- Email: [email protected]
The psychosocial impact of opioid treatment
Rep/Y
The Psychosocial Treatment
Impact of Opioid
Charles Chabal, Louis Jacobson, Edmund F. Chaney, and Anthony J. Mariano -
T
he major goal of our focus article was to show that much of the disagreement regarding the role of narcotics in treating chronic nonmalignant pain has been due to the conflicting and often implicit conceptual models of the various proponents. A secondary purpose was to introduce our own position and briefly describe the way we utilize narcotic medications. We are pleased to take this opportunity to respond to commentaries of Fordyce and Portenoy. Both Fordyce5 and Portenoy” have recognized the value of examining fundamental assumptions about pain and explicated their previous positions within the context of a more comprehensive biopsychosocial model of pain. Fordyce’s emphasis on the important role of behavioral outcome assessment and Portenoy’s call for therapeutic trials of opioids extend the arguments each has made within this debate. Our focus article proposed a treatment paradigm that emphasizes the interaction between the provider and patient in which the patient is actively engaged as part of the treatment team and assumes, albeit gradually, much of the responsibility for his or her health care. This codisciplinary model of treatment and our emphasis on the interpersonal process has been described elsewhere.‘sg In our view, chronic pain treatment is fundamentally a psychosocial interaction involving a patient and health care providers. In our therapeutic approach, emphasis is placed on communication between the patient and provider team. Prescription constitutes an important part of
From the University of Washington Center, Seattle, Washington.
and
Reprint requests: Charles Chabal, MD, (112-A) Veterans Affairs Medical Center, Way, Seattle, WA 96106.
APS Journal
l(4): 289-291,
1992
Veterans
Affairs
Anesthesiology 1660 South
Medical Service Columbian
this communication process. For those who view chronic pain predominantly through a biomedical model, the prescription of narcotics communicates and reinforces the conception that the responsibility for the control of pain lies with the physician. If prescriptions cured chronic pain, there would be no need to broaden the biomedical approach. Instead, this model encourages an endless search for the next generation of nonsteroidal, narcotic, or surgical procedure. We prefer to communicate by our dialogue and actions that the eventual control of chronic pain lies not from prescribed potions but from within the individual. Portenoy’s complaint is that our guidelines are not “flexible” and that we communicate our “biases” to the patient. In both of these regards, Portenoy is correct. We have a uniform policy with regard to narcotics that is clearly communicated to all patients within the broader context of our basic assumptions about the nature of chronic pain and its appropriate treatment. A major challenge in treating chronic pain is often assisting the patient in moving from a biomedical to a biopsychosocial model of pain. The importance of the initial phase of reconceptualization of the pain problem has been discussed in great detail by other authors.6,12 We believe that it is essential to educate the patient about the relatively minor role opioids play in chronic pain management and clearly communicate our treatment model (bias). We use the introduction of a novel pain medication (pain cocktail) as a teaching opportunity and encourage discussion of our rationale for only using pain cocktail. The search for pain relief through medication is minimized as a therapeutic goal by explaining in advance that tolerance is likely to develop over time and that we will not respond to decreased analgesic efficacy with steadily increasing doses of narcotics. Providing minimal doses of opioids facilitates the integra289
290
REPLY/Chabal,
Jacobson,
Chaney,
Mariano
tion of new patients into our clinical and provides an opportunity to establish a therapeutic relationship. Thus, narcotics are used an adjunctive component of therapy, not to alleviate all pain but to provide a bridge until the patient no longer feels the compelling need to rely on them. Narcotics are not the therapeutic remedy as suggested by Pot-tenoy, but are instead a means to the goal of patient self-reliance. They are used to “validate” alternative approaches to pain management and to forestall the problems inherent in rigid detoxification regimens. Rather than representing “significant inconsistencies,” these policies follow directly from our position that maintains that opioids play a useful but minor role in the management of chronic pain. One should not confuse “sophistication in opioid pharmacotherapy” with a willingness to respond to patient reports of discomfort by tinkering with a variety of medications. The concept of the “therapeutic trial” is prototypic of the difference between the biomedical and biopsychosocial viewpoints, Portenoy’s focus on therapeutic trials belies a biomedical perspective in spite of his recognition of the importance of a more comprehensive perspective. Turk and 13rody13 have already raised a number of important questions regarding his guidelines for patient selection for therapeutic trials, definitional ambiguities, and alternative interpretations of the available literature. Our additional concerns are that therapeutic trials convey a strong message to the patient regarding the goals of pain treatment, the source of responsibility for improvement, and well-being, and the locus of pain control. The adjustment of medications as a primary response to patient requests for help reinforces a biomedical model of chronic pain and results in treatment interactions that are determined by reported pain levels. As every pain clinician can testify, the pursuit of pain relief can result in significantly impaired patient-provider relationships in which the issues of opioids overrides all other concerns and undermines broader treatment efforts. Statistically, about 45% of patients referred to pain clinics have already failed single or multiple therapeutic trials of opioids. 