Pain Management: Addressing the Stigma
Addressing the issue of pain management is difficult. Most people with endometriosis wait an average of ten years for a diagnosis. And let’s face it- by that time, we’ve tried most everything. We’ve gone through rounds of different hormonal treatments, taken enough Advil and Tylenol that we should’ve bought stock in it, burnt our skin with heating pads, tried supplements, tried diets, and if it’s a cream, lotion or potion…yep, we’ve tried that too. Unfortunately, there is no easy answer to how to deal with pain and other symptoms until you can have surgery with an expert in endometriosis. And the fact that endometriosis comes with its own gang of other symptom generators, like adenomyosis and interstitial cystitis, doesn’t make the path any clearer. Add in the effects of many years of pain that alters the body’s pain processing, then pain becomes even more difficult to treat (Fine, 2011).
The years of inadequately treated pain can have negative consequences. King and Fraser (2013) state that:
“Untreated pain has a profound impact on quality of life and can have physical, psychological, social, and economic consequences. Inappropriately managed acute pain can result in immunological and neural changes, which can progress to chronic pain if untreated… Patients with chronic pain often experience social isolation, dependence on care givers, and impaired relationships with friends and family, and are four times more likely to experience depression or anxiety than those without pain. The financial burdens of untreated chronic pain—absenteeism, income loss, healthcare costs, and workers compensation—place the same strain on countries as cancer and cardiovascular disease. In the United States, the annual cost of untreated pain is reported to be between US$560–US$635 billion.”
Pain management strategies can include the use of pain medications such as opioids. There is a sizeable stigma around opioid use. This is further confounded by the inadequate knowledge the general population has about the pain involved with endometriosis. One of the big misconceptions associated with long term use of opioids is the difference between tolerance, dependence, and misuse. Using a medication as directed by your healthcare provider- who has taken into consideration your treatment options, your health history, other medications you may be prescribed, and discussed risk versus benefit with you- is different than misuse of that medication. Part of the discussion about use of opioids should include the risks of building tolerance and dependence.
The American Academy of Family Physicians (n.d.) states that “regular opioid use, including use in an appropriate therapeutic context, is associated with both tolerance and dependence. The presence of tolerance or dependence does not necessarily mean that an individual has an opioid use disorder. Tolerance is present when an individual needs to use more of a substance in order to achieve the same desired therapeutic effect. Dependence is characterized by specific signs or symptoms when a drug is stopped. “Opioid misuse” is a broad term that covers any situation in which opioid use is outside of prescribed parameters; this can range from a simple misunderstanding of instructions, to self-medication for other symptoms, to compulsive use driven by an opioid use disorder. “Abuse” is also a nonspecific term that refers to use of a drug without a prescription, for a reason other than that prescribed, or to elicit certain sensory responses.”
Key Terms and Definitions (Kaye et al., 2017):
“Substance use disorder: A cluster of cognitive, behavioral and physiological symptoms indicating that an individual continues to use the substance despite significant substance-related problems. A diagnosis based on pathological pattern of behaviors related to use of the substance.
Tolerance: A state of adaptation in which markedly increased drug doses are required to achieve desired effect or exposure results in diminution of one or more opioid effects over time.
Physical Dependence: A state of adaptation manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.
Addiction: A primary, chronic, neurobiologic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. This term is no longer applied as a diagnostic term.
Aberrant drug-related behavior: A behavior outside the boundaries of the agreed-on treatment plan, which is established as early as possible in the doctor-patient relationship.
Misuse: Use of a medication for nonmedical use, or for reasons other than prescribed (DSM IV TR 2000). Misuse can be willful or unintentional use of a substance in a manner not consistent with legal or medical guidelines, such as altering dosing or sharing medicines, which has harmful or potentially harmful consequences. It does not refer to use for mind altering purposes.
Abuse: Misuse with consequences (DSM IV TR 2000). The use of a substance to modify or control mood or state of mind in a manner that is illegal or harmful to oneself or others. Potentially harmful consequences include accidents or injuries, blackouts, legal problems, and sexual behavior that increases the risk of human immunodeficiency virus infection.
Diversion: The intentional transfer of a controlled substance from legitimate distribution and dispensing channels into illegal channels or obtaining a controlled substance by an illegal method.
Withdrawal: A syndrome occurring when blood or tissue concentrations of a substance decline who had maintained prolonged heavy use resulting in withdrawal symptoms that vary greatly across the classes or substances.”
American Academy of Family Physicians. (n.d.).Chronic Pain Management and Opioid Misuse: A Public Health Concern (Position Paper). Retrieved from https://www.aafp.org/about/policies/all/chronic-pain-management-opiod-misuse.html
Fine, P. G. (2011). Long-term consequences of chronic pain: mounting evidence for pain as a neurological disease and parallels with other chronic disease states. Pain Medicine, 12(7), 996-1004. Retrieved from https://doi.org/10.1111/j.1526-4637.2011.01187.x
Kaye, A. D., Jones, M. R., Kaye, A. M., Ripoll, J. G., Galan, V., Beakley, B. D., … & Manchikanti, L. (2017). Prescription opioid abuse in chronic pain: an updated review of opioid abuse predictors and strategies to curb opioid abuse: part 1. Pain physician, 20(2S), S93-S109. Retrieved from https://www.painphysicianjournal.com/current/pdf?article=NDIwMw%3D%3D&journal=103
King, NB & Fraser, V. (2013) Untreated Pain, Narcotics Regulation, and Global Health Ideologies. PLoS Med 10(4): e1001411. https://doi.org/10.1371/journal.pmed.1001411