Untreated Chronic Pain is Acute Pain

Untreated Chronic Pain is Acute Pain

The controversy over non-treatment of pain with pain medicine has filled the pages of pain advocacy journals in recent months.

Kurt W.G. Matthies

Kurt W.G. Matthies

Let’s face it. The CDC is going to do what it likes behind closed doors, regardless of what we say here, without consulting the American Academy of Pain Medicine (AAPM), and in spite of the Washington Legal Foundation. Our opinions, as people who live in pain and the doctors that treat us, are irrelevant. So say Ballantyne, Freiden, and the insular CDC junta.

They are missing the point.

Pain Medicine is and has never been about a patient’s comfort level – that’s called palliative medicine. Instead, the treatment of chronic pain is a necessary medical intervention to attenuate the progression of physiological disease, and to affect an improvement in a patient’s quality of life or QOL. When medical care creates a positive change in the QOL of someone who lives with daily intractable pain, it improves that patient’s ability to function as a parent, employee, student, or other participating member of society.

Pain medicine and its use of opioid analgesics as a modality in the treatment of chronic pain, seeks to improve a person’s QOL for the benefit of all. The anti-analgesic cartel thinks only in terms of the harms of treatment, and claims that they outweigh the benefits.

Again, they are missing an important point.

It is a physician’s ethical duty to treat pain and suffering.

So says emergency physician Dr. Andrew Luke Aswegan, MD in his September 2007 story for the American College of Emergency Physicians [1], who reminds us that:

Pain as a presenting complaint accounts for up to 70% of emergency department visits, making it the most common reason to seek health care. Often, it is the only reason patients seek care.” 

Breakthrough pain is very real. I won’t bother to list the many authorities who recognize the existence of this phenomenon in the person with intractable pain treated with chronic opioid therapy (COT).

Many in the chronic pain community have experienced rejection in the emergency department at their local hospitals, and new rules developed from the poorly-named concept of Universal Precautions in Pain Medicine [2] put many who are treated for chronic pain at risk of losing their COT if they receive analgesic treatment from any doctor other than their pain doctor.

“Patients should be allowed to make autonomous decisions when appropriate, and the principle of justice guides us to evaluate and alleviate pain in a nonprejudicial and nonjudgmental manner. Our ethical duty to relieve suffering is clear. If we don’t provide adequate pain relief, we risk losing our patients’ trust, and, ultimately, our patients,” concludes Dr. Aswegan.

Emergency room physicians ignoring an ethical imperative by refusing to treat people on COT who experience acute exacerbations of pain are considered by many to be limited by an extreme professional bias called Opiophobia.

What is Opiophobia?

In their authoritative article for the BJA, Chronic Pain and Prescription Opioid Misuse,  Dr. Simon G Tordoff FRCA, FIPP and Dr. Praveen Ganty, FRCA write that

“Opiophobia describes the reluctance of prescribers to use opioid medication for fear of causing addiction or toxicity. There are many factors involved, for example, pressure from peers or patients or carers, regulatory restrictions by government agencies, a lack of education and understanding of the use of opioids, or social and moral prejudice. Staff might be fearful to prescribe or administer opioids for fear of causing respiratory depression, addiction, or both.” [3]

In short, Opiophobia is a doctor’s reluctance to prescribe an opioid analgesic for a person in pain.

Dr. Tordoff’s definition implies that Opiophobia can mean different things to different doctors. To one, it’s a fear of reprisal from an authority for prescribing these medications. To another, Opiophobia is caused by a concern for doing harm to the patient. Finally, some people have a bias against the use of drugs – a bias that is re-enforced in our business culture.

Many people treated for pain believe that the authority that doctors fear is the Drug Enforcement Agency. While this may have been true in the last decade, what we’re finding is that doctors today are much more likely to be disciplined by their state board of medicine for “over-prescribing” opioids. The case of Dr. Mark Ibsen of Helena, MT, as reported in these pages, is a typical example of the risks physicians face when they attempt to effectively treat pain. [4] [14]

As for that other reason – the treatment of pain with opioid analgesics causes more harm than benefit – let’s examine the nature of pain, and how forces are attempting to change our ideas about it.