2*10*14Portenoy suggests that opioids should be discontinued if the trial “demonstrates serious adverse effects.” He does not, however, specify exactly what should be done with these patients who had presumably already failed “all other reasonable approaches” to pain management. We have yet to meet a patient who is referred for medication management who evidences the “strong desire for a rapid cessation of therapy” that Portenoy describes as “the usual response of a patient to a failed
therapeutic trial.” More often, the typical problem from the patient perspective is one of access to opioids in the pursuit of pain relief. Undoubtedly, there will be anecdotal success stories of patients treated for chronic pain with opioids for prolonged periods of time. However, for a condition like chronic low back pain in which the greatest predictive risk factor has been reported to be job dissatisfaction, the notion that these patients suffer from a opioid receptor agonist deficiency is simplistic.’ Finally, any discussion of drug trials would be incomplete without considering certain inherent risks. A recent review of chronic pain patient characteristics by Fishbain et ale4 reported prevalence ranges from 3 to 19% across studies with regard to diagnoses of drug abuse, dependence, and addiction. As such, one might expect that a small but significant minority of chronic pain patients would be at risk for experiencing abuse problems during opioid trials. The treatment guidelines suggested in our focus article have evolved from accumulated clinical experience but also have been strongly influenced by our interpretation of research. For example, in perhaps the only prospective, controlled, double-blinded study to date, for patients who suffered from chronic osteoarthritis, codiene failed to provide sustained analgesia superior to acetaminophen yet produced side effects so significant that the authors prematurely concluded the investigation. In our own clinic, we have observed that referred patients consuming narcotics failed to demonstrate any improvement in reported pain, or in a number of psychosocial outcomes when compared with otherwise similar patients not consuming narcotics2 Indeed, the patients consuming narcotics tended to be more depressed and showed significant functional impairment. Our data show that our paradigm does reduce narcotic use and increase function in patients treated for 6 months3 These data are from a group of patients in whom the mean duration of pain was 9 years. The initial mean reported pain score was 9 out of 10, and the mean number of (International Association for the Study of Pain) pain sites per individual was 3. Finally, we feel compelled to reply to Portenoy’s statement that “it should not be anticipated that debate among pain specialists about chronic opioid therapy for nonmalignant pain will be resolved by altering clinical constructs . . . these constructs are largely a given, and the discussion relates to numerous other complex issues.” We would like to underscore the primary role that one’s model of pain plays in the choice of which issues are relevant, in the interpretation of the available data, and in the manner in which future research questions are framed. An
REPLYKhabal,
underappreciation of the importance of assumptions that are often unstated can lead to seemingly endless discord and create confusion rather than clarification in the scientific literature. In our opinion, this debate will eventually be resolved in the same manner as other “great controversies.” Debates that have been cast as dichotomies (e.g., nature versus nurture) typically end with a whimper of exhaustion rather than a bang of empirical findings. The eventual answer to the question of whether or not narcotics have a role to play in the management of chronic pain will be “it depends.” We have little doubt that future research will eventually demonstrate that opioids are useful for some of the patients some of the time under some conditions. The research challenge is to begin to understand and predict the variability among patient responses to such medications. In the meantime, we think guidelines consistent with a biopsychosocial model are necessary for meeting the more immediate clinical challenges inherent in the use of opioids for chronic pain.
4. 5. 6.
7.
6.
9.
10.
References Bigos SJ, Battie MC, Splengler DM et al: A prospective study of work perceptions and psychosocial factors affecting the report of back injury. Spine 16:1-6, 1991 Chabal C, Jacobson L, Mariano AJ, Chaney EF: Nar-
11.
cotic use and psychosocial function in chronic pain patients. American Pain Society Meeting, New Orleans, November, 1991 (Abstr)
13.
