The Topical Review by Sullivan and Ballantyne6 identifies the frequent dilemma faced in treating patients with chronic pain where nothing seems to work. They raise a provocative question as to whether assessing the intensity of pain should be deprioritized. They suggest that focusing on the rating of pain intensity in the clinical setting sets the wrong goal, and may lead to misguided interventions, in particular treatment with opioids.
The intent of the “pain the fifth vital sign” campaign (Presidential Address to the American Pain Society, 1996, Campbell) was to encourage doctors and nurses to listen to their patients and assess their pain. This was because health care professionals often ignored patients' suffering from pain. There was no intent to have everyone take an opioid. The hope really was that by this time, now nearly 20 years later, we would be able to talk about other innovations in pain care rather than still focusing on the use of opioids. When this initiative was launched we were in a world where the principles of palliative care were first being articulated, where postoperative pain was often ignored, and where many patients died with severe pain from cancer. We have moved forward by leaps and bounds. Hospital ratings of quality of care by patients in part relates to how well pain is treated. The authors acknowledge these monumental gains, but worry that there may now be an overemphasis on pain ratings, and that this overemphasis may lead to overzealous efforts to control chronic pain with opioids. Although this logic may apply in some instances, there is a danger that we end up simply being less sensitive to our patients. In a medically refractive patient with hypertension, should we just stop measuring the blood pressure?
A singular focus on reducing pain intensity without considering the patient's overall quality of life is clearly misguided. However, it is equally self-evident that if we can reduce pain effectively and safely, we should. Defocusing the assessment of pain intensity has risks of being paternalistic. Pain care is largely empirical. Ideally we try different interventions in a tiered proportional manner aimed at balancing risk and benefit and quality of life. The assessment of pain intensity is an important component of the patient-doctor dialogue. It is not the unitary focus. It may be helpful in many circumstances to try to help a patient defocus on pain and to engage in other rehabilitative measures. But unfortunately, the quality of life may not be improved by these interventions alone.
The authors pose a clinical problem where a patient complains of intense low back pain. The patient takes an opioid which initially helped, but has stopped being effective. The patient had imaging studies, which indicate the presence of degenerative disk disease at a single level, not particularly striking in its severity. The pain seems out of proportion to the underlying disease. In such instances, a patient's pain may be magnified by psychological factors (eg, depression, anxiety, or pain catastrophizing). If this is the case, pain interventions (eg, surgery, implanted drug pump, spinal cord stimulation) may be ineffective. Training in psychological strategies, guided exercise to increase activity, or even no treatment at all may be best. Low back pain could be part of a “central sensitization” or fibromyalgia syndrome in which case the range of effective treatment options might be very limited. However, we should be cautious in thinking that a magnetic resonance imaging scan necessarily tells us how much pain a patient feels. There are too many variables from the process of transmission of physical energy, to neural transduction, to nociceptive processing, to the report of pain before we even get to the richness of the myriad of psychological variables.
It is instructive to consider that there is often a disconnection between x-rays and reports of pain in areas of the body other than the lumbar spine. For the hip, the knee, the shoulder, and other examples, the level of disease and the level of pain are only weakly correlated.1 A small tear of the rotator cuff may be very painful whereas large tears may be associated with no pain. Often our failure to understand the pathophysiology of a disease affects our attitudes about the symptoms. Back pain problems dominate pain clinics. It is possible that the greater anatomical complexity of the lumbar spine makes pain management much harder from the perspective of biomechanics. We have to be careful about how our limited ability to treat and understand a painful condition translates to believing our patients. Surgery for chronic hip pain is highly successful overall.5 Patients with chronic pain associated with osteoarthritis of the hip typically do not make their way to pain clinics. Our attitudes about chronic pain are influenced by whether we understand the underlying disease.