What is Chronic Pain?

According to Johns-Hopkins Medicine,

“Pain is an uncomfortable feeling that tells you something may be wrong. It can be steady, throbbing, stabbing, aching, pinching, or described in many other ways. Sometimes, it’s just a nuisance, like a mild headache. Other times it can be debilitating.

Pain can bring about other physical symptoms, like nausea, dizziness, weakness or drowsiness. It can cause emotional effects like anger, depression, mood swings or irritability. Perhaps most significantly, it can change your lifestyle and impact your job, relationships and independence.” [5]

At that point, the discussion continues into the difference between acute and chronic pain.

That’s odd.

The other day I was traveling in the Wayback Machine [6] and read this very same page at Johns-Hopkins from December 8, 2013. Then, the discussion of chronic pain continued with …

“Chronic pain has been said to be the most costly health problem in U.S. Increased medical expenses, lost income, lost productivity, compensation payments, and legal charges are some of the negative economic consequences of chronic pain. Consider the following:

  • Low back pain is one of the most significant health problems. Back pain is the most frequent cause of activity limitation in people younger than 45 years old
  • Cancer pain affects the majority of patients in intermediate or advanced stages of cancer
  • Arthritis pain affects nearly 50 million Americans each year
  • Headaches, according to the National Institute of Neurological Disorders and Stroke, affect millions of U.S. adults. The three most common types of chronic headaches are migraines, cluster headaches, and tension headaches
  • Other pain disorders such as the neuralgias and neuropathies that affect nerves throughout the body, pain due to damage to the central nervous system (the brain and spinal cord), as well as pain where no physical cause can be found–psychogenic pain–increase the total number of reported cases.” [7]

On another 2013 Hopkins page discussing pain management in acute pain, we read:

“Pain is your body’s way of telling you something is wrong.” [8]

Two years ago, one of the most respected medical organizations in the world tells us that chronic pain is the most important health care problem in America, and that certain pain disorders cause damage to the central nervous system. They say, rightly, that pain is a sign of disease.

Today, they call pain a “feeling”, a “nuisance” that may interfere with your relationships and lifestyle.

Is the truth about chronic pain being minimized and ‘spun’?

Sadly, Johns-Hopkins appears to be another American medical institution who has succumbed to the politicization of pain, and has therefore redacting any reference to the physiological damage caused by untreated chronic pain, and the millions who suffer from this silent epidemic – the American Pain Epidemic.

Untreated Chronic Pain as an Acute Clinical Episode

People who live with chronic pain are treated with COT, which are usually extended release formulations of common opiates like morphine. A good doctor will titrate pain medication to an effective therapeutic dose providing the patient with a better QOL.

However, people with chronic pain disease experience frequent episodes of increased pain, called breakthrough pain, even if their day-to-day pain is well-managed with opioid analgesics and other modes of therapy. Although not well studied, when it was studied, the prevalence of breakthrough pain is found in 50% to 75% of patients receiving COT. [9][10][11]

Moderate to severe pain causes physiological changes in the body’s sensory and endocrine systems. There is an evolutionary connection to these physiological responses to pain within the body. From the brain through the nervous system, and the chemical messengers known as hormones, this response is classically understood as the “fight or flight” reaction, explained by physiologist W.B. Cannon in The Emergency Function of the Adrenal Medulla in Pain and the Major Emotions, published in the 1914 American Journal of Physiology.

Cannon’s elegant words describe how adrenalin, “Liberated Normally in Fear, Rage, Asphyxia and Pain,” is a reflex response to pain and major emotion, which leads to a release of glycogen into the bloodstream, necessary…

“for putting forth supreme muscular efforts,” and to the vascular changes that shunt blood away from vital organs in the gastrointestinal and urinary system in order that the “tripod of life – the heart, lungs and brain (as well as the skeletal muscles) – are, in times of excitement… abundantly supplied with blood…” [12]

Cannon concludes this well-known medical tract with these words:

“These changes in the body are, each one of them, directly serviceable in making the organism more efficient in the struggle which fear or rage or pain may involve; for fear and rage are organic preparations for action, and pain is the most powerful known stimulus to supreme exertion.” [13]

This is a pain flare, wherein, chronic pain becomes acute pain. The fight/flight mechanism is all wound up, and all body systems are under enormous stress.

