It is my great pleasure to author my first column as President of the Southern Pain Society. In trying to find some inspiration for this column, I went through my New York Times’ collection of articles about chronic pain. I have long been a print and then digital subscriber to the Times, and now have amassed a collection its articles about chronic pain, pain management, and palliative care issues (with thanks to my father-in-law, who dutifully sends to me any article that escaped my eye).

Looking at these articles chronologically, it shows the great arc of change that our field has been through during our professional careers. From one practice standard and swinging to another – pain management as a field and as a professional practice has experienced marked changes and intense scrutiny that few fields of medicine have undergone over the last thirty years.

Just looking at the headlines (not even the articles themselves) will give you a good taste of this:

  • August 26, 1985 – “Helping Families Deal With Chronic Pain”
  • March 28, 1993 - "Patients in Pain Find Relief, Not Addiction, in Narcotics"
  • July 29, 2001 - "The Alchemy of OxyContin"
  • December 21, 2001 - "Few States Track Prescriptions As Way to Prevent Overdoses"
  • November 25, 2003 - "The Delicate Balance Of Pain and Addiction"
  • October 19, 2004 "Doctors Behind Bars: Treating Pain Is Now Risky Business"
  • May 30, 2006 - "Doctors Struggle to Treat Mysterious and Unbearable Pain"
  • March 27, 2007 - "Trafficker or Healer? And Who’s the Victim?"
  • June 17, 2007 - "Doctor or Drug Pusher"
  • August 29, 2007 - "A Surplus of Treatment Options, Few of Them Good"
  • May 13, 2008 - "Back Pain Eludes Perfect Solutions"
  • November 05, 2009 - "Treating the Pain Epidemic"
  • April 09, 2012 - "Tightening the Lid On Pain Prescriptions"
  • May 21, 2016 - "Prescription Dip Seen as Advance in Opioid Battle"
  • March 16, 2016 - "New Standards for Painkillers Aim to Stem Overdose Deaths "
  • November 23, 2016 - "If the Doctor Orders Marijuana, Will Insurers Pay?"
  • December 29, 2016 - "Ethics and Pain: It’s Complicated"

See what I mean? From recognizing that many were languishing unnecessarily due to pain; to beginning to recognize the societal trade-offs that would stem from aggressive pain management; to re-evaluating the legitimacy of providers who treat patients' pain zestfully; to recognizing that effective pain management treatments are often elusive or expensive (or both); to trying to craft new guidelines to stem prescription abuse; to grappling with the impact of the medical cannabis movement; and to finally recognizing that our field is inherently complicated and perennially chock-full of contradictions.

Many of these articles have the term “double-edge sword” in their text, either as an interview quote or as a journalistic conclusion. This term does capture the dichotomy of our work – the very treatments that can be nearly life-saving for one of our patients can be ineffective for another, or even life-destroying. This dichotomy is true whether our treatments include extended release opiates, nerve blocks, rhyzotomies, kyphoplasties, spinal stimulators, infusion pumps, mindfulness exercises, or any other treatment that we render.

I personally know patients that have had such positive responses to each of these treatments, the word ‘miracle’ tumbles out repeatedly as they describe their response. I also know patients that would describe each of these treatments as having ruined their lives, leaving them even more disabled and embittered than prior to treatment (well, truth be told, I don’t know anyone who would describe ‘mindfulness’ as ruinous – just a hippy-born, navel-gazing, fantastic waste of time).

As we start 2017, the arc of change continues. Many state legislatures and healthcare payers / insurers are considering tremendous regulatory changes in light of both the CDC’s recommendations on opiates for the treatment of chronic pain and the nation’s changing attitudes towards the use of cannabis for the treatment of pain. Several recent articles have suggested a “swap” of chronic opiates for chronic cannabis – suggesting that this would lead to less societal pain such as traffic accidents and overdose deaths [1]. Even as some authors suggest these changes, disturbing reports about dramatic increases in traffic accidents, accidental childhood exposure, intense side effects, and – yes – overdose deaths are appearing in medical [2] and legal reports [3].

I am not “poo-pooing” medical marijuana. Rather – if there is anything the last 30+ years has demonstrated to us over and over again – it is that there are no easy answers in pain management. An approach that may work wonders for one patient may fail miserably in another. What remains the truest ‘answer’ is the ethos that I have seen demonstrated over and over again from our colleagues, in our newsletters, and at our conferences. We treat our patients with zealous compassion, encouraging that they deserve to live a life free of intense daily suffering, and advocating to institutions about preserving and enhancing treatment options for people with chronic pain.

I guarantee you that 2017 will bring new challenges to this ethos. But I also guarantee you that we have together faced similar challenges in the past and that our organization will continue to educate and promote our highest healing ideals.

REFERENCES

[1] Eric Sarlin. Study Links Medical Marijuana Dispensaries to Reduced Mortality From Opioid Overdose. NIDA Notes, published 05/17/2016 and accessed at  https://www.drugabuse.gov/news-events/nida-notes/2016/05/study-links-medical-marijuana-dispensaries-to-reduced-mortality-opioid-overdose
[2] Howard S. Kim, et al. Cyclic Vomiting Presentations Following Marijuana Liberalization in Colorado. Academic Emergency Medicine. Volume 22, Issue 6, June 2015, Pages 694–699
[3] Rocky Mountain High Intensity Drug Trafficking Area. The Legalization of Marijuana in Colorado: The Impact. Volume 2 / August 2014. http://www.rmhidta.org/html/August%202014%20Legalization%20of%20MJ%20in%20Colorado%20the%20Impact.pdf