TMC PULSE

t m c » p u l s e | m a y 2 0 1 6 25 "I think it's a great start, but it's almost a little too late," said Alok Madan, Ph.D., director of the Pain Management Program at the Menninger Clinic and McNair scholar. "If you look at best practices, what the CDC has put out, we've known for awhile. We just didn't have the political will to actually push forward." There's insufficient evidence to show that prescription opioids have any long-term benefits in improving chronic pain, function and quality of life, but their rampant use has been deeply ingrained in the country's approach to chronic pain manage- ment since the 1990s. "We looked at how effective [opioids] seemed to work for acute pain and relief of suffering at the end of life. There were some small studies looking at a small number of hospitalized patients with chronic pain who seemed to do well on opioids," Dowell said. "There was a lot of optimism, a lot of hope, that these medications could work for the long term as well as we've seen them work for the short term, but I think our optimism got ahead of the evidence." With the Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) push to improve pain management standards and assess- ment in 2001, health care providers were encour- aged to document high levels of unrelieved pain and lift barriers in the health care system that prevented patients from receiving medication. The report essentially supported the use of opioid med- ications and downplayed the serious risks studies have since corroborated. "Health care professionals […] have inaccurate and exaggerated concerns about addiction, toler- ance, respiratory depression, and other opioid side effects, which lead them to be extremely cautious about the use of these drugs," the JCAHO report stated. "Pain essentially became the fifth vital sign," Madan said. "I think what we're seeing today is the pendulum just swinging completely in the opposite direction from there. We might have gone a little too far with that." Madan leads a team of specialized clinicians at the Menninger Clinic to help treat patients suffering from chronic pain, using a combination of nonpharmocological interventions—including Pain essentially became the fifth vital sign. — ALOK MADAN, PH.D. Director of the Pain Management Program at the Menninger Clinic and McNair Scholar cognitive behavior therapy, experimental brain stimulation technologies and genetic testing—with physical therapy, exercise and non-opioid medica- tions. But because chronic pain is characteristically accompanied by comorbidities, such as depression, simply treating the symptoms rather than the cause can exacerbate the condition, prolong medication and risk drug use disorder. "You're in chronic pain, so you can't do as much as you did. You start getting frustrated, you start getting angry, you start getting sad, [and then] you start getting depressed," Madan said. "Lo and behold, the depression makes your pain worse, so now you've got chronic pain with clinically signif- icant depression on top of it. Both are feeding on one another and you're spending more and more time in bed, you're not getting out, you're not even getting sunlight, not bathing, you're not eating. You can see how this type of situation could quickly spiral out of control. "I think we have failed in trying the [nonphar- mocological interventions] first," he added. "We quickly go to second- and third-tier treatments, in large part because it can be hard to get patients to go to a physical therapy appointment, while it's much easier for them to go to the pharmacist and fill up a bottle." Prescription opioid medication may provide patients with the path of least resistance, but experts agree that the uncertain benefits of those painkillers come with known risks of addiction and drug abuse, and that physicians should consider nonpharmacological and nonopioid approaches for successful, lasting outcomes. So while national adoption of the CDC's new guidelines has great potential to help curtail the opioid addiction epidemic, long-term change requires redefining the country's approach to chronic pain management and refraining from either overprescribing or underprescribing. Just as Goldilocks navigated through the home of the three bears in pursuit of things that were not too much or not too little, the way forward lies in finding the happy medium of "just right." Madan demonstrates a transcranial direct current stimulation device, which is currently being tested in clinical trials for patient use and has been shown to effectively treat chronic pain, depression and anxiety.

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