When pain levels rise above acceptable, people in pain are moved by these physiological forces to find relief. If they cannot find that relief through attention, distraction, mindfulness, exercise, ice, meditation, CBT, OTCs, positive attitudes, soaking in the tub, or their regular prescription medication, they seek treatment in an emergency room.

And in American emergency rooms, people in acute pain are being denied care. Why – because they are diagnosed and treated for chronic pain. This Opiophobia-based discrimination is tantamount to torture.

And torture is a violation of human rights, prohibited under international law.


[1] http://www.acep.org/Clinical—Practice-Management/Our-Ethical-Duty-Is-to-Relieve-Pain-and-Suffering/

Another great reference on ethics and Opiophobia in the treatment of chronic pain can be found on Dr. Forest Tennant’s Practical Pain Management site:


[2] The authoritative Medscape article by Gourlay and Heit on Universal Precautions in Pain Medicine http://www.medscape.org/viewarticle/503596

Read why pain patients have regular UDTs and sign additional contracts for treatment, and consider this: who do universal precautions protect?

[3] Dr. Tordoff’s informative article titled Chronic Pain and Prescription Opioid Misuse can be found here. http://www.medscape.com/viewarticle/728575_2

It is a recommended read for anyone interested in the patterns of opioid use and abuse in the chronic pain community.

[4] For an introduction to the Dr. Mark Ibsen story, see:

A New Approach to Prescribing Narcotics

And search for the name Ibsen for other stories. Although we reported in June that Dr. Ibsen “won” his case, as of this week, Dr. Ibsen’s Montana medical license is under threat of removal by the Montana BOM.  Breaking 12/4/15 – See note [14] below.

[5] What is Pain? from Johns-Hopkins Blaustein Pain Treatment Center


[6] In his seminal volume, The Life of Reason or The Phases of Human Progress: Reason in Common Sense (2nd ed., Charles Scribner and Sons, NY, 1924.), the philosopher George Santayana wrote “Those who cannot remember the past are condemned to repeat it.”

The Wayback Machine is the closest thing we the people have to a historical record in our modern era. Use it, and support it.


[7] From the site HopkinsMedicine.org, December 5, 2013


[8] ibid.


[9] Bennett, DS, Simon, S., et. al. (2007) Prevalence and characteristics of breakthrough pain in patients receiving opioids for chronic back pain in pain specialty clinics.

“Eighty-seven subjects (74 percent) experienced 93 types of BTP.”


[10] Portnoy, RK, Bennett, DS, et. al. (2006). Prevalence and characteristics of breakthrough pain in opioid-treated patients with chronic noncancer pain.

“This article presents results from a survey that demonstrates that breakthrough pain is highly prevalent and varied in opioid-treated patients with chronic noncancer pain. These findings will assist clinicians in assessing and managing this type of pain.”


[11] Gatti A, Mediati RD, et. al. (2012). Breakthrough pain in patients referred to pain clinics: the Italian pain network retrospective study.

“Despite breakthrough pain (BTP) being one of the most severe forms of pain, there are no definitive data on its prevalence.”

“The authors analyzed records of 1,401 patients (58% women, 33.1% patients with cancer). Transient episodes of severe pain or BTP were referred by 790 patients (56.4%), including 58.2% of the men (342 of 588) and 55.1% of the women (448 of 813). Among the 464 patients with cancer, 70.3% reported daily exacerbation of pain.”


[12] Cannon, W. B. (1914). The emergency function of the adrenal medulla in pain and the major emotions, Am J Physiol, 33(2), 356–372.

[13] Cannon (1914), op. cit., page 372.

[14] Sadly, Dr. Mark Ibsen was forced to close his urgent care clinic this week.