A major point in the Sullivan and Ballantyne article is that asking a patient to rate his or her pain intensity may have the unintended consequence of fostering the overuse of opioids leading to greater harm. There undoubtedly are many cases where this is the case. The converse likely also applies, where patients who might benefit from the skillful use of opioids are denied care. In the absence of much needed data, the use of opioids is a polarizing emotional issue for the public, for doctors, and for our patients. Obviously we need much more research to understand how to use this very important class of medications to its best advantage, given the spectrum of treatments presently available. So called “titration to effect” where the dose of an opioid continues to be increased may backfire. “More” may not be better and opioid-induced hyperalgesia may be an issue. One lesson in taking care of patients is the role of personalized medicine, acknowledging that each patient responds differently.
The assessment of pain intensity should go beyond thinking about whether to write a prescription for an opioid. The authors paint a pessimistic picture of what can be offered to a patient in chronic pain. Initially, a decision might be made to help a patient try to defocus on pain intensity as a therapeutic strategy. If the patient's quality of life improves sufficiently, then this option should be pursued. However, the patient may continue to have a poor quality of life because of pain. The patient both alone and, if possible, together with the family, need to be brought into a careful consideration of the treatment alternatives. In time, one option may be a trial with opioids. By some accounts, favorable outcomes may be achieved with surgery in particular for single-level disk disease such as that described in the clinical vignette.2,3 In recent years, spinal cord stimulation technology also has advanced to the point that in at least some patients, axial pain (in addition to radicular pain) can be helped.4
Teaching doctors that in the context of chronic pain, the assessment of pain intensity should be deprioritized threatens to send the wrong message. In the beginning part of my career, I became aware of the often devastating consequences of chronic serious pain. It was clear that many individuals were underserved because doctors were too busy to assess their patients' pain and because they believed that persistent pain was a relatively unimportant health problem. Converging lines of evidence, however, now demonstrate that persistent pain (as measured by intensity) is an important health care problem. Now, hospitals and doctors in hospitals are judged in part on how well they care for conditions such as postoperative pain. We have witnessed a surge of growth in pain medicine and a shift of attitudes such that it is now clearly unacceptable to ignore a patient's pain and suffering, whether it is acute or chronic. In describing pain as the fifth vital sign, the message is that pain assessment is a priority. Assessment should not equate to giving a patient an opioid. Assessment also does not mean that we cannot work with strategies to help patients adapt and to try to focus their lives away from pain. Assessment, however, does mean that we care, that we empathize, and that short of evidence to the contrary we believe the patient's report of pain. Belief offers hope to our patients, and belief motivates us, the doctors, the nurses, and the scientists, to continue to search for better ways to enhance the quality of our patients' lives.
Conflict of interest statement
J. N. Campbell serves as President, and Chief Scientific Officer of Centrexion Therapeutics, a company aimed at the development of new therapeutics for the treatment of pain.
. Bedson J, Croft PR. The discordance between clinical and radiographic knee osteoarthritis: a systematic search and summary of the literature. BMC Musculoskelet Disord 2008;9:116.
. Guyer RD, Pettine K, Roh JS, Dimmig TA, Coric D, McAfee PC, Ohnmeiss DD. Five-year follow-up of a prospective, randomized trial comparing two lumbar total disc replacements. Spine (Phila Pa 1976) 2015. Epub ahead of print.
. Jacobs WC, Rubinstein SM, Willems PC, Moojen WA, Pellisé F, Oner CF, Peul WC, van Tulder MW. The evidence on surgical interventions for low back disorders, an overview of systematic reviews. Eur Spine J 2013;22:1936–49.
. Kapural L, Yu C, Doust MW, Gliner BE, Vallejo R, Sitzman BT, Amirdelfan K, Morgan DM, Brown LL, Yearwood TL, Bundschu R, Burton AW, Yang T, Benyamin R, Burgher AH. Novel 10-kHz high-frequency therapy (hf10 therapy) is superior to traditional low-frequency spinal cord stimulation for the treatment of chronic back and leg pain: the SENZA-RCT randomized controlled trial. Anesthesiology 2015;123:851–60.
. Rolfson O, Kärrholm J, Dahlberg LE, Garellick G. Patient-reported outcomes in the Swedish Hip Arthroplasty Register: results of a nationwide prospective observational study. J Bone Joint Surg Br 2011;93:867–75.
. Sullivan MD, Ballantyne JC. Must we reduce pain intensity to treat chronic pain? PAIN 157;1:65–9.