Pain and opiates: A discussion with Dr. Aneesh Singla

Background:
“The United States is home to approximately 5% of the world’s population, yet we use 80% of the world’s opiates. How did this happen? Are we leading the rest of the world in compassionate use of these medications for pain, or are we traveling down the wrong road?” writes pain management expert Dr. Aneesh Singla in a new book, Why It Hurts: A Physician’s Insights on the Purpose of Pain.

According to the Centers for Disease Control and Prevention (CDC), the number of prescription opioids sold in the United States since 1999 has nearly quadrupled, yet the amount of pain that Americans reported hasn’t changed overall.

“Pain helps reveal the root causes of what ails us,” Dr. Singla writes. “It is a highly developed alarm system the body uses to help us prevent further injury and properly attend to our underlying conditions.” Ignoring that alarm system is one reason why we may be headed down “the wrong road,” as he puts it.

In this interview, Dr. Singla discusses the current opioid crisis, the myth of “zero pain,” and why it’s important to keep patients functional in the face of pain.

MDLinx: In your view as a pain specialist, what do you think is the main contributor to the current opioid crisis?

Dr. Singla: There are many factors to the opioid crisis, but one contributing factor is the use of opiates to manage chronic pain and to relieve suffering. I believe that pain is protective to us and that opiates will never cure pain 100%; so we set expectations for perhaps 50% pain relief from opiates, so that opioids are not overused in search of 100% pain relief. I tell my patients that a 50% reduction in pain is a reasonable goal when treating chronic pain, and we seek this with multiple treatment options, not simply through opiates.

I see the greatest problems when the goals of therapy are not defined well. If you continually strive toward zero pain, opiate therapy will fail, leading to overuse of these medications.

MDLinx: Are opioids as a class being demonized in the public eye right now?

Dr. Singla: Prescribing opioids is one tool in our toolbox to treat chronic pain. The decision to use opiates is based on the individual needs of the patient when the risks are outweighed by the benefits of the therapy.

MDLinx: You mention that psychological pain can be as real as physical pain. Some patients are told by specialists that their pain is “all in your head,” when in fact the pain is caused by an unaddressed physical problem. How can physicians get away from the “it's all in your head” mentality but yet embrace the idea of genuine psychological pain?

Dr. Singla: All pain is eventually interpreted “in our head.” But there are many components to pain. For example, physical pain is when there is an injury, like an ankle sprain, and then your feelings around that pain—say you are depressed or anxious about the injury and your ability to return to activity—could be interpreted by some people as psychological pain. Although overlap of psychological pain and physical pain is very common, it’s important to separate out the physical problem from the psychological one wherever possible, and treat each one appropriately. Don’t let anxiety drive the treatment of physical pain.

MDLinx: Many doctors say: “Pain is a symptom not a diagnosis.” How does that idea align with the view you express in your book?

Dr. Singla: Pain is clearly first and foremost a symptom of a problem. To treat pain as an isolated entity is to risk missing a warning sign that our body is trying to send us. We, as physicians, need to follow the path that pain takes us when we formulate a diagnosis for the underlying “pain generator,” and try to manage the pain as best as possible to decrease pain and maximize function. Zero pain is not the goal, but avoiding zero function is. The only way to avoid any pain at all would be to put the patient into a coma, which clearly isn’t a long-term solution. Patients must learn to accept that some degree of pain is unavoidable and adapt to live with it.

About Dr. Singla: Aneesh Singla, MD, is Medical Director of The Rockville Center of National Spine and Pain Centers in Rockville, MD. His practice currently focuses on minimally invasive options for the treatment of chronic pain.