A Letter Released to Chiropractic Physicians on
September 5, 2006

The Role of Analgesics in
Efficient Pain Management

Holistic practitioners often express concern that allopathic practitioners use medication to relieve the symptoms of a biomechanical or neurological lesion without directly addressing the source of the symptoms. Of course, few physicians on either side of the allopathic / holistic divide would argue that pain medicine has no role in the treatment of painful conditions. A quick review of what we already know about the human neurological response to pain will put the role of analgesics into perspective.

The longer a painful stimulus continues the more sensitive a person will become to it. Unrelieved pain leads to hyperalgesia – a lowered pain threshold. Prolonged pain stimulates the release of spinal neurotransmitters that cause the body to recruit nerve fibers not normally associated with pain. Recruited nerve fibers cause normally nonpainful stimuli such as vibration or touch to become painful. Recruitment can result in long-lasting or even plastic alterations in our patients’ pain sensory system, setting up chronic pain syndromes.¹ During acute pain, a window of opportunity exists for physicians to provide rapid and appropriate analgesia, mitigate the development of chronic pain, and relieve patient suffering. In many cases, the original insult to the body has been resolved, but chronic or plastic alterations in the nervous system continue to cause hyperalgesia and allodynia – persistent pain. In cases where the pain sensory system has begun the process of plastic alterations toward chronic pain, rapidly effective pain medications can interrupt the pain cycle, give nerve fibers the opportunity to “reset”, un-recruit nerve fibers, and restore more normal pain thresholds.

Pain can reach a point of duration or intensity where it becomes more appropriate to look at pain as a disease process in and of itself. Pain causes impaired GI function, imparied pulmonary function, impaired immunity and healing, insomnia, and increased blood clotting.² Psychological effects include anger, resentment, despondency, anxiety, depression, isolation, impaired family function, marital conflict, and even requests for physician assisted suicide.²

Of course, most of these arguments about the necessity for rapid and effective analgesia make little mention of biomechanical lesions which may have caused the pain originally or which may still contribute to the chronic nature of pain. These arguments also ignore the lasting and more desirable analgesic effects of manipulative and physiological therapeutics. Unfortunately, the safest methods and those with the least side effects, tend to be the methods that are the slowest acting and the methods requiring greater dedication on the part of our patients. The ideal treatment approach to moderate, severe, or chronic pain is one that uses fast-acting medications to avoid or reverse the neurological sequelae of pain, while maintaining the ultimate goal of discontinuing drug therapies in favor of more natural, holistic approaches. This is where a two-fold approach to pain management becomes most beneficial to our patients – a physician trained to work with the body’s natural capacity to heal itself co-managing with a physician who can expertly coordinate medical approaches as needed.

I invite chiropractic physicians to enlist me, Dr. Neal Taub, MD, ABPM&R, when they have cases of recalcitrant, moderate to severe pain, or cases of chronic pain. As a physiatrist, board certified in pain medicine, my role is to co-manage conditions that fall under the physiatrist realm of expertise. When therapeutic goals are met, the patient returns to the life-long care of his or her primary care practitioner.

Call today to discuss co-management options for one of your patients.

References

1. Ducharme J. Acute pain and pain control: state of the art. Ann Emerg Med 2000; 35: 592-603.
   
2. Berry PH, Dahl JL. the new JCAHO pain standards: implications for pain management nurses. Pain Manag Nurs 2000; 1: 3-12.