Wringing, and a Hand-Crafted Graph.
Part 2 – We Were Wrong 20 years Ago, Our Current Response to the Opioid Crisis is Wrong, But We Should Still Be Helping Most of our Long-Term Patients Reduce Their Opioid Doses
Part 3 – Opioids Have Ceiling Effects, High-Doses are Rarely Therapeutic, and Another Hand-Crafted Graph
Part 4 – Everything We Were Taught About High Doses Was Wrong, And The Same Hand-Crafted Graph

For more Pallimed posts about opioids.
For more Pallimed posts by Dr. Rosielle click here.

Drew Rosielle, MD is a palliative care physician at the University of Minnesota Health in Minnesota. He founded Pallimed in 2005. You can occasionally find him on Twitter at @drosielle.

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