The Quandary of Chronic Pain

How can we handle a patient in chronic pain? It’s a difficult dilemma. On the one hand, all of our effective analgesics come with long lists of side effects, from constipation to addiction to life-threatening GI bleeds. On the other, we have individuals mired in anger, depression, and hopelessness due to a debilitating symptom.

I spent this past summer studying the medications used by older adults with osteoarthritis, one of the most common conditions that affect us as we age. The average patient was taking 10 medications, which obviously raises concerns about drug interactions and over-prescription. What struck me most, however, was the number of people reporting severe daily pain that were not being treated for it in any capacity.

NSAIDs have been shown to exacerbate hypertension and, considering the skyrocketing rates of cardiovascular disease and diabetes, it is no wonder that doctors are hesitant to prescribe them to many older adults. However, the fact remains that the chronic pain of osteoarthritis, known as a ‘non-life-threatening ailment’, receives far less attention than other comorbid conditions.

I’m not sure what the answer is. Would you choose painkillers if you knew it might lead to a higher chance of heart attacks and strokes? Or would you choose to live with the pain? My concern is that this question is not properly being posed to our patients, and that the decision to avoid analgesics may be being made for them. In addition, there are number of non-pharmaceutical strategies for dealing with pain, including physical therapy and meditation, that are not being recommended or encouraged by many physicians. Most of these strategies are also not covered by public or private insurance.

As the number of people living with multiple chronic conditions increases, these are issues we will have to deal with more and more. And while no one wants to increase their diabetic patients’ blood pressure, consider the negative consequences of having too much pain in your knees to exercise, or too much pain in your hands to make your own meals. It’s no wonder that people with both diabetes and osteoarthritis report worse control of both conditions.
One particular patient story captures all of these issues. Mrs. M was an older lady, still living on her own and caring for a husband with dementia. She began the interview all smiles and spunk, talking about how arthritis was just something you had to live with, make the best of. She described difficulty with many activities of daily living – showering, preparing meals, even opening pill bottles. She took half a regular Tylenol when the pain was “excruciating”. She wasn’t prescribed NSAIDs due to long-standing hypertension, and refused opioids due to fear of addiction. As the interview progressed, her real fears and concerns surfaced – how she would continue to care for her husband, and even herself. “Some days I can’t even make myself get out of bed,” she whispered. “I’m so angry with my body for doing this to me”. This frustration and depression is typical of patients who see their chronic pain as a life sentence, and who are told to ‘live with it’ or ‘make the best of it’ by their health care providers.

There is no cure for chronic pain, and our existing analgesics are less than stellar. Still, the acknowledgement of pain as a real and distressing symptom, coupled with a consideration of non-pharmaceutical strategies for treating it, can go a long way to alleviate some of the suffering and mental anguish that these individuals face.