“The Healing Begins When You Walk Through the Door” is still painted on the front door of the Helena, MT clinic. Our condolences Mark, to you, your staff, patients, and the citizens of Helena. Illegitimi non carborundum.

At this time of Thanksgiving, I would like to express my gratitude to my friends and copyeditors for their generous contributions of time and expertise to these stories. Thank you. Also, I wish to send a special thank you to my friend Alex, who inspired this story and taught me much about the nature of pain and pain medicine.






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Copyright © 2015 by Kurt W.G. Matthies and National Pain Report. All Rights Reserved.

Authored by: Kurt W.G. Matthies

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Doc Anonymous

Heather, thank you for your kind words. Retirement has given me the opportunity to expand my horizons and post thoughts and information. The inordinate work of keeping a practice going when the patients are ALL chronic pain patients leaves virtually no time for any other activity, even with a limited number of patients. One fact that never gets discussed is that patients with pain who are NOT getting injections take far more work at far less pay than other kinds of patients.

Dee Green

Well written article, and so very true. What will it take to restore compassion & care to the hearts of the opiophobes? Maybe, they’re in the wrong field or profession! With the continued media propaganda machine pumping out stories about the “criminals in lab coats” that do nothing, but lessen the prestige and trustworthiness of being a physician. The Physicians who treat all forms of pain are, themselves, being vilified! Who will care for our aging and dibilitated citizens with chronic pain? Are we all doomed to suffer, even though medical science has developed medications that can ease the burden? Do we live in 2015 or are we returning to the “Dark Ages” of medical care? It is time to put a stop to this nonsense and speak up loudly and strongly in support of compassionate pain care! Until there is a cure for chronic pain, don’t let them remove one of the few remedies that we have access too😊


Doc Anonymous: I’d admit I read your comments with great interest. I also have to admit that I went from thinking what a wonderful, perceptive doctor you must be to your patients to feeling my heart sink when I saw that you were retired.

I pray you’re using your experience, intuition and understanding to try to influence the current state of affairs. I’m not sure how someone (even a layperson, let alone a doctor) would accomplish this, but I think you have much to contribute and I hope you find a way that also brings you satisfaction.

I don’t read all comments, so I apologize if you’ve given more of your background somewhere. I wish you the best and thank you for participating here!

I did find the terminology “breakthrough pain” to be hard to understand in my situation and since my original diagnosis was fibromyalgia (before OA and then Sleep apnea which seems to be the true root of the fibromyalgia-like symptoms) I latched onto “flare-up” easily. I guess I didn’t imagine that other doctors might not understand this. It is helpful to know. Communicating well with my physician is critical to my care.

Sadly, newly-diagnosed patients don’t have the experience, vocabulary, relationship with a doctor… let alone be free of the emotional and cognitive burdens that would help them communicate clearly in a way that a doctor would be most responsive. I still see patients who are grasping at straws take the advice of others who tell them that they should go to their doctor and demand a specific drug. (which will get them labeled as drug-seekers… but really stems from the advice that folks get off the internet from other patients).

I’m grateful to get by on tramadol, btw. I’m grateful my pain is managed. But initially, I was told I was just depressed, and I WAS desperate – and my quality of life was declining. My mother’s OA is aggressive, and at (now) 36 years old… well, let’s say that I feel kind of sad but appreciative when an orthopedic doc looks over my records and looks up to say, “You’re too young for this.”

If only. C’est la vie? (Actually, I was in my late 20’s or early 30’s when the doc made the comment but it stands out because of how ironic it seemed. He’s a great doc, and he wasn’t wrong to say what he did.)

William McKinley

Each of these comments sound like my life in some way. Is anyone doing anything about our situation ?

