What You Don't Know Can Hurt You!

Think back to the last time you saw your healthcare provider—What were you being seen for? Were you feeling tired or run down? Were you hurting somewhere?  Or was it related to the management of a chronic condition? In my experience, what drives many people to see their primary care provider ultimately has to do with pain or discomfort of some kind.

A study published in the journal Mayo Clinic Proceedings this January reports that 2 of the 3 top 10 reasons that people visit their healthcare provider are related to pain. Skin issues, coming in at number one rounds out the top 3 though I would still argue that there could definitely be a component of discomfort here. That being said, there isn’t always a lot of direction when it comes to the management of both acute and chronic pain.

Surely the most important part of any pain management regimen includes a good diagnosis. Our primary goal is to identify and treat the underlying problem, not just the symptoms. When the cause is clearly identifiable, the treatment is easily directed at the source. Treating the actual problem more often than not relieves the pain but what about those times when the diagnosis is less clear or when definitive treatment is not readily available?

First of all, let me express my gratitude to medical specialists. The field of family practice provides an excellent background to diagnose and treat the vast majority of both acute and chronic complaints but when initial treatments fail or when the diagnosis in unclear, I for one am grateful that there are providers whose training and experience is much more focused than my own. We utilize their skills whenever possible.

But even then some diagnoses remain unclear or definitive treatment may remain elusive. Individual response to treatment can also be highly variable. Many times our focus ultimately returns to a single complaint: pain.

Luckily there are specialists in this area as well! I have found, however, that accessibly is an issue. And when there is no one else to manage a patient’s pain, I believe that the responsibility falls to the family doctor or PA. The remainder of this article will focus on available resources to guide the treatment of pain, both acute and chronic, in the family practice setting.

The World Health Organization makes the following recommendation:

If pain occurs, there should be prompt oral administration of drugs in the following order: nonopioids (aspirin and paracetamol [acetaminophen or Tylenol]); then, as necessary, mild opioids (codeine); then strong opioids such as morphine, until the patient is free of pain.

While I generally agree with this statement, I take issue with a few of the implications. The first of which is the idea that all patients can and will achieve a completely pain-free state. That is simply not a true statement at best and a potentially devastating one at worst! I personally believe that a 25%-50% reduction in pain is not only indicative of a successful treatment regimen but is also a much more realistic goal. Physical pain at some level is an unavoidable part of life.

Another point that I would argue is that drugs are the only way, or even the best way, to treat chronic pain. While there may not be a wealth of scientific evidence regarding the efficacy of alternative treatments, I often recommend several modalities, which in my opinion, are still valid options. The list of alternative treatments is quite extensive but some of the more commonly recommended ones in my office include weight loss, exercise, physical therapy, TENS (transcutaneous electric nerve stimulation), cognitive behavior therapy, therapeutic ultrasound and massage.

There are also several medications not technically classified as analgesics (pain killers) but can be very useful in treating chronic pain of various types. These medications include duloxetine (Cymbalta) and gabapentin (Neurontin) among others. Some of these adjunctive treatments as they are called also treat depression which I believe forms a very important component of pain whether initially or later in treatment.

I would also disagree with the WHO in saying that opioids are for everyone. They most certainly are not! While I do believe that pain is grossly undertreated at times, especially among minority groups, and that opioids can be very helpful in relieving both acute and chronic pain, it is also over treated as well. A recent Drug Enforcement Agency (DEA) report indicates that the sale of opioid medications such as Vicodin, Norco, and OxyContin has been steadily climbing over the last two decades. They also clearly indicate that overdose deaths have been rising as well. The number of patients in addiction treatment programs has also kept pace. These medications are “scheduled”, read controlled, for a reason: They can be dangerous and addictive. But when a patient and his provider work together with complete transparency, they are certainly an option for some.

Comprehensive care of both acute and chronic pain require more than a simple assessment of physical distress. The astute provider will also assess a patient’s social and occupational functioning, personal and family relationships as well as a history of mental illness and substance abuse.

Whatever your concern, be open and honest with your healthcare provider. Develop a relationship of trust with him or her. Do your very best to take proper care of yourself and to follow his or her directions and when pain inevitably rears it’s ugly head, don’t hesitate to give us a call.

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