THE ORIGIN AND PURPOSE OF THE LABEL: INTRACTABLE PAIN

By Forest Tennant M.D., Dr. P.H.
No. 2 – Jan., 2018 REPORT
INTRACTABLE PAIN
The term “intractable pain” (IP) is a mystery to many people including health professionals. This is most unfortunate because it is an old concept that has, unfortunately, been largely ignored in recent years. I submit that a failure to understand the origin and purpose of the IP label is largely responsible for many aspects of the current opioid public health issue or “crisis”, as many call it.
In the 1960’s and 70’s some Canadian and British physicians considered themselves to be intractable pain specialists and they believed it caused profound biochemical changes in the body.(Footnotes 1,2) Their thinking and logic is summarized in a 1978 British Medical Journal article entitled “Biochemical Changes Associated with Intractable Pain”. (Footnote 3) Their definition of IP was “pain of at least one month’s duration that had not responded to conventional treatment”. This article makes three enduring points: (1) IP means pain is incurable: (2) IP means that conventional or standard treatment has failed to relieve pain; and (3) IP causes biochemical changes in the body that can be detected.
Physicians, such as myself, who began pain practice in the 1970’s, adopted the concept of intractability when dealing with pain patients, and we were quite reticent to prescribe opioids unless conventional therapy had proven to fail. This concept was further ingrained by the World Health Organization’s 3-Step Analgesic Ladder of 1982 and 1986. (Footnote 4) Step One on the ladder are non-opioid measures such as physical therapies and anti-inflammatory agents. If step one was not successful, a weak opioid such as codeine was added as Step Two. Step Three is the addition of a potent opioid such as morphine or oxycodone.
The concept of intractability was well accepted and institutionalized in the 1980’s and early 1990’s, because it separated simple chronic pain from IP. Potent opioids were the last treatment resort for bonafide pain patients. At the State level in 1989 and 1990, Texas and California adopted “Intractable Pain Laws”. The intent was to make a “safe harbor” for physicians such as myself who treated IP. For example, the California Intractable Pain law authorized a physician to treat an incurable pain patient with IP who had failed conventional treatment and it “would prohibit the Medical Board of California from disciplining a physician for that prescribing or administering” to the patient. (Footnote 5)
IP laws worked quite well until the late 1990’s when a powerful, moneyed, yet well-intended coalition of physicians, pharmaceutical companies, device makers, and government agencies, collectively rejected the concept of intractability and the WHO 3-Step Ladder. They developed, championed and aggressively marketed a set of technologic advances including long-acting, potent opioids, implanted electrical stimulators, epidural corticoid injections, and intrathecal, opioid infusion devices. They truly believed that this new set of technology advances would eliminate the need to separate pain patients into the classic 3 categories: acute, chronic, and intractable. An attempt was even made to reject the classic terms of chronic and intractable and substitute a more all-inclusive and less-defining term, “persistent”. We were no longer to use the terms “incident”, “rescue”, or “flare” pain, but to use the term “breakthrough” pain, because all “persistent” pain patients were to be on one of the new, long-acting opioids. Underpinning their movement was what later proved to be the false scientific belief that the central nervous system had only one neurotransmitter and receptor for each purpose or function. Their sole pick for the function of pain relief was endorphin and the opioid receptor. I now count seven different brain areas and receptors for pain relief. Furthermore, with the new technological advances and terminology, there wasn’t much need for training, family, or a therapeutic team. Just follow the cook book protocol for any patient who registered pain on a 1 to 10 scale, and they could expect a computer to tend them at their next clinic visit! Unfortunately, while much of the new technology benefited many patients and should be retained, there has been profound, unintended consequences.
Now the Nation is paying for the rejection of the WHO 3-Step Ladder and the concept and purpose of identifying intractable versus simple chronic pain patients. High tech and a new vocabulary hasn’t been a substitute for training, clinical competence, family, and a diagnostic evaluation based on an old-fashioned history, physical, and laboratory testing for biochemical changes. For example, I’ve personally found that I can almost always separate deserving and needy IP patients from simple chronic pain patients and blatant drug addicts with a history, physical, and drawing a little blood for biochemical tests.(Footnote 6) Lately almost every day we hear stories of drug abuse, diversion, raids, overdoses, the undertreatment of pain, and suicides of those who are just “done”. Although I clearly support some of the technical advances, I’ve never wavered from the three precepts of intractability: an incurable cause, conventional treatments that fail, and detectable biochemical changes. Isn’t is time to join me in a return to the basic principles of intractability?
References
1. Shenkin HA. Effect of pain on diurnal pattern of plasma corticoid levels. Neurology 1964;14:1112-1117.
2. Evans RJ. Acid-base changes in patients with intractable pain and malignancy. Can J Surg 1972;15:37-42.
3. Glynn CJ, Lloyd JW. Biochemical changes associated with intractable pain. Br Med J 1978;1:280-281.
4. World Health Organization. Cancer Pain Relief, Geneva, 1982 & 1986.
5. California Intractable Pain Act. Senate Bill No. 1802, 1990. 6. Tennant F, Herman L. Using biologic markers to identify legitimate chronic pain. Amer Clin Lab, June 2002.

Filed under: General Problems