Management of Chronic Nonmalignant Pain

LETTERS TO THE EDITOR Management of Chronic Nonmalignant Pain To the Editor: I was dismayed to read the case report by Dr. Sanders in the September/October issue of JAMDA regarding the management of chronic nonmalignant pain.1 Dr. Sanders presented a case of an institutionalized 64-year-old woman whose chronic pain was obviously mismanaged utilizing various analgesics, including opioids. The patient suffered from chronic obstructive pulmonary disease and intractable pain secondary to osteoporosis and vertebral compression fractures, and was eventually treated with intravenous morphine and a fentanyl patch, a combination that was undoubtedly an erroneous approach to this patient’s chronic pain. Although the patient was moribund, she was eventually rehabilitated and the opioids discontinued. However, Dr. Sanders notes that while her function improved, she did state, “I hurt all the time.” He then states, “If we aggressively prescribe opioids to chronic nonmalignant pain patients in an effort to eliminate pain, we are doomed to failure and may injure them severely.” I have two comments regarding this case. First, the pain in this case was unquestionably mismanaged, but the use of opioids in chronic pain should not be condemned because of one case report. Perhaps Dr. Sanders has seen other similar cases, however, I would respond that education in pain management is definitely needed in his clinical community (and lamentably, in many areas of the country). But to state that the use of opioids to mitigate chronic pain is “doomed to failure and may injure them (patients) severely” is alarmist and just plain not true. Second, is functionality and being in pain all the time compatible with good medical care? Dr. Sanders relates that the patient’s only medication after discharge from the nursing home was an antidepressant, although the patient stated she was in pain all the time. Why couldn’t an analgesic(s) be tried to alleviate pain, including, if necessary, an opioid started at a low dose and gradually and carefully titrated according to clinical response and patient function? I agree that chronic nonmalignant pain can be exceptionally difficult to treat and requires a comprehensive approach that includes behavior modification, but is our goal not improved pain control as well as an acceptable level of daily functioning? I would respond with an unequivocal yes, but to rebuke the use of opioids in chronic nonmalignant pain is wrong, and just plain bad medicine. Paul Rousseau, MD Associate Chief of Staff for Geriatrics and Extended Care VA Medical Center, Phoenix, Arizona Medical Director RTA Hospice and Palliative Care Phoenix, Arizona Adjunct Assistant Professor Midwestern/Arizona College of Osteopathic Medicine Glendale, Arizona 36 Letters to the Editor

REFERENCES 1. Sanders JH. Severe adverse effects of aggressive opioid therapy in chronic nonmalignant pain. J Am Med Dir Assoc 2001;2:239 –240

Comments on Case Report To the Editor: We would like to compliment Dr. Sanders for reporting his excellent clinical work improving the functional status of a resident by tapering and discontinuing large doses of narcotics for chronic nonmalignant pain.1 We would like to specifically comment on the last paragraph of the report. We agree that the elimination of pain is seldom possible. In fact, the total elimination of chronic musculoskeletal pain is probably contraindicated. Some level of pain may serve a useful purpose to remind the individual to perform exercises and maintain postural alignment to minimize anatomic traction or impingement generating the pain. Exercises or self-maintenance of posture may be beyond the capacity of many residents. However, pain may guide optimal positioning by caregivers. We agree that improved function (including mood) is the most important goal of analgesia in chronic, nonmalignant pain. It has been our experience that opioids may be part of the solution for chronic, nonmalignant pain if one pays attention to the resident’s functional response during a monitored therapeutic trial of opioid therapy. Treatment of coexisting depression and anxiety should be ongoing. A monitored therapeutic trial of opioids requires that the resident be assessed as soon as the effects of each dose advance have peaked. The assessment must include efficacy and adverse effects. The clinicians who cared for this resident before Dr. Sanders apparently failed to carry out such aggressive monitoring and continued high doses of narcotic despite weight loss and the patient “becoming bedfast.” Chronic narcotic therapy should be given with “aggressive” monitoring during a therapeutic trial. Dosing should be continued or advanced only if the balance between pain relief and function is favorable. Paul J. Drinka, MD, CMD Wisconsin Veterans Home King, Wisconsin Clinical Professor, Internal Medicine/Geriatrics University of Wisconsin—Madison and Medical College of Wisconsin—Milwaukee Peggy Krause, RNC, CCRC Senior Research Nurse Wisconsin Veterans Home King, Wisconsin JAMDA – January/February 2002