NCAD West: Focus on Function When Treating Chronic Pain

All pain is real, Mel Pohl, MD, DFASAM, told NCAD West attendees on Thursday afternoon in Denver. But, as he went on to explain during his session, the way acute pain and chronic pain affect patients’ bodies are different, and they need to be treated as such.

When treating chronic pain, practitioners should work with patients to establish reasonable goals, focusing on improving patients’ ability to function.

“Don’t ask what’s the matter,” said Pohl, the chief medical officer at Las Vegas Recovery Center. “Ask what matters to you.”

If patients can resume the activities that are important to them, their perception of pain will go down. Maintaining and/or improving function and reducing discomfort by 50% are reasonable goals, Pohl said.

While opioids, when prescribed responsibly, can be effective in treating acute injuries, practitioners should be cautious when using them to treat chronic pain, as opioids over time can cause inflammation in the brain and ultimately make patients’ pain worse. When introducing opioids into the treatment of chronic pain, prescribers should enter with an exit strategy in mind and closely assess patients along the way while the medications are used.

Pohl highlighted a pair of the Centers for Disease Control and Prevention’s appropriate opioid prescribing guidelines:

• Carefully reassess doses greater than 50 morphine milligram equivalents (MME) per day, and avoid increasing dosages to more than 90 MME per day. Pohl shared a study that showed higher opioid doses were linked with higher overdose risk, with patients taking between 50 and 90 MME doses three times more likely to overdose and patients taking doses over 100 MME shown to be 11 times more likely to overdose.
• Prescribe the lowest effective dose of immediate-release opioids. Three days or less is often sufficient for the treatment of acute pain and more than seven days rarely is needed. First opioid prescriptions with more days’ supply have been linked to a greater probability of continuing use, Pohl said.

In lieu of prescription pain killers, cognitive behavioral therapy, dialectical behavioral therapy, acceptance and commitment therapy, and attention/distraction were among the ways Pohl listed to reduce pain intensity. He also noted that at LVRC, the following non-medication treatments have proven effective with patients:

• Physical therapy or exercise or yoga
• Chiropractic treatment
• Therapeutic massage
• Reiki, a hands-on alternative technique that focuses on the transfer of energy from clinician to patient
• Acupuncture
• EMDR and hypnotherapy
• Individual and group therapy
• Mindfulness-based stress reduction
• Nutrition

On that last point, Pohl added that sugar is the leading substance to cause inflammation.