Female therapist helps a man with his back pain

The Evolution of Pain Management

Before the dawn of modern medicine, pain was an acute issue as it was unlikely someone would survive a serious injury. With the advent of better medical care, the way U.S. doctors approached pain management evolved. By the 1990s, opioids were the go-to pain management solution in America for non-cancer related chronic pain for reasons that have contributed to today’s public health crisis: 19.7 million people battled a substance use disorder in 2017. As the health care system reins in opioid use, alternative pain management methods are proving to be effective long-term solutions to chronic pain.

Beginning of the American Opioid Crisis

The American opioid crisis has its roots in the way society understands and views pain. Pain management became more prominent during the Civil War – when morphine was used to treat wounded soldiers – and in the mid-1900s, as World War II veterans returned home. Increasingly, doctors perceived pain to be undertreated and opioids were used for those with cancer-related and acute pain. In the 1990s, pain management experienced a shift:

  • Doctors began using opioids to treat non-cancer patients with chronic pain without considering the behavioral and psychological health of the patient.
  • The addiction risk for opioids was downplayed early on by pharmaceutical companies.
  • Pain was made the “fifth vital sign” and state governments made it a civil penalty for physicians not to address pain.
Confronting an Epidemic

By 2004, the number of first-time abusers of prescription opioids had hit 2.4 million, up from 628,000 in 1990. While the rate of opioid prescriptions peaked by 2010 in the U.S. and has declined since 2012, the amount of opioids prescribed per person is still three times higher than the rate in 1999.

In order to combat the public health emergency, the health care system began changing its practices at every level – from doctors to researchers to pharmacies. There are a variety of treatments designed to help people recover from opioid abuse and to regain control of their lives:

  • Inpatient treatment programs
  • Community support groups
  • Medication-assisted treatment (MAT)
  • Psychotherapies
Management Strategies for Chronic Pain

The main goal of any chronic pain management program is to increase function – not to eliminate pain entirely. Patients must learn to accept a compromise of improved mood, function and tolerable pain level.

  • Acupuncture and acupressure: For some individuals these interventions can be of assistance.
  • Alternative and complementary nutraceutical preparations: These can sometimes complement the use of topical applications or other combinations of interventions. They are worth considering but usually have significant drug interactions and should only be taken under the expert guidance of a medical professional.
  • Behavioral health evaluation: Regardless of the cause, individuals with sustained chronic pain have a higher likelihood of developing major depression. Utilization of psychotherapies and, if needed, medications can be helpful to eliminate this portion of chronic pain syndrome.
  • Comprehensive evaluations and treatment planning: Primary care providers work in tandem with psychologists who have special training to provide comprehensive evaluations of patients’ pain. It is the best and most effective way to determine a safe and long-term treatment for chronic pain. Part of the evaluation should include an opioid risk tool to gauge if the patient has a higher than normal risk for habituation should the need for opioids arise.
  • Injections or local surgical interventions: Where appropriate, a doctor may prescribe injections or permanent nerve disruption to address pain. Correction of underlying anatomy damage can decrease or eliminate the cause of the pain.
  • Lifestyle modifications: Weight loss, exercise, proper sleeping habits, a healthy diet, yoga, meditation, relaxation techniques and several other factors can all play into chronic pain intervention.
  • Other drug combinations: If approved by a doctor, anti-inflammatory preparations like topical anesthetics or topical steroids can provide substantial relief without systemic effects. In some instances, the use of hot and cold applications can relieve local discomfort. Changing to oral medications such as ibuprofen and Tylenol can provide relief to patients with few side effects and essentially no risk of addiction. It’s critical for patients to talk with their doctor before changing a medication regimen.
  • Physical therapy and functional rehabilitation: In certain cases, physical therapy can relieve pain over time through the natural strengthening of the body. Functional rehabilitation also has a psychological care component that’s beneficial to all patients.

Prescription opioids are meant to make pain more manageable, not to stop pain entirely. However, there are conditions that are best treated with an opioid prescription:

  • End-of-life care
  • Pain related to a cancer diagnosis
  • Patients whose pain is not effectively managed through non-opioid treatments

Each patient will experience and respond to pain differently. Patients with chronic pain should talk to their doctor about whether a prescription opioid is necessary, how to manage its effects and all other medications they are currently taking in order to avoid serious side effects.

Dr. William Beecroft, M.D., D.L.F.A.P.A., is a medical director of behavioral health at Blue Cross Blue Shield of Michigan.  

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