Pain Awareness Month Interview: Howard Fields

This September marks the 18^th annual Pain Awareness Month, which was created by the American Chronic Pain Association in 2001 to help spread awareness of Americans who suffer from chronic pain and to help improve treatment for them. According to a study performed by the Centers for Disease Control and Prevention in 2016, 20 percent of adults in the United States have chronic pain while 8 percent had high-impact chronic pain, which means that at least one life event had been affected by their condition. Howard Fields, M.D., Ph.D., professor emeritus of neurology and physiology at the University of California, San Francisco, and a member of the Dana Alliance for Brain Initiatives, has been studying the mechanisms of pain and opioid analgesia and addiction. He responded in writing to our questions about the use of opioids for chronic pain and safer alternatives.

Since pain is subjective, how is a person’s pain measured? (Why is it that two people who experience the same injury experience pain differently?)

The person’s verbal report is the most common method for assessing pain; there is no objective way to measure pain in an individual. There are indirect measures, but they are uncertain: withdrawal reflexes, changes in pupil size, heart rate, skin resistance, and blood pressure have been used. Functional imaging is not there yet. For that reason, we assume; but do not know for sure whether different people experience pain differently.

What’s your thinking on Oxycodone and other opioids being used for pain management, particularly given the opioid epidemic that has flourished in recent years?

Unfortunately, no current medications are more reliable and effective for pain than opioids. When used for acute pain, for example, following surgery, burns, or trauma, especially when given in the hospital, opioids are safe and effective and their use seldom leads to significant problems. The use of opioids for chronic pain is more controversial in that their use for greater than 2-3 months has not been established as effective; nor for that matter, as ineffective. It’s probably the case that opioids should not be used as first line drugs for pain that is expected to be long term; usually musculoskeletal pain, like back pain. That said, it is certainly reasonable to try an opioid if the patient is in moderate to severe pain. Risk factors for opioid use include a history of substance abuse or mental illness, such as depression or anxiety. The use of opioids in combination with anti-anxiety drugs like benzodiazepines is particularly risky and should be avoided.

Are there safer alternatives than prescription opioids, or any other recent developments, for pain management?

There are many alternative approaches to chronic pain management, including cognitive-behavioral methods, mindfulness, physical therapy, and massage. There are also interventional approaches, including nerve blocks and neuroaugmentation methods such as spinal cord and peripheral nerve stimulation. Beyond that, certain non-opioid pharmacological agents are effective for certain types of chronic pain syndromes; these include anticonvulsants, antidepressants and, for example for migraine, there are triptans and calcitonin gene related peptide antibodies. There are also promising new approaches to inflammatory pain syndromes like rheumatoid and osteoarthritis.

Are there any neuroethics issues tied to pain?

Absolutely. Perhaps the biggest problem is the abandonment of patients by doctors who are afraid to prescribe opioids for fear of creating addiction. The profession has an obligation to treat the patient’s pain. The patient’s obligation is to be open with the treating health care professional about possible substance abuse or obtaining pain meds from multiple sources.

Is there an increasing interest in this field? Is there enough funding?

The cohort of treating professionals with specific interest in treating pain has grown significantly, as has the number of scientists working in the field. Funding for pain and opioid research has expanded greatly over the past few years. The National Institutes of Health is doing a terrific job identifying good scientists doing clinically relevant research and Congress has supported funding in this area. It’s a great time to be entering the field. That said, there are significant financial barriers to providing full multidisciplinary treatment of pain, an approach which has the potential to greatly ameliorate the need for opioid analgesics. It’s probably the case that, in many parts of the country, a multidisciplinary pain clinic is not available and that needs to be addressed by educating primary care physicians and training more pain specialists.

What do you think the general public should know about both chronic and temporary pain, especially as it pertains to young people, who are generally assumed to be healthy?

Opioids for acute pain treatment are quite safe when used as directed by a physician familiar with the cause of the pain. It’s probably not a good idea to leave bottles of opioid analgesics around your home and definitely a bad idea to share them with anyone. The use of opioids for fun is potentially dangerous. For treating chronic pain, use the lowest dose that provides significant relief. It is probably not realistic to try for complete pain control. Think about the things that you would like to be able to do (especially if it involves activity) but cannot do because of the pain; use the minimum dose of analgesics specifically to achieve those goals.