It is a few years that I started treating Chronic Pain. It seems I entered in a very challenging time when the difference between chronic pain and the acute pain was not very well known by doctors. In 1986, the World Health Organization (WHO) developed a simple model for the slow introduction and increased the dose of painkillers that became known as the WHO analgesic stepladder. Before this, people were dying in unnecessary pain because drug regulations introduced earlier in the century had increased the stigma and fear associated with both prescribing and taking opioids.
In the start of my practice, we had to fight against ignorance of pain. Doctors tend to ignore what they do not know. As a physician, I remember those days that my nightmare was seeing a patient with chronic back pain. I felt miserable, helpless and a failure to help my patients. That was why I ask questions about depression, which I knew better and treated that symptom. I do not, for a second, judge people who did not want to prescribe narcotics to chronic pain patients, in the fear that they may get addicted.
In 2009, many other up-to-date doctors and I felt obligated to ask for seeing and believing chronic pain and accepting it as a chronic disease that needs treatment. WHO has already given us a very amazing tool, why not using it. I am admitting that I was wrong. WHO was wrong. All Western Medicine got it wrong.
Based on the classical teaching of the medicine of acute pain, every time I saw the patient, I asked him/her about the intensity of pain. According to the response, I increased the dose of narcotics. This is a practical, accurate and acceptable way of finding the right dose of the painkiller for a patient after an operation.
In 2003, an article published in one of the very relevant journals that started waking us up. In this article pointed out that every pain in human, unrelated to the anatomical or etiology, always accompanying with some change in the brain. We all know that some of us have more tolerance for the same pain. In this article, the author suggested that in acute or cancer-related pain, the amount of pain is related and relevant to the tissue injury, the bigger the damage, the more pain. However in Chronic Pain that is long lasting, the amount of pain is not relevant to the size of the damage. In fact, after a while, emotions and psychosocial factors are more relevant to the reported pain by the patient!
Hashmi JA, Baliki MN, Huang L, et al. Shape shifting pain: chronification of back pain
shifts brain representation from nociceptive to emotional circuits. Brain 2013;136:2751-68.
Therefore asking a patient with a chronic long standing pain to score the pain and prescribe narcotics, was an entirely a mistake! I feel I was part of the problem and these days, I am doing my best to destroy the monster that I was involve creating.
We still don't know what the right way is. Honestly, this science is so young that we are learning every day. We just learn how to "see" pain effect on the brain. By using an fMRI, the scientist started seeing some amazing relevance between the increase of the blood flow to some parts of brain and intensity of pain. The issue is, they still could only inflict an acute pain, like a small electric shock. The results and findings would probably have no relevance to chronic pain patients. It is only one more step forward.
In the end, I would like to hear from you, over 5000 patients that I know since 2009. Do you think being on chronic painkillers had increased your quality of life? Could you work? Could you go back to the activities that you have loved to do? What parameter is more relevant to your well being?
Sleep? Appetitle? Walking distance? The amount of time you could stand in one place? How many laugh you had in the last 24 hours? How many times have you cried in the last week? How many meals you enjoyed making in the last week? Last 24 hours? Help us making it right.
Dr. Ramin Safakish, anesthesiologist and pain interventionist, is a full time pain interventionist in Allevio Pain Management.