Intensity of Chronic Pain — The Wrong Metric?

Intensity of Chronic Pain — The Wrong Metric?

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.

Kristen and Louis Ogden

Kristen and Louis Ogden

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.

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Authored by: Kristen Ogden

There are 8 comments for this article
  1. Kristen Ogden at 7:55 am

    My sincere thanks to all who have commented. I appreciate and learn from the perspectives that you share in your comments. Carla Cheshire, thanks for suggesting that we put comments on Dr. Richard W. Rosenquist’s Cleveland Clinic website. That’s a great idea and I will certainly do that. It is critical that we all continue to speak out. Never give up!!

  2. I. Hollis at 7:46 pm

    Kristen, This is such a well written and truthful article! Thank you ! I couldn’t agree more that where you state ” It seems we are living in a post-fact era in which our reality is determined by whatever “narrative” is dominating the national conversation.” I am so tired of the false narrative about prescription drug abuse that is overtaking the media and affecting policy. These “agendas” leave out the pain patient entirely. This NEJM article is so regressive as they are basically saying “it’s all in your head to pain patients” and offer no viable, effective treatments ! They are creating a false a problem and crisis where is is none!! Addiction is a separate issue! These pain patients aren’t hurting anyone, and their medications often bring much needed help to be able engage in activities of daily living. To take away these lifesaving medicines will create a real national health crisis. To ignore the wise words Kristen has quoted by Dr. B. Elliot Cole will create untold damage to these patients and their families. “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.” To not use every tool in the toolbox at hand currently and to leave people to suffer and die is immortal. These Paternalistic models where it is assumed “the experts” know best, and it turns out they aren’t even experts in pain care, have got to go. It is and will create great harms!
    Please please please consult real experts who know something about the treatment of pain before instituting any, ANY new policies. The NIH is a good place to start.

  3. Susan C Romero at 9:11 am

    First of all I want to tell Kristen Ogden “thank you” for the artical, it is wonderful! Then I want to let Carla Cheshire know that I did go to Dr. Richard W. Rosenquist’s clinic website and commented. Below is what I wrote with a little help from Kristen’s article:
    I am a Chronic Pain Sufferer
    I am a Chronic Pain sufferer due to Peripheral Neuropathy, Cervical Dystonia, Fibromyalgia, Sciatica, and Spinal Stenosis in the Cervical & Lumbar regions. I, like many other legitimate and responsible pain sufferers are being discriminated against because of the use of Opioids by those who abuse them or don’t really need them. The prescription for my pain medicine has been changed to from a schedule II one to a schedule I one that does not even come close to relieving my daily pain. My quality of life has gone back to just existing and not being able to participate in life. I have a new grand daughter who is 6 months old and I’m not even able to play with her and enjoy her.

    Many chronic intractable pain patients like me, 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 us patients experience without opioid medication is pain that human beings cannot and should not be expected to willingly endure. “Pain that can be relieved should be relieved!”

    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.”
    Many chronic pain patients like me, do well on long-term opioid therapy. We 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 sufferers to continue working at their jobs too, which is obviously beneficial to them and their families.

    Working with a well-trained, knowledgeable Pain Management Physician who has empathy and who understands, can effectively use opioid medications to give patients a chance at a hugely improved quality of life. The numeric pain rating scale they use is one of many tools they rely on and it should remain available in the toolkit and not discarded.
    Please reconsider and stop making opioids seem so bad, because they are so helpful in relieving pain for so many. Until there is a cure found or at least medication that works as well without adverse side affects, please allow us Chronic Pain Sufferers to use the option of Opioids with a legitimate prescription. Stop putting pressure on those physicians who are able and willing to prescribe and monitor their patients on Opioid medication. Physicians are now reluctant to prescribe them for fear of being reprimanded or having their Medical License revoked along with the fact they have tons of paperwork to keep track of on their patients using Opioids. Someone needs to come back to reality and admit this is a major problem in the care of Pain Management! Maybe those making these decisions for us need to be dealt a few months or years of what we go through on a daily basis. Then they will know how detrimental this has been for all who suffer and can’t get their med’s to relieve their pain and have some quality of life!

  4. Becky at 2:46 am

    Very well written, and understood! Our pain does need to be recognized, I am so tired of the stigma PROP and the CDC, are putting on us that suffer daily.

  5. Carla Cheshire at 4:13 pm

    I too agree entirely with Kristan. There is a “War on Pain Patients,” I too have been a chronic pain patient due to failed back surgery that left me with intolerable pain that is only relieved by opioids. The fact that you can live a (much better) life and are NOT drug seeking, NOT upping your dose and remain under control, myself for 12 years just doesn’t fly with their narrative that everyone that ingests opioids is a drug addict! I think this is the crux of the issue. We are proof positive that what they put out as facts are in fact lies!

    I am sick of this constant drumbeat that all opioid users are addicts! Why are we, the patients, NEVER asked when officials are having discussions involving opioid use and its efficacy. It always doctors that are not in our shoes making decisions about we live with pain when they are in fact clueless.

    I urge you all to comment on Dr. Richard W. Rosenquist’s Cleveland Clinic website where he slams opioid use for chronic pain patients, calling them ineffective. Every comment refutes his judgement, lets add to it. http://consultqd.clevelandclinic.org/2015/02/opioids-for-chronic-pain-2/#.VghfzURGR_8.twitter

  6. D Parker at 3:05 pm

    Thank you Mrs Ogdan for you insightful internation of the facts. The NEJM has lost credibility with this article. In fact I’m sure the reason NEJM stop posting comments was because of the enormous amount of criticism readers commits. It is a travesty that this type of behavior has fallen on such an important treatment modality. Claiming opinion as fact, repeating lies until they are believe to be true says a lot about their interity and how far they are willing to go to get their agenda accomplished. We will not sit idle by, it will not stop those who activity advocate daily against PROPs agenda to restriction all opioids medications form all chronic pain patients. Adhesive Arachnoiditis pain cannot simply be “lived with”. The advanced disease produces severe intense piano that any human would do anything to relieve including resort to suicide. Severe Intense Pain cannot be allowed to lord over life, dictate evey moment of life. pain eroads the will to live. As an advanced society humanity cannot allow needless human torture. If pain can be treated it should be.

  7. Bill Halper at 11:33 am

    I agree completely with Kristen! Her well written response to such a biased research with false conclusions hit the nail on the head. I simply do not understand why in today’s world, research, studies and and other similar reports, and now simple statements are full of false, inaccurate information, and for what purpose? Can we no longer truly believe what is told to us? As much as I hate speaking of politicians, they seem to be the experts, and therefore others follow. My question is why did Dr. Ballantyne even suggest after all studies being done say that the opiates are the scourge of life? What purpose does that serve beyond the media having a field day with it? The harm she is doing is reprehensible to say the least. Sadly the damage is done! It is now up to us, those with Chronic Pain, to show the real truth. I do understand about abuse whether it be drugs or alcohol, but no matter how many safe guards are placed, there will always be those who still use medications illegally for a cheap thrill. But with the population of this country at about 325 million people, 12 million of them are abusing this drug (I cannot remember where I had read that, but it was published in a highly respected website) which really is a very small percentage. It seems ludicrous to me that the approximately 3% of the population has the control to take away our only means of having a somewhat tolerable life!

    But I believe that honesty will win out over biased, mean spirited reports as this one. I have faith that the powers that be will understand that we have no other choices that are effective as much as the opiates, oxycodones are. Too bad that these incomplete, opinionated studies are also out there. I am curious as to the purpose behind Dr. Ballantyne’s pick and choose report/study, why would she want to do such harm to others? She should remember how she felt when she was still human!