Editor’s note: The following article was submitted by reader and NationalPainReport.com contributor Kristen Ogden, in response to a recent story we ran: Accepting Pain More Important than Reducing Pain Intensity Because Opioids Are Harmful, Docs Write in NEJM Commentary.
Yes, Drs. Ballantyne and Sullivan, reducing pain intensity is a valid goal for medical treatment!
That the authors have posed this question at all speaks volumes about their approach to pain care and commitment to healing as a profession. In the first paragraph, they state their view that “pain that can be relieved should be relieved.” From that point on, there is little said in this article that passes any common sense test.
While the increase in use of opioids to treat chronic non-cancer pain has coincided in time with an increase in adverse events linked to prescription opioids, the authors surely know that correlation is not equivalent to causation. Furthermore, their assertion that increased use of opioids for chronic pain has produced “no demonstrable reduction in the burden of chronic pain” is not supported by the source they cited, and is clearly a statement of the authors’ opinions – not a statement of fact. The authors predictably go on to suggest that there is little evidence supporting the efficacy of long-term opioid use. However, the truth is that there are actually multiple published studies demonstrating the long-term benefit of opioid pain relievers for some patients. We find it very concerning that Dr. Ballantyne once again is pushing her personal beliefs and agendas at the expense of truth and transparency.
This is not the first time we have noted such behavior by Dr. Ballantyne. For example, as the President of Physicians for Responsible Opioid Prescribing (PROP), she signed the organization’s comments to NIH on the draft National Pain Strategy. In the letter, Dr. Ballantyne states that there is no “evidence for long-term use of opioids for common chronic pain conditions, or for a “safe use” campaign for opioids intended to reduce their harms. She then selectively quotes from a research report compiled for the NIH Pathways to Prevention Workshop: The Role of Opioids in the Treatment of Chronic Pain, held September 29–30, 2014. The quotes chosen support the view that opioids cannot be used safely to treat chronic pain. Nowhere in the letter does Dr. Ballantyne acknowledge that the final report of the workshop clearly states “Clearly, there are some patients for whom opioids are the best treatment for their chronic pain.” Ms. Ballantyne personally participated in the NIH Pathway to Prevention Workshop, so she clearly knows what was discussed and what conclusions were reached. However, her approach in commenting on the National Pain Strategy was to present from the NIH panel meeting only those anti-opioid sentiments that reflect her own views and to suggest that those quotes reflect the sum and substance of the NIH panel’s conclusions.
It seems we are living in a post-fact era in which our reality is determined by whatever “narrative” is dominating the national conversation. In recent days, stories about the evils of opioid pain medications have blanketed the main-stream media and are heavily influencing elected officials to “do something” to stop the so-called prescription opioid drug epidemic. Drs. Ballantyne and Sullivan, along with certain of their colleagues, seek to dominate the national conversation among members of the medical establishment and high-level policy-makers in Federal health-care agencies. They clearly seek to impose their version of the “truth” about opioids upon those who are working in good faith to establish policies to curb prescription drug abuse, overdose, and deaths. However, no matter how strongly they state their positions, many of their assertions do not hold up under scrutiny. Many chronic pain patients do well on long-term opioid therapy, experience a significant reduction in pain intensity, have greatly improved quality of life, enjoy greatly increased capabilities and functionality, and do not require escalating doses. Long-term opioid therapy allows many patients to continue working at their jobs, which is obviously beneficial to them and their families.
The authors of this paper ultimately venture into what amounts to a philosophical exploration of the meaning of pain and suffering…an endeavor we believe is best left to clergy or spiritual counselors. From the viewpoint of chronic pain patients, their family members, and advocates, the following philosophical assertion by Ballantyne and Sullivan is ludicrous and highly insulting. “Willingness to accept pain, and engagement in valued life activities despite pain, may reduce suffering and disability without necessarily reducing pain intensity.” Many chronic intractable pain patients who depend on long-term opioid therapy need these medications to relieve pain that otherwise invites suicide…pain that is so bad that it is all one can think about…pain so bad that the medications are needed just to be able to get out of bed and carry out the basic activities of daily living…pain so bad that one could not possibly engage “in valued life activities” without the medication. The pain that some of these patients experience without opioid medication is pain that human beings cannot and should not be expected to willingly endure…which brings us right back to our authors’ opening paragraph. “Pain that can be relieved should be relieved.” The authors clearly do not understand the magnitude of pain suffered by many, nor do they understand these two key points. First, that reducing the intensity of chronic pain can often be achieved with opioids and when the pain is relieved, improvement in function and quality of life will follow! Second, absent such pain relief, patients will likely suffer increased harms. In his article “Pain Management: Classifying, Understanding, and Treating Pain” in the June 2002 issue of Hospital Physician, B. Eliot Cole spoke to the significance of untreated pain. “The axiom ‘No one ever died from pain’ is clearly incorrect, given the modern recognition that unrelieved pain increases cardiac work, increases metabolic rate, interferes with blood clotting, leads to water retention, lowers oxygen levels, impairs wound healing, alters immune function, interferes with sleep, and creates negative emotions.”
Finally, we question the authors’ apparent assumption that a numerical rating of pain intensity is the only measure or indicator used by an effective pain physician to assess a patient’s chronic pain state. Our experience is that knowledgeable pain physicians who understand how to prescribe opioids appropriately will use many tools, techniques, and modalities to assess and to treat their patients. Long-term opioids will only be prescribed when all other standard treatments have failed to achieve good pain relief and will most likely be used in conjunction with other treatments, including hormone supplementation, diet management, and appropriate exercise or physical therapy. Well-trained, knowledgeable pain physicians understand and can effectively use opioid medications to give patients a chance at a hugely improved quality of life. The numeric pain rating scale is one of many tools they rely on and it should remain available in the toolkit.