Billies' help page for pain understanding

Essential Considerations in the Treatment of Intractable Pain

Psychological Factors

Another major factor in effective treatment is careful attention to the psychological sequel of chronic and intractable pain. Intractable pain patients universally are disabled from their usual vocational and avocational activities. Pain patients consistently complain of depression because they can no longer do the things that made their lives satisfying. Relief of chronic pain without the concomitant relief of depression is clearly inadequate medicine. Treatment of the situational depression is essential and readily available through the use of the many new anti-depressant medications. Although the orthopedic and pain literature frequently mention the use of the tricyclic anti-depressants, the many negative side-effects which typically result from their use, including sedation, weight gain and multiple anti-cholinergic complications, argue against their use in contemporary treatment.

Second Opinion

The importance of obtaining a second, independent medical opinion cannot be over-stressed. Not only does this confirm the diagnosis, it also safeguards the treating physician against the pitfalls of the treatment of intractable pain, and guarantees that comprehensive treatment is provided. Typically an anesthesia-based pain practitioner, the second opinion also makes available the full spectrum of the new pain-treatment procedures, eliminating any chance of over-dependence on oral medication. Orthopedic consultation is similarly indicated when there is a reasonable prospect of attaining greater relief from pain by an invasive procedure, where indicated, such as a laminectomy in cases of spinal stenosis.

Rehabilitation Focus

No matter the severity of the underlying pathology, improvement in the physical function of the patient must be the goal in all but the worst cases with multiple failed surgical procedures. The patient can make demonstrable progress in range of motion, and tolerance of activities, with a devoted regimen of hot baths, stretches and other physical therapies. Indeed, relief from pain should be targeted as in large part only a means to making physical therapy possible.

In summary, careful and consistent attention to these seven major factors in the treatment of chronic, intractable pain, both of malignant and non-malignant causes, insures the greatest probability of successful and effective treatment outcome, while minimizing iatrogenic complications.

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Therapeutic Alliance

Another major consideration is therapeutic alliance. As in every study of treatment outcome in psychiatric medicine, a strong therapeutic alliance is a significant predictor of success. So also in the treatment of pain, a positive transference between the patient and the prescribing physician is the best guarantee of treatment compliance. Therefore by firm policy the prescription of medications should be consistently limited to a single physician and, if at all possible, to a single pharmacy. Rotating physician coverage, or practice in a clinic setting in which multiple physicians attend the patients, should be avoided in every instance. Long-term treatment is also always more reliable than brief intervention, and in-depth knowledge of the patients, their diagnoses, and their course in treatment is an essential and powerful positive influence - for the reduction of pain, for effectiveness of pain medication and rehabilitative interventions, for the reduction of the need for medication, and for the avoidance of tolerance, diversion or recreational abuse of medications. When patients unequivocally know that they are well-known to the treating physician, abuse of treatment is highly unlikely. Assembly-line medicine virtually guarantees treatment failure and pharmacological dependence and abuse.