Chabal C, Mariano AJ, Jacobson L, Chaney EF: Patterns of narcotic, sedative hypnotic, and adjunctive medication use on intake and after six months of pain
14.
12.
Jacobson,
Chaney, Mariano
291
clinic treatment. American Pain Society Meeting, San Diego, October, 1992 (Abstr) Fishbain DA, Rosomoff HL, Steele Rosomoff R: Drug abuse, dependence, and addiction in chronic pain patients. Clin J Pain 6:77-85, 1992 Fordyce WE: Opioids, pain, and behavioral outcomes. APS 1:282-284,1992 Hanson RW, Gerber KE: Coping with chronic pain: a guide to patient self-management. The Guilford Press, New York, 1990 Jacobson L, Mariano AJ, Chabal C, Chaney EF: Simultaneous interview technique for patients with persistent pain. Pain 45105-106, 1991 Kjaersgaard-Andersen P, Nafei A, Skov 0 et al: Codeine plus paracetamol versus paracetamol in longterm treatment of chronic pain due to osteoarthritis of the hip: a randomised, double blinded, multi-centre study. Pain 43:309-318, 1990 Mariano AJ, Jacobson L, Chabal C, Chaney EF: The simultaneous interview technique (SIT) and the codisciplinary made1 of chronic pain treatment. Pain (in press) Maruta T, Swanson DW, Finlayson RE: Drug abuse and dependency in patients with chronic pain. Mayo Clin Proc 54:241-244, 1979 Portenoy RK: Chronic opioid therapy for nonmalignant pain: from models to practice. APS J 1:285-288, 1992 Turk DC, Meichenbaum D, Genest M: Pain and behavioral medicine: a cognitive-behavioral perspective, New York, Guilford Press, 1983 Turk DC, Brody MC: Chronic opioid therapy for persistent noncancer pain: panacea or oxymoron? APS Bull l(l):l-6, 1991 Turner JA, Calsyn DA, Fordyce WE, Ready LB: Drug utilization patterns in chronic pain patients. Pain 12: 357-363,1982
The Psychosocial Treatment
Impact of Opioid
Charles Chabal, Louis Jacobson, Edmund F. Chaney, and Anthony J. Mariano -
T
he major goal of our focus article was to show that much of the disagreement regarding the role of narcotics in treating chronic nonmalignant pain has been due to the conflicting and often implicit conceptual models of the various proponents. A secondary purpose was to introduce our own position and briefly describe the way we utilize narcotic medications. We are pleased to take this opportunity to respond to commentaries of Fordyce and Portenoy. Both Fordyce5 and Portenoy” have recognized the value of examining fundamental assumptions about pain and explicated their previous positions within the context of a more comprehensive biopsychosocial model of pain. Fordyce’s emphasis on the important role of behavioral outcome assessment and Portenoy’s call for therapeutic trials of opioids extend the arguments each has made within this debate. Our focus article proposed a treatment paradigm that emphasizes the interaction between the provider and patient in which the patient is actively engaged as part of the treatment team and assumes, albeit gradually, much of the responsibility for his or her health care. This codisciplinary model of treatment and our emphasis on the interpersonal process has been described elsewhere.‘sg In our view, chronic pain treatment is fundamentally a psychosocial interaction involving a patient and health care providers. In our therapeutic approach, emphasis is placed on communication between the patient and provider team. Prescription constitutes an important part of
From the University of Washington Center, Seattle, Washington.
and
Reprint requests: Charles Chabal, MD, (112-A) Veterans Affairs Medical Center, Way, Seattle, WA 96106.
