Intractable Pain: Causes, Characteristics, Treatment & Management, Diagnosis

Intractable pain is a chronic pain, which does not go away or subside with medical treatment. Intractable pain is a sub-group of chronic pain where the patient has constant, unrelenting and excruciating pain. Intractable pain is also incurable and extremely severe; such that it dominates the patient’s every waking moment causing mental and physical debilitation. The patient suffering from intractable pain can also experience a desire to commit suicide for the sole purpose of escaping from the pain. If treatment or management of intractable pain is not started, then patient can also become bed- or house-bound.

In order to differentiate from chronic pain patients, intractable pain patients are commonly referred to as IP patients. There have been many IP laws or established standards and guidelines which are passed to allow the doctors to prescribe opioids along with other end-stage treatment for such type of patients without any legal repercussions. As patients suffering from intractable pain will always have some sort of underlying, incurable condition, making the management of intractable pain complex and often requiring a specialized clinical setting. Lifetime care is required for intractable pain patients due to its incurable nature.

None of us likes to experience pain, but inevitably do suffer from it at some time or other. The quality and nature of the pain indicates the problem which we have and how to treat it. The type of pain which we feel when we fall down and injure ourselves is acute pain. The cause of acute pain is easily identifiable and this pain is usually short-lived.

If a person has been in a car accident and experiences persistent pain which lasts for more than three months then it is known as chronic pain. Chronic pain is not short-lived like acute pain and is usually present all the time or can come and go.

Around 40% of people suffer from some type of chronic pain, the common cause of which is arthritis and other musculoskeletal degenerative conditions. Amongst this group of people, some experience chronic pain, which is intractable in nature, i.e. the pain is present at all the time with a severity that the person is unable to perform the daily activities