Managing persistent or chronic pain is complex. Frequently there is a lack of objective reason for persistent pain yet it is real, personal and subjective and people with persistent pain are of then desperately seeking effective pain relief. I recently attended an “Explain Pain” course in Cairns (which was lovely and warm), which looks at ways to reconceptualise pain from a modern neuroscience perspective. How does this help? Well knowledge is power. There is a growing body of research showing that we can target our natural analgesic systems with simple but effective education about pain. This is particularly pertinent given the numbers of people suffering with persistent pain and the failure of common pain medications to effectively manage pain.
In Australia opioid prescribing is frequent, with up to 72% off people with both cancer and persistent non-cancer pain taking prescription opioids. However, unlike those in acute pain, in those with persistent pain the prescription and ongoing use of opioids may not be wise. There is significant evidence of ineffectiveness in persistent pain along with risk of dependence. The mechanisms behind the loss of effectiveness with long term use of opioids are gradually coming to light and include factors such as the metabolites of opioids being perceived as a threat to the body resulting in ‘alarm’ signals and loss of opioid receptors over time, leading to less effective pain relief.
Discontinuation of opioids for those who have been on long-term therapy may be seen as a risk due potential changes in pain intensity. Little was known about the potential changes until a recent study looked at this very issue. Following opioid discontinuation in 551 patients, which chronic pain researchers sought to characterise pain intensity over a 12-month period. To make effective comparisons researchers also compared pain intensity data from the participants 12 months prior to discontinuation. A 0-10 pain numeric rating scale was used to compare pain scores over time.
Researchers identified for pain classes, which were characterised by their post discontinuation pain levels:
- no pain
- mild clinically significant pain
- moderate clinically significant pain
- severe clinically significant pain.
The changes in pain intensity over time showed a small but statistically non-specific reduction over 12 months in all characterised pain trajectory classes, with those with mild and moderate pain experiencing the most significant pain reductions post-discontinuation. Importantly pain did not increase in any of the groups, and may slightly improve in those with mild to moderate pain at the time of discontinuation. This research is significant as it indicates that those in persistent pain may actually be better off without opioid medications.
Over the next few months I will write more about persistent pain and how it can be more than just managed but also effectively treated.