Managing Chronic Pain - A Structured Approach for More Effective Patient Care

Argoff, Charles E., MD
Professor of Neurology
Albany Medical College
Director, Comprehensive Pain Center
Albany Medical Center
Albany, NY Also by this Author 

Chronic pain affects a significant proportion of adults in the United States – over 100 million Americans according to recent estimates.1 This is more people than are affected by heart disease, diabetes, and cancer combined, yet chronic pain management and prescription drug monitoring are often less than optimal.

Dr. Charles Argoff, Professor of Neurology at Albany Medical College and Director of the Comprehensive Pain Center at Albany Medical Center, reviews the shortcomings of chronic pain management and outlines a structured approach to improve the care of those suffering from chronic pain.

A Common Condition, Not Well Understood

Despite the high prevalence of chronic pain, it is often not adequately treated due to a lack of knowledge about the condition.

“The sheer number of people who experience chronic pain is astounding,” says Dr. Argoff. “Both the number of people who have chronic pain associated with their medical condition or those suffering from chronic pain without a definition of their chronic condition is overwhelming.” Yet healthcare professionals receive little training about the condition and are not kept well informed of developments in the field.

“Very few medical professionals are exposed to state of the art information about chronic pain during their training,” he notes. “So they may have clinical skills, which are appropriate for common diseases like diabetes, heart disease and cancer, but they’re not adequately prepared for the most common condition which is chronic pain. This is because chronic pain has been viewed as a symptom and not necessarily as a disease of the nervous system. But we now know chronic pain is associated with changes in how the nervous system functions.”

From Deficient Knowledge to an Informed Approach

Dr. Argoff believes the deficiency in knowledge about chronic pain leads to many patients being inadequately assessed and treated. “We’re treating people with less than complete knowledge and without the kind of precision with which we would treat, say, strep throat, where you take a culture and know what treatment will work and what treatment will not. That kind of precision is not generally applied for treating chronic pain.”

The way forward for Dr. Argoff is to establish “a disciplined, logical and methodical approach” to evaluate and treat people with pain. “We should conduct a full assessment, including a diagnosis, to understand their pain type to the fullest degree possible. We should then match their pain type to the best available treatment for that condition.” But, he cautions, treatment has to be individualized, since not all treatments are going to be effective for each person. This may be because of heterogeneity in the condition, or because of heterogeneity in the pharmacogenetics of drug metabolism, which may be determined by pharmacogenetic testing such as the cytochrome P450 genotype test.

A more structured approach provides a basis for treating patients more effectively and safely. This is particularly important in relation to the use of opioids. “Opioids have essentially become the default therapy for many physicians,” says Dr. Argoff, “partly because they are more familiar than other drugs. Many people assume they work for everything, yet they may not be helpful for a certain percentage of people because of side effects, tolerability issues, or drug metabolism. Additionally it might not be the right choice because of behavioral or substance abuse issues, or if there are concerns about cognitive function. In all these cases alternative therapies should be considered.”

“You have to be clinically critical before initiating therapy,” stresses Dr. Argoff. “Is this drug the right drug for this person? Do we have the benefit documented?”

Diagnosis

Dr. Argoff outlines steps for a precise diagnosis. “Physicians should utilize the most appropriate tools to make the most precise diagnosis that can be made for a patient’s condition.” For chronic headache that’s going to be MRI. For significant lumbar radicular pain it might be a combination of MRI and CT Myleogram.”

He cautions against making conclusions without a sound scientific basis. “If someone has burning sensations in their legs and their nerve conductions are normal, the standard response is they don’t have neuropathy. But this makes no sense: nerve conductions measure large nerve fiber function, but burning sensations, are caused by smaller fibers. These days we would do either quantitative sensory testing and/or skin biopsies to assess for small fiber functions.”

To illustrate his approach, Dr. Argoff recalls a diabetic patient with normal nerve conductions, and somewhat abnormal vascular studies, who was not being effectively treated for her pain. “I told her we needed to assess her arterial circulation and perform a skin biopsy to understand if there was a different kind of nerve problem. This assessment was critical because the treatments that would be helpful for diabetic neuropathy wouldn’t be helpful for vascular disease.”

Risk Assessment

Patient assessment is of particular importance before prescribing opioids and must include an assessment of risk. While risk stratification tools, such as the Opioid Risk Tool (ORT) and Screener and Opioid Assessment forPatients in Pain(SOAPP®), are helpful, Dr Argoff says there is no substitute for thorough questioning to enable an “eyes wide-open approach”. “You should be asking about the kind of pain the person experiences, whether they have consistent pain throughout the day, if some days are bad and others aren’t, and the factors which make it better or worse. At the same time you need to ask whether family members have issues with controlled substances, or whether there is a personal history of drug abuse or alcoholism, whether they smoke or currently use recreational drugs.”

“We should be using our common sense,” he continues. “Do a good history and use one of the tools, so that in a few minutes you can understand the risk: is the person in front of you at high risk of misusing? Then you have to ask yourself whether you’re comfortable taking care of that person in your practice.”

Urine Drug Monitoring

Urine drug monitoring is recognized by pain experts as an important tool to use in conjunction with opioid therapy for chronic pain.2, 3 Dr. Argoff uses urine drug testing before initiating opioid therapy for chronic pain and then to monitor treatment on a random basis. “Before committing someone to long-term therapy is the time when you should get your first urine drug screen. That way you will have learned key information about who you're treating before you start treatment. Subsequently, I’ll test randomly a couple of times a year.”

At the same time, Dr. Argoff discusses the importance of storing controlled drugs safely to minimize the risk of misuse. “I tell patients it’s their responsibility, otherwise they’re putting other people at risk and they’re not a good candidate for opioids.”

Looking Ahead

In considering how the field of pain management and prescription drug monitoring will develop, Dr. Argoff emphasizes the importance of appropriate assessment as a starting-point. “Our field will not evolve unless we remain committed to doing the best proper assessment. No one would think it proper to treat breast cancer without doing biomarkers these days, so why should anyone think it’s proper to treat somebody in pain without doing a careful assessment?”

Over time, a better understanding of pain will lead to more effective therapies. “We will learn more about the biology of different pain disorders and how best to treat them. We will and must also learn to use opioids more safely and effectively than currently.”

References

  1. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Institute of Medicine. Institute of Medicine of the National Academies. June 29, 2011
  2. Chou R, Fanciullo G, Fine P, et al. Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain. JPain 2009;10:113–30.
  3. Peppin J, Passik S, Couto J, et al. Recommendations for Urine Drug Monitoring as a Component of Opioid Therapy in the Treatment of Chronic Pain. Pain Med. 2012 Jun 13. doi: 10.1111/j.1526-4637.2012.01414.x.


Released on Tuesday, July 03, 2012