Doc Anonymous

Great Article!! I wholeheartedly agree that the mistreatment of chronic pain and the opioiphobia today is am massive violation of the human rights of chronic pain patients. Kurt you have given some good insight into the nature of chronic pain and acute pain, but there is a real need for doctors across the board to step back from today’s rhetoric and begin assessing pain more objectively in the context of chronic pain. To start, chronic pain is just that: Chronic, there on a long term persisting basis. The term “beakthrough” pain arose in the palliative care of cancer patients in whom the goal was to provide peaceful and relatively pain free exit from life. Breakthrough pain was pain that interupted that medication induced state of serenity. Over years of treating chronic pain patients and dealing with some episodic minimally disabling neck pain, I have concluded that “breakthrough” is the wrong term for what happens with chronic pain. So here is my take on pain. Chronic pain people suffer FLARE UPS that are essentially elevations in the intensity of the chronic pain. Unlike “Breakthrough” they can last a longer time lasting days to weeks. Flare ups also interfere with baseline mobility or activity and the degree of physical mobility impairment is generally proportional to the degree of increase in pain. The intensity and duration of the flare up may be moderated by pain meds and the duration may be shortened, but the overall pattern of the flare up is not altered by medication. Breakthrough pain as it was originally defined remains an interuption of a state of serenity that can rapidly be controlled by added medication and breakthrough pain does not last for days to weeks. Flare ups can also be triggered by a variety of stimuli form a sudden but locally forceful twitch in a structurally damaged area such as a disc, or it can be triggered by added activity. In response to activity, intense and/or sustained, there is a “delayed crescendo” of the flare up pain. It is not felt at the moment of activity — that would be acute pain. It reaches its peak hours to days after the triggering activity. As a retired physician I can assure you that this concept is foreign to almost ALL physicians. It is one I have experienced and it is one that most of my patients seemed to have experienced. Chronic pain people also develop added acute medical problems that cause added pain that is generally different than the chronic pain and the flare ups. Sadly, unethically and almost criminally too many doctors seem to adopt the attitude that a chronic pain patient has ONLY chronic pain and any pain they suffer is just part of the chronic pain. I have seen numerous instances of MISSED, life threatening diagnosis from my colleagues. They do need to be educated but we need better terminology too. Finally chronic pain also affects motor control but nobody wants to study these objectively measurable aspects of… Read more »


Wow, what a great article! I learned so much from it. Thank you! Mr. Matthies, just wondering what you consider the most powerful, most effective route for us to take to try and stop this wayward train? Or is it futile?

Brenda Trudy Myers RN

I am sickened by how pain patients are treated like pain is just an irritant. my pain gets so bad I do have fight or flight kick in-but you can run out of your body! You Will find a way to alleviate it-pills, booze, heroin, or suicide. Thats what they dont seem to get-you will lose a lot of good people whose suffering they can no longer bare. Its a Shame our doctors and the DEA and CDC seem oblivious to that.


Kurt, I greatly appreciate this well-researched article. I wish it were required reading for our providers. I wonder how many have been brainwashed by the politics and how many providers feel disillusioned that they’re hands are tied and this isn’t what they bargained for when they signed up to HELP people. How many are fearful…? And thank you so much for explaining about State Boards. I’ve focused on the DEA because they’re so public… the CDC is getting into the act. But… how do we, as pain patients, influence the State Boards? And who influences the State Boards? Does someone have oversight over the State Boards? It’s sad… what you’ve written. Chronic pain patients are isolated from friends, family… maybe unable to work. But I remember when I was looking for help with chronic pain and chronic fatigue. I was absolutely crushed at the attitude o the doctors I encountered… when I was desperate for help. “Stigma” or “Bias” doesn’t describe the venomous response of the doctor who shoved an anti-depressant script in my face, interrupted me while I was trying to describe my symptoms of pain and fatigue, and then spat out: “Are you through with your ‘little list’ there?” (the list I had jotted notes on because I was a cognitive mess from the memory problems related to my undiagnosed sleep apnea and I couldn’t concentrate from my untreated osteoarthritis pain). My conversation with her was less than 10 minutes… maybe even 5 minutes, before she literally got up and walked out of the exam room, shutting the door while I was mid-sentence. Because I knew… I knew… it wasn’t “just depression.” It’s worse than not being understood. It’s having the very people who can help you turn their backs on you and take away your hope for the future. I wasn’t functioning well at my job. I was going home and going straight to bed. It was winter-time and my joints were screaming and I had mobility issues. I was so physically exhausted, I thought my knees were going to buckle on me and leave me lying in the street. Day after day. I became depressed. Let me be clear. I had HOPE in the doctors for help, like any person would have. This wasn’t the first time I asked for help… At that point, I was turned away by FOUR doctors… over a period of about 5 years. One of them was a rheumatologist who told me to exercise and take over the counter naproxen sodium. He wrote in his records that I had fibromyalgia… but he didn’t tell me. He copied two of my other doctors in a letter. One doctor dismissed me as a patient. I’d seen him for an initial appointment before he had shoulder surgery. I saw his colleague while he was recovering and then returned to see him. He DID try one NSAID but when I had severe stomach pain, he told me that all NSAIDs were alike. Then he asked… Read more »