APS Journal
l(4): 289-291,
1992
Veterans
Affairs
Anesthesiology 1660 South
Medical Service Columbian
this communication process. For those who view chronic pain predominantly through a biomedical model, the prescription of narcotics communicates and reinforces the conception that the responsibility for the control of pain lies with the physician. If prescriptions cured chronic pain, there would be no need to broaden the biomedical approach. Instead, this model encourages an endless search for the next generation of nonsteroidal, narcotic, or surgical procedure. We prefer to communicate by our dialogue and actions that the eventual control of chronic pain lies not from prescribed potions but from within the individual. Portenoy’s complaint is that our guidelines are not “flexible” and that we communicate our “biases” to the patient. In both of these regards, Portenoy is correct. We have a uniform policy with regard to narcotics that is clearly communicated to all patients within the broader context of our basic assumptions about the nature of chronic pain and its appropriate treatment. A major challenge in treating chronic pain is often assisting the patient in moving from a biomedical to a biopsychosocial model of pain. The importance of the initial phase of reconceptualization of the pain problem has been discussed in great detail by other authors.6,12 We believe that it is essential to educate the patient about the relatively minor role opioids play in chronic pain management and clearly communicate our treatment model (bias). We use the introduction of a novel pain medication (pain cocktail) as a teaching opportunity and encourage discussion of our rationale for only using pain cocktail. The search for pain relief through medication is minimized as a therapeutic goal by explaining in advance that tolerance is likely to develop over time and that we will not respond to decreased analgesic efficacy with steadily increasing doses of narcotics. Providing minimal doses of opioids facilitates the integra289
290
REPLY/Chabal,
Jacobson,
Chaney,
Mariano
tion of new patients into our clinical and provides an opportunity to establish a therapeutic relationship. Thus, narcotics are used an adjunctive component of therapy, not to alleviate all pain but to provide a bridge until the patient no longer feels the compelling need to rely on them. Narcotics are not the therapeutic remedy as suggested by Pot-tenoy, but are instead a means to the goal of patient self-reliance. They are used to “validate” alternative approaches to pain management and to forestall the problems inherent in rigid detoxification regimens. Rather than representing “significant inconsistencies,” these policies follow directly from our position that maintains that opioids play a useful but minor role in the management of chronic pain. One should not confuse “sophistication in opioid pharmacotherapy” with a willingness to respond to patient reports of discomfort by tinkering with a variety of medications. The concept of the “therapeutic trial” is prototypic of the difference between the biomedical and biopsychosocial viewpoints, Portenoy’s focus on therapeutic trials belies a biomedical perspective in spite of his recognition of the importance of a more comprehensive perspective. Turk and 13rody13 have already raised a number of important questions regarding his guidelines for patient selection for therapeutic trials, definitional ambiguities, and alternative interpretations of the available literature. Our additional concerns are that therapeutic trials convey a strong message to the patient regarding the goals of pain treatment, the source of responsibility for improvement, and well-being, and the locus of pain control. The adjustment of medications as a primary response to patient requests for help reinforces a biomedical model of chronic pain and results in treatment interactions that are determined by reported pain levels. As every pain clinician can testify, the pursuit of pain relief can result in significantly impaired patient-provider relationships in which the issues of opioids overrides all other concerns and undermines broader treatment efforts. Statistically, about 45% of patients referred to pain clinics have already failed single or multiple therapeutic trials of opioids. 2*10*14Portenoy suggests that opioids should be discontinued if the trial “demonstrates serious adverse effects.” He does not, however, specify exactly what should be done with these patients who had presumably already failed “all other reasonable approaches” to pain management. We have yet to meet a patient who is referred for medication management who evidences the “strong desire for a rapid cessation of therapy” that Portenoy describes as “the usual response of a patient to a failed
