The increase in narcotics use that has led to the current opioid crisis reveals the dire need to re-examine the concept of medical pain management. For many years, the media, pharmaceutical industry, special interest groups, experts, and medical leadership have expressed concern about an epidemic of chronic pain and the thousands of sufferers in its clutches. However, no explanation has been proposed to account for this new scourge in an era with so many ways to control pain, including joint replacement, novel medications, private and public pain clinics, recognition of the role played by mental health, and better management of diseases such as rheumatoid arthritis.

Pain is one of the most common reasons to visit a family physician and can be challenging to manage for all physicians, especially when it becomes chronic. Pain management for inpatients rarely involves the long-term use of narcotics, yet we commonly see outpatients at rehabilitation clinics taking high-dose narcotics for musculoskeletal pain. This suggests we need to understand how misuse of narcotics occurs and identify the factors contributing to the patient’s pain rather than prescribing additional painkillers. We also need to provide patients with pain management tools other than narcotics and recognize that easy solutions are not the answer. 

Chronic pain 
As a specialist in physical medicine and rehabilitation, I see patients suffering from different degrees of pain. At the worst, I see pain caused by catastrophic accidents, brain injuries, spinal cord injuries, damaged nerves, severe strokes, multiple sclerosis, bone diseases, and neuromuscular diseases. Thankfully, I also see less devastating pain caused by routine musculoskeletal injuries and the normal aging process. Between these two extremes I see chronic pain caused by stroke, spinal injury, arthritis, illness, and disease. None of these are newly discovered conditions. 

Chronic pain syndrome is a biopsychosocial diagnosis, a catchall term for widespread pain and dysfunction that far exceeds what would be expected from the initial injury or illness. After I give talks on pain management, I am often approached by physicians who trained in countries such as Mexico, South Africa, Poland, Iraq, and even the UK. They admit that they struggle to manage patients with chronic pain syndrome. They never received training in the condition or saw patients with debilitating pain from soft tissue injuries, arthritis, and back or neck problems. They were not trained to write letters and complete forms for disability benefits or to prescribe narcotics for long-term use in the absence of severe disease or injury. They cannot help comparing these chronic pain patients who have vague to moderate symptoms and extreme complaints with patients who function far more fully despite experiencing horrible diseases and terrible accidents.

Pain management for inpatients
It is rare to see long-term treatment with narcotics on hospital inpatient wards. Patients with shattered limbs, strokes, and amputations are quickly weaned off their initial doses of narcotics in the acute care ward or after entering the rehabilitation unit. They are treated by a team of nurses, doctors, pharmacists, nutritionists, psychologists, and social workers and by physical, occupational, and speech therapists. Their experience of pain is validated and typically they receive boundless expressions of love and support from family and friends. If a barrier to wellness is identified, it is addressed. If there is no pain in a joint at rest, no painkillers are used. If pain prevents sleep, sleep aids are used. Lighter anti-inflammatory medications, acetaminophen, and the lowest possible dose of narcotics are used. Ice, heat, compression, and bracing are optimized. Nerve pain drugs are prescribed when necessary. If depression is a factor, this is acknowledged and treated. Targeted cortisone injections may be used for the pain in knees caused by arthritis or the severe shoulder pain typical in strokes. These injections can offer dramatic relief from pain for weeks and allow joint use to ensue and mobility to improve. If the pain cannot be stopped, coping strategies are suggested. 

In my experience and that of my physical medicine and rehabilitation peers, rehabilitation patients rarely leave hospital using narcotics and are rarely prescribed narcotics once they are safely home. 

Pain management for outpatients
Given the way narcotics are used in the inpatient setting, why are so many outpatients referred to rehabilitation clinics already taking narcotics for musculoskeletal pains? And why are these narcotics often being used in combination with sedatives, sleeping pills, and marijuana?

People with chronic pain typically do not receive validation from friends and family, but instead face frustration, a lack of support, or dismissal. Narcotics use begins for many of these patients with visits to the emergency room or walk-in clinics, and continues with endless prescription renewals. We give people with acute soft tissue traumas such as whiplash narcotics rather than recommending rest, ice, compression, and elevation.  A campaign in the United States challenges this practice by asking, “Would you give your child heroin for a sports injury?”