Kristine (Krissy)

Thank you, Kurt for one of the most well-written and best-described articles on pain.

I live with a lot of breakthrough pain everyday, and although I don’t use the emergency departments anymore, I certainly understand why people do; and I hope this battle we are facing in the U.S. will allow doctors to treat emergencies properly and without fear.

Pain truly kills one’s ability to live any kind of normal life, and it robs your mind of so much. I have “grown up” most of my adult life with constant increasing pain for 30 years. But I am happy about many things and grateful for many things, despite the anger, sadness and all-out brutality to the soul that comes with pain. I wish you good holidays and as much wellness as you can have! Thank you again for your great writing and the links you’ve added!

Kim Miller

This REALLY shows how far down the the medical profession has sunk in its efforts to “stay out of hot water”. Damn the patients! Like that’s got a anything to do with our profession, they appear to believe. Those who DO treat chronic pain will tell you you’re maxed out and even though you have a car wreck, broken leg, whatever, you are already treated with enough opioids, per whatever current standards, and that’s IT! No allowance for extra pain.

Got an abscess of you tooth, too bad. You have a pain contract, we’ll give you these 10 lortabs, but you must call the pain doctor to see if it’s alright. There’s no such thing as the pain doctor NOT knowing about the 10 lortabs, they get a report on you before every visit. Violation of your pain contract over those 10 lortabs is an absolute reality and will result in you being fired from your pain doctor. Good luck getting an appointment with another one.

You must know, as a pain patient, if you go to the ER for any reason, it’s only going to be to confirm you won’t die during that visit. It certainly doesn’t matter how much pain you’re in, YOU have a pain contract.

Kurt nailed this one. At my doctor’s office, you don’t get long acting opioids and a breakthrough med, it’s one or the other. I have 24 hour per day pain. 4 pills, 4 hours each, leaves me 2 pills short, or no sleep. There’s a great choice to have to make, huh? Lack of sleep is a known factor for increasing pain. Why not take the long acting option, you might ask? The dosage is so much smaller, it would be a ridiculous choice.

I realize my pain doctor is doing his best to keep a practice going in a very unfriendly environment, but he is a pain warrior, and this is the best HE can do!!!

We are losing the fight. If we lose this fight, I will lose my life.

I don’t know how much more definitive an article could possibly be to explain the fallacious basis of opiophobia and the inhumane, unlawful –indeed, unconstitutional–practice of denying pain relief to patients who otherwise must suffer. Just as egregious is the destruction of the lives of physicians who actually deserve that title, whose commitment to care for the suffering of pain patients has been rewarded with jail sentences, and losses including license to practice medicine, the medical practice itself, even family and friends. I feel like I have every right to raise my voice against the discrimination perpetrated by opiophobes, as one who has suffered for 46 years with degenerative disc disease, widespread osteoarthritis, and diabetic neuropathy. My entire spine is now affected. But I have never, in those 46 years, been afforded the relief of opiates because I can’t take them. And the pain is every bit as bad–and sometimes even worse–than our author describes. I have seen my physicians with tears in their eyes because they could do nothing more to help me. I do not understand why the physicians who remain true to their calling are being punished, along with their patients, while others brandish their MD degrees like absolution from responsibility while pretending that all people in pain must do is accept their pain.

KWGMatthies speaks well when he encourages us: illigitimi non carborundum.