therapeutic trial.” More often, the typical problem from the patient perspective is one of access to opioids in the pursuit of pain relief. Undoubtedly, there will be anecdotal success stories of patients treated for chronic pain with opioids for prolonged periods of time. However, for a condition like chronic low back pain in which the greatest predictive risk factor has been reported to be job dissatisfaction, the notion that these patients suffer from a opioid receptor agonist deficiency is simplistic.’ Finally, any discussion of drug trials would be incomplete without considering certain inherent risks. A recent review of chronic pain patient characteristics by Fishbain et ale4 reported prevalence ranges from 3 to 19% across studies with regard to diagnoses of drug abuse, dependence, and addiction. As such, one might expect that a small but significant minority of chronic pain patients would be at risk for experiencing abuse problems during opioid trials. The treatment guidelines suggested in our focus article have evolved from accumulated clinical experience but also have been strongly influenced by our interpretation of research. For example, in perhaps the only prospective, controlled, double-blinded study to date, for patients who suffered from chronic osteoarthritis, codiene failed to provide sustained analgesia superior to acetaminophen yet produced side effects so significant that the authors prematurely concluded the investigation. In our own clinic, we have observed that referred patients consuming narcotics failed to demonstrate any improvement in reported pain, or in a number of psychosocial outcomes when compared with otherwise similar patients not consuming narcotics2 Indeed, the patients consuming narcotics tended to be more depressed and showed significant functional impairment. Our data show that our paradigm does reduce narcotic use and increase function in patients treated for 6 months3 These data are from a group of patients in whom the mean duration of pain was 9 years. The initial mean reported pain score was 9 out of 10, and the mean number of (International Association for the Study of Pain) pain sites per individual was 3. Finally, we feel compelled to reply to Portenoy’s statement that “it should not be anticipated that debate among pain specialists about chronic opioid therapy for nonmalignant pain will be resolved by altering clinical constructs . . . these constructs are largely a given, and the discussion relates to numerous other complex issues.” We would like to underscore the primary role that one’s model of pain plays in the choice of which issues are relevant, in the interpretation of the available data, and in the manner in which future research questions are framed. An
REPLYKhabal,
underappreciation of the importance of assumptions that are often unstated can lead to seemingly endless discord and create confusion rather than clarification in the scientific literature. In our opinion, this debate will eventually be resolved in the same manner as other “great controversies.” Debates that have been cast as dichotomies (e.g., nature versus nurture) typically end with a whimper of exhaustion rather than a bang of empirical findings. The eventual answer to the question of whether or not narcotics have a role to play in the management of chronic pain will be “it depends.” We have little doubt that future research will eventually demonstrate that opioids are useful for some of the patients some of the time under some conditions. The research challenge is to begin to understand and predict the variability among patient responses to such medications. In the meantime, we think guidelines consistent with a biopsychosocial model are necessary for meeting the more immediate clinical challenges inherent in the use of opioids for chronic pain.
4. 5. 6.
7.
6.
9.
10.
References Bigos SJ, Battie MC, Splengler DM et al: A prospective study of work perceptions and psychosocial factors affecting the report of back injury. Spine 16:1-6, 1991 Chabal C, Jacobson L, Mariano AJ, Chaney EF: Nar-
11.
cotic use and psychosocial function in chronic pain patients. American Pain Society Meeting, New Orleans, November, 1991 (Abstr)
13.
Chabal C, Mariano AJ, Jacobson L, Chaney EF: Patterns of narcotic, sedative hypnotic, and adjunctive medication use on intake and after six months of pain
14.
12.
Jacobson,
Chaney, Mariano
291
clinic treatment. American Pain Society Meeting, San Diego, October, 1992 (Abstr) Fishbain DA, Rosomoff HL, Steele Rosomoff R: Drug abuse, dependence, and addiction in chronic pain patients. Clin J Pain 6:77-85, 1992 Fordyce WE: Opioids, pain, and behavioral outcomes. APS 1:282-284,1992 Hanson RW, Gerber KE: Coping with chronic pain: a guide to patient self-management. The Guilford Press, New York, 1990 Jacobson L, Mariano AJ, Chabal C, Chaney EF: Simultaneous interview technique for patients with persistent pain. Pain 45105-106, 1991 Kjaersgaard-Andersen P, Nafei A, Skov 0 et al: Codeine plus paracetamol versus paracetamol in longterm treatment of chronic pain due to osteoarthritis of the hip: a randomised, double blinded, multi-centre study. Pain 43:309-318, 1990 Mariano AJ, Jacobson L, Chabal C, Chaney EF: The simultaneous interview technique (SIT) and the codisciplinary made1 of chronic pain treatment. Pain (in press) Maruta T, Swanson DW, Finlayson RE: Drug abuse and dependency in patients with chronic pain. Mayo Clin Proc 54:241-244, 1979 Portenoy RK: Chronic opioid therapy for nonmalignant pain: from models to practice. APS J 1:285-288, 1992 Turk DC, Meichenbaum D, Genest M: Pain and behavioral medicine: a cognitive-behavioral perspective, New York, Guilford Press, 1983 Turk DC, Brody MC: Chronic opioid therapy for persistent noncancer pain: panacea or oxymoron? APS Bull l(l):l-6, 1991 Turner JA, Calsyn DA, Fordyce WE, Ready LB: Drug utilization patterns in chronic pain patients. Pain 12: 357-363,1982