On Pain Meds – Can 5+ Patients Do Without Them and Get Better?

June 22, 2009 | Filed Under: Opiods | Comments(0)

BACKGROUND: Over the years that I’ve been treating pain patients, I have literally read hundreds of articles from around the world on treatments for chronic non-cancer pain. I don’t do this for entertainment I do it because I have to, to maintain my certification in pain management active. In short, I’m expected to keep myself up to date for my patients. One of the most frequent issues I hear from pain patients concerns their fears about taking “powerful” pain medications.

My purpose in this post is to sum up everything I’ve come across from around the world, and from our pain program’s own randomized controlled trial (RCT) that involved more than 400 legitimately diagnosed chronic non-cancer pain patients who reported a minimum of 5 (out of 10) level pain in our pain program on the campus of Scripps Memorial Hospital between 2000 and 2006. We compared 3 treatments with pain medications to assess under what conditions was functionality most effectively restored.


– First we looked only at primary care physicians and what and how physicians who are not certified specialists in pain, and were not part of our program, prescribed pain drugs to patients with 5+ level pain and what outcomes they posted at the end of 3 months;

– Then, we looked separately at certified pain management anesthesiologists who were part of our program and what and how physicians who were specialists certified in pain prescribed pain drugs to the same type of patients and what outcomes they posted after 3 months of treatment; and

– Finally, we looked separately at a combination of a certified pain anesthesiologist and a pain psychologist expert in operant behavioral and lifestyle modification – the “pain program” treatment – and what and how that combination of those two types of specialists in our program, with their specific interventions, wound up using pain drugs and what functionality outcomes they posted at the end of 3 months.

I’ve gone into the details of this RCT elsewhere. The key finding was that drugs alone do very little to restore 5+ patients’ functionality. The combination treatment was the only one to produce statistically significant change in relevant (to the patient) functionality. Primary care physicians had no impact on functionality; certified pain anesthesiologists had some, non-statistically significant impact on functionality. And the combination program had highly statistically significant impact on restored functionality. There’s no secret to this. It’s a matter of controlling the potential error in the treatment. If you can’t see it, you can’t control  it, so it constitutes random error. And since physicians can’t “control” the conditions that  increase or decrease functionality, they’re essentially not treating functionality directly so random error is to be expected in a drug-only treatment, especially  if the prescribing is in the hands of people not specialized in the control of pain.  That’s just commonsense.  So, in the same way that I can’t control the conditions that lead to metabolic changes in diabetes,  whatever I do, I’m not treating diabetes, regardless of any good intentions I may have. It’s simply not my area of practice.  And, functionality (or highly nuanced, higher-order, highly integrated behavior) is simply not physicians’ area of practice.

IS DRUG-FREE TREATMENT POSSIBLE?  Let’s follow the implications of the data and see what the numbers say about whether 5+ pain patients can do without pain drugs and show significantly greater functionality?

The short answer is, it depends on what the treatment conditions are. What is also obvious from this study is that not one 5+ pain patient was able to start restoring their functionality without the help of appropriately, specialist-prescribed pain drugs PLUS highly specific lifestyle and habit change conditions aimed at restoring very specifically defined functionality for each patient.  In short, neither drugs-alone nor lifestyle/habit-change alone works alone. A drugs-only approach restores little if any functionality, and a functionality-only approach, without drugs, also fails to restore functionality. Our findings simply were consistent with what we find in the worldwide literature on chronic diseases:  a combination approach (drugs PLUS behavior/lifestyle modification in expert hands) is the Gold Standard for restoring patients’ ability to again function as close as possible to normal.

So the answer is clear. No patient who did not take specialist-prescribed pain drugs was able to decrease their pain enough to focus on doing what they needed to subtly modify their behavior and lifestyle and begin to restore their functionality. The way it’s done “right” is that pain drugs are used to create just enough pain relief to begin to increase what constitutes priorities in the topography of each patient’s functionality. As functionality increases and comes under control of the patient’s normal life circumstances again, the need for medication drops and, in about 6 months, most patients can begin to titrate down from their beginning doses of pain drugs.

So, can 5+ pain patients go without taking pain drugs and increase their ability to function normally?  No, they can’t. All those who posted statistically significant changes in their functionality scores needed pain drugs to begin restoring their functionality. There is no mystery to this because 5+ pain leaves one – from experience – very “ditzy.” You can’t focus, you can’t concentrate, you can’t remember details of what to do to have success in consistently controlling the conditions of your functionality’s occurrence.

Dr. Henry Adams