Patients who deal with pain can be stratified into a three general categories: acute, sub-acute and chronic in terms of the length of symptoms. This is not an absolute, but a general system. Acute pain is the time immediately associated with an injury or surgery and during the first three months of treatment. Sub-acute is the period of time roughly three to six months after the initial injury. The most difficult time is the chronic period after six months when injuries may be permanent and long-term strategies will need to be determined. Determining treatment options during each period is challenging.
The acute pain phase is hopefully the only time a person will have problems. It is the period right after injury or surgery, and for most people this is a very short period of time, lasting several days to a week. Many people are able to pass through this period with minimal problems and are on to healing and recovery without the use of any significant medications. With more major problems, symptoms are more prolonged, and more extensive use of treatments are necessary from therapy or long-term medications. Furthermore, everybody has a different need for management and finding the correct strategy may be quite complex.
This also is a period where a person with a tendency toward addiction psychologically or physically can develop a problem. Up to 15-20 percent of the population may be at risk for addiction to opioids. For those people, even within a few doses, the brain starts abnormally seeking the dopamine release stimulated by these drugs. The injury may heal, but the brain continues to desire opioids. This is one of the main times when people develop addiction and start a downward spiral. It is extremely difficult to predict who will develop an addiction and that is the reason for medical practitioners to try to limit exposure. The crisis in drug abuse has pushed the need to reduce the exposure and risk for everyone.
The sub-acute phase of pain management is the period of time between three and six months after a medical problem. A management strategy needs to be developed at this point to determine what the diagnosis and prognosis is for the condition. At this point, a specialist is often appropriate so that the best strategy can be determined. Finding the correct person to treat a problem that is not resolving is often the most difficult issue. Physicians are often lacking knowledge and experience to solve the more difficult medical problems.
Fortunately, 90 percent of physicians can guide you through the medical maze. If you are one of those with a particularly difficult problem, you will need one of the best physicians in that field. These physicians are often not in prestigious places like universities or major medical centers, but are the hardworking private practitioners. They often have been in practice for a number of years and they have enough experience to determine what is the best path forward for the complex issues and are not constrained by a single strategy. During this time, hopefully a patient can be transitioned away from opioid-type medications and toward a comprehensive strategy.
The last phase is when a problem turns chronic. That time period is after six months. Sometimes, if the initial treatment has not been successful, this is the period when a skilled physician needs to be found to fully diagnose the issues and develop a new strategy. These skilled experts can clarify and define issues others have not seen. They are also the ones who will act as a guide through the maze of medical issues and not give up. If you listen and work with them, it is likely that a positive outcome will be achieved.
Chronic pain problems may or may not be well served with opioid medications. There are far more down sides to these medications than positives. They may seem helpful, but often are treating the anxiety associated with pain more than the pain itself. Opioids increase the sensitivity in the nervous system to painful stimuli and suppress the body’s own pain fighting ability. Everyone will become tolerant to opioids and up to 20 percent of the population will develop an addiction. With over 140 deaths/day and over 60,000 deaths/year associated with opioid addiction, it is a very limited treatment option. Most pain physicians therefore are reluctant to use these medications and push every other option. If they are used, then strict compliance rules are mandated for safety. Break any of the established rules and the option disappears, possibly permanently. If these medications are maintaining high levels of function such as full-time gainful employment, then they may be reasonable.
If you use opioids either short-term or for a long span of time, expect strict rules. These drugs are notoriously dangerous, and they often have a narrow range of safe dosage. Any improper usage can lead a provider to stop prescribing. Addiction, death and damage to the patient or others are always a concern. Further, if there is a better treatment available, then prescribing opioids may be a poor choice for both the patient and prescriber.
If you are told this is not the best treatment for you, there is probably a good reason and you should try every other option offered. Often a person in pain has poor insight into their own behavior and listening to others is necessary. Pain can be extremely complex, and often there is no solution but only management options. For chronic pain, sometimes one needs to look at your own situation and determine a different path to follow in life such that life can be more enjoyable.
Thomas Cohn, MD
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