Thursday, Jan. 8th 2015

Treating Chronic Pain

Chronic pain is a challenging condition that is estimated to affect 15 -20% of the adult population of the United States.    One of the most critical questions about any specific treatment for chronic pain is, “does it work?”   The answer to this simple question is complex and with all honestly, “it depends”.     This sort of answer really upsets academics and payers when we try to devise strategies to treat pain. In medicine we want our treatment plans to be based on evidence-based medicine (EBM).   The idea here is that modern medicine can predicted best treatment by plans that have been established by good research data.   The best form of this research is called a double blind, randomized controlled trial (RCT).    Unfortunately the challenges in using evidence based medicine approach and creating good randomized controlled trials are massive particularly in pain management which has so many variables. Just a few of these involve unique Injuries and pain generators , personalities, upbringing, expectations, support systems, psychological and emotional stressors, co-illnesses, access to care, not to mention a payer system which has every patient playing by a different set of rules.

Don’t get me wrong, we’d love RCT with EBM to direct all our treatments, but they aren’t there.   Many advertised treatments report that they have been successfully studied, but most of these claims are based on limited data and often not the gold standard research discussed above. Pain specialists are called on to help in difficult cases.   We are in not in the position to simply turn patients away after some Tylenol, a couple of NSAID trials, an anti-depressant and some expensive medications that have high side effect profiles that half our patients can’t afford.

We have some treatments that work well, but all treatments don’t work the same for every patient even with similar diagnosis. .   We use our experience and knowledge to find what helps but unfortunately many restrictions often block our efforts.   More restrictions seem to be on the way.    Using trials of therapy has been our approach.   The key to treating pain successfully is to take excellent history, examine the patient, review the available studies, order new ones when appropriate then start trying the safest treatments most likely to help.   We also must be ethical and cost conscious.      If the initial treatments are not successful a different treatment must be trialed.    There may be a time when we can neatly wrap all this into a fixed plan that makes payers and academics happy but we are a long way from that ideal.   The skill and experience of   physicians must be respected in this endeavor or our patients will lose out on many successful treatment options.

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