Bill H. McCarberg, MD


March 13, 2009

Is it possible to achieve 100% pain relief in all people all of the time?

Response from Bill H. McCarberg, MD
Assistant Clinical Professor, Department of Family Practice, University of California San Diego School of Medicine; Founder, Chronic Pain Management Program, Kaiser Permanente, San Diego, California

Patients frequently seek medical attention because of pain. Pain relief is a major motivation for the provider visit but getting a diagnosis and some reassurance about the painful condition is the reason for the office visit. Patients tolerate pain and often self-medicate for pain without seeking medical advice. Pain is ubiquitous and is understood by many patients to be a normal part of living.

Any provider who treats chronic pain knows that complete pain relief is rarely achieved. Patients may have surgery for a disc or radiation for a metastatic bone lesion, resulting in miraculous relief, but even when clear structural lesions are repaired, all pain may not stop. When we surveyed a large sample of patients with chronic pain, we were surprised to find that they did not anticipate or expect complete pain relief. When asked how much pain reduction would be acceptable after treatment in a pain clinic, the most common answer was 50% reduction of pain.

We also know that everyone can get 100% pain relief with total anesthesia. However, many patients are not willing to put up with the side effects (unconsciousness) to achieve the pain reduction. Many patients with terminal cancer opt for higher pain levels to be awake and alert during the final stages of life.

This is not to say that a total absence of persistent pain would not be welcome. Most people with pain desire a return to normal life with normal function, including work, hobbies, sexual activity, sleep, and other activities that are taken for granted when accessing quality of life. Those with persistent pain, especially with of time, know what to expect. They have been through failed drug trials, injections, physical therapy, acupuncture, and even surgery without the desired result.

Knowing that complete relief from the pain is rarely possible and understanding that most patients recognize this dilemma, the provider should not promise this outcome. When discussing the continuing treatment of a patient who has been examined, has failed multiple therapies, and returns to the provider with pain levels of 7 or 8 out of 10, the discussion should focus on other aspects of treatment. Statements from a pain provider such as "There is nothing more I can do," "You will need to learn to live with this pain," or "The doctor who deals with this type of pain is a psychiatrist," are all dreaded phrases to the patient with persistent pain. The provider should instead promise continued support and, despite lack of treatment efficacy, should not give up on the patient or stop being creative in providing help. Appropriate statements include "Even though we have not found anything to stop your pain, I am still here for you," and "You and I are going to continue to work on this pain problem to improve your function." For the patient with persistent pain, promise what you can deliver: comfort, compassion, creativity, teamwork, a caring environment, and most of all, yourself.

Patients seek help and wish for a cure but are comforted by our style and manner. We can always deliver compassion and continuity of care, which may not seem like much, but it is greatly valued by our patients.


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