Many patients have longstanding mental health conditions that take hours to assess and treat. It is easier to prescribe medication for a widespread chronic pain disorder than to complete a detailed mental health assessment and identify the life stressors affecting the patient. Fibromyalgia has no cure. Should we give up when we make this common diagnosis, or fight to fix what we can?

We see patients in rehabilitation programs celebrating each gain as they struggle against pain to walk down a hallway, dress themselves, and complete other tasks without high-dose narcotics. We see athletes enduring tremendous pain to achieve their goals, blocking out the pain and finding pleasure as they balance pain against gain. We hear patients who are self-employed state that they have no choice but to keep working and do not want to take pain medications that will interfere with alertness. Daily, many patients say, “Please do not give me drugs, I want to do this myself.” So why can these individuals achieve maximal function on  minimal medication, while individuals experiencing lesser pain require escalating doses of narcotics?

Misuse of narcotics
Unfortunately, physicians have been told they can safely increase doses of narcotics. The truth is that when a patient is not receiving good pain relief from a low-dose opioid it is absolutely wrong to escalate. If the pain is not reduced, the pain is not responding to the drug.

In a clinic in a small town on Vancouver Island, I saw a young man who had originally presented with back strain and was still taking high doses of hydromorphone, a drug 5 times more potent than plain morphine (e.g., 6 mg of hydromorphone is the analgesic equivalent to 30 mg of morphine). Over time the tablets he had been prescribed increased from 3 to 6 to 12 to 24 mg. His physicians likely forgot the multiplication factor and soon he was taking the equivalent of over 1000 mg of morphine a day. This was contrary to the recommendations of the National Opioid Use Guideline Group at that time (2010), which set 200 mg of morphine equivalents as the upper limit for chronic noncancer pain, an upper limit that the current guideline (2017) has lowered to 90 mg.[1,2] Yet this young man no longer had any pain! He could jog, snowboard, and maintain a physical job, and had normal examination and X-ray results. He was receiving unnecessary treatment for a condition that had resolved with time. 

On the same occasion I saw a man in his late 50s who had terrible pain in his back from years of physical labor. He was taking over 700 mg of morphine and it was not helping his pain. His examination revealed a typical stooped forward posture, limping gait, and severe deconditioning. He could not stand fully upright to walk smoothly because of compensatory muscle tightness. Images from his CT scan revealed routine age-related degeneration. He had been waiting for over 18 months to see a neurosurgeon, yet he was never once referred to a physiotherapist, despite having arthritis that might have responded well to routine physiotherapy in his own community. Instead of receiving this or facet injections, he was treated with narcotics that left him impaired mentally, in pain, and deconditioned.

Buchbinder and Underwood[3] have stated that there is limited evidence for what works when treating back pain and that future research should focus on the factors that make people disabled after back injury. Chou and Shekelle[4] have noted that the most helpful indicators for predicting persistent disabling low back pain are maladaptive pain coping behaviors, nonorganic signs, functional impairment, general health status, and the presence of psychiatric comorbidities.

Finally, Colman and colleagues[5] have addressed depression and reviewed factors that predict recurrence of depression. When the factors were assessed, only smoking and low scores on a scale of self-mastery predicted future recurrence. Interventions designed to increase self-mastery—the ability to work toward and achieve a goal, to have control over personal actions—were found to carry additional benefits, including improvements in pain management. 

Providing patients with the right tools
As physicians we must help patients use self-mastery and other tools to work through pain. We need to explain the injury or the natural history of the disease, the reason for treatment, and the reason why surgery or another treatment is not required. We need to offer reassurance. For example: 
• Your back pain may flare again. Just wait and do not panic. Your pain will often return to baseline. 
• You may hurt more when you exercise, but will likely recover by the next day. If you do, it is okay to increase activity. 

Patients need to know that understanding and visualizing the source of pain is key to healing and can be supported by targeted interventions: local bracing, a sleeping pill, a cortisone injection for an inflamed joint or tendon, the proper evidenced-based medication protocol for migraines. They also need to understand the effect of depression and stress on the body.

As physicians we are often afraid to say no to a patient who may be miserable, unemployed, or depressed. Family physicians struggle with multiple psychosocial factors that are beyond their capacity to treat alone. In addition, third parties may advise a patient to make medical appointments many times a month to report neck or back pain after an accident and to continue with endless trials of pain medication. When asked why they continue to see their doctor so often, patients often say my lawyer or insurer tells me I must go every month. 

As physicians we write letters explaining why a patient should not return to work for months or years. We are often pressured to advocate. Yet the literature reveals that worklessness is associated with poor outcomes for physical and mental health, social welfare, and life expectancy. The longer we keep patients off work the worse the outcome. 

Perhaps a different kind of compassion must be extended. I recently heard that one of my colleagues uses this approach. At times we need to say, “I do not accept your pain. I do not accept that you have no quality of life. I do not accept your misery. I will be your champion. There is work to be done, and we will attack each barrier together, but I will not disrespect and dismiss you by just labeling you with an incurable chronic pain syndrome and giving you drugs. Your imaging does not reveal a severe condition, the specialists have no operations. I will fight and advocate for you. I will write letters insisting on modified duties at work to keep you employed and productive. I will demand that you be offered therapies.” 

Easy solutions not the answer
On a daily basis I am humbled and made proud by my patients’ fight against pain and sometimes I am defeated by their pain. Writing a prescription is an easy solution, but unless the prescription is for a disease-modifying treatment it is not a long-term solution. There is no greater pleasure than giving patients the tools to regain function, stop medications, and take ownership of their health. The right medication can change a life, but giving drugs that do not improve quality of life is ultimately harmful.

When there is no clear diagnosis of disability we should not simply take a history and repeat verbatim information from what are often very leading intake forms that list symptoms and include self-report pain scales. What we must do is ask the right questions. What are the individual factors that make you suffer so? Why are you off work and unable to care for your family? Why do you use so many drugs, or conversely, why do you avoid all drugs and offers of mental health intervention? We must seek the causes and the barriers. 

Rehabilitation should maximize potential and restore function. It is unfair and unhelpful to leave physicians, particularly family physicians, with so little access to the supports patients need. Our medical model offers easy access to medications and spends thousands of dollars each year on painkillers. In contrast, access is more limited to physical and occupational therapy, trained psychotherapists, vocational rehabilitation, addiction specialists, and daycare to allow an overwhelmed parent the time to seek help. It takes a team and dedication to overcome patient barriers and work toward health. We must be honest with our patients when we feel their symptoms outweigh their signs and work with them to mitigate disability, not promote it. 

If pain persists the response should never be to prescribe yet another painkiller. Making the proper diagnosis is all important when patients present with pain. If patients require narcotics for severe injuries and diseases, cancers, inoperable back conditions, and arthritis, a fine balance of side effects and efficacy must be made. We should use narcotics only if a patient is better on the drug than off. We should not raise the dose unless it gives relief and greater function. We should wean the patient from the drug as soon as possible. Prescribing narcotics on a long-term basis should no longer be seen as acceptable, unless it is to provide improved quality of life in fully investigated and closely monitored conditions and all other treatments have been explored.

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This article has been peer reviewed.

References

1. National Opioid Use Guideline Group. Canadian guideline for safe and effective use of opioids for chronic non-cancer pain. 2010. Accessed 26 June 2017. http://nationalpaincentre.mcmaster.ca/documents/opioid_guideline_part_b_... [9].
2. National Opioid Use Guideline Group. The 2017 Canadian guideline for safe and effective use of opioids for chronic non-cancer pain. Accessed 26 June 2017. http://nationalpaincentre.mcmaster.ca/documents/Opioid%20GL%20for%20CMAJ... [10]
3. Buchbinder R, Underwood M. Prognosis in people with back pain. CMAJ 2012;184:1229-1230.
4. Chou R, Shekelle P. Will this patient develop persistent disabling low back pain? JAMA 2010;303:1295. 
5. Colman I, Naicker K, Zeng Y, et al. Predictors of long-term prognosis of depression. CMAJ 2011;183:1969-1976.

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Dr Winston is a specialist in physical medicine and rehabilitation. He is medical director of Rehabilitation and Transitions for Island Health and clinical associate professor with UBC. His practice includes patients with neurologic and musculoskeletal impairments.