Providing chronic pain management in the "Fifth Vital Sign" Era: Historical and treatment perspectives on a modern-day medical dilemma

Abstract

Background: Over 100 million Americans are living with chronic pain, and pain is the most common reason that patients seek medical attention. Despite the prevalence of pain, the practice of pain management and the scientific discipline of pain research are relatively new fields compared to the rest of medicine - contributing to a twenty-first century dilemma for health care providers asked to relieve suffering in the "Fifth Vital Sign" era.

Methods: This manuscript provides a narrative review of the basic mechanisms of chronic pain and history of chronic pain management in the United States - including the various regulatory, health system and provider factors that contributed to the decline of multidisciplinary pain treatment in favor of the predominant opioid treatment strategy seen today. Multiple non-opioid pain treatment strategies are then outlined. The manuscript concludes with three key questions to help guide future research at the intersection of pain and addiction.

Conclusions: The assessment and treatment of chronic pain will continue to be one of the most common functions of a health care provider. To move beyond an over reliance on opioid medications, the addiction and pain research communities must unite with chronic pain patients to increase the evidence base supporting non-opioid analgesic strategies.

Keywords: Chronic pain; Chronic pain management; John J. Bonica; Multidisciplinary pain treatment; Opioids.

Fig. 1

Cumulative citations of two influential articles on the “low risk” of addiction with opioid use. A letter published in 1980 by Porter and Jick that dealt with opioids for acute pain as well as a report by Portenoy and Foley in 1986 on 38 cases of persons treated with opioids for chronic non-malignant pain were used hundreds of times as evidence to demonstrate that opioids had low risk for addiction. Cumulative citations for each article were obtained from Google Scholar.