Ask Doctor K: Pain specialist can find right combination of therapies

DEAR DOCTOR K: I have been in pain since a car accident a few years ago. My doctor is very conservative in prescribing pain medication. Why not just give me what I need to feel better?

DEAR READER: I don’t know the particulars of your case, but I think you are talking about narcotic (opioid) pain medicines. And your doctor probably is reluctant to prescribe opioid medicines for chronic pain – the kind I assume you now have if your accident was a few years ago.

Opioid pain medicines are of unquestioned value in treating acute pain – the kind you had immediately following the accident. They definitely reduce pain, and many of their side effects don’t become a problem until a person has been taking them for a long time.

In contrast, the treatment of chronic pain is tricky. I spoke about the treatment of pain with my colleague, Robert T. Edwards. He is a licensed clinical psychologist in the Pain Management Center at Harvard-affiliated Brigham and Women’s Hospital. He pointed out that opioids can have very bothersome side effects, even in the short run. For example, they make people tired and cause constipation and memory problems.

Another major issue, as the ongoing opioid crisis illustrates, is that opioids carry the risk of abuse and overdose. They are not to be prescribed lightly. Approximately 25,000 people died in 2014 from opioid overdoses. In many cases, those deaths were from prescription opioids.

Many pain experts say that while opioids are potent relievers of acute pain, there is not much evidence that they are more effective than other forms of therapy for chronic pain.

So in treating your pain, your doctor (and you) have to balance benefits against risks and consider multiple options for relieving pain. Opioids are not the only option. For some people, the risk of abuse is small, the side effects are minor and the drug reduces their pain by a lot. But for others, these drugs reduce pain only a little, and cause severe fatigue and cognitive side effects.

The best pain-management treatments are tailored to each individual; they combine several different therapies to help minimize side effects. Take a person with chronic low back pain, a history of alcohol abuse and depression. This person might do best with a combination of non-opioid pain relievers, cognitive behavioral therapy and an antidepressant. But another person, also with chronic low back pain, may get the best results with daily low-dose opioids and weekly acupuncture.

Of course people with chronic pain want to experience less pain. But they also care about enjoying life more and having a strong sense of emotional well-being. They want to increase their physical activity, sleep better and reduce fatigue. They want to participate in social and recreational activities. These goals need to be balanced against the downsides of pain treatment.

I’d recommend that you see a pain specialist. Such specialists are best trained to find the combination of therapies that will both give you pain relief and spare you side effects that might be as difficult to deal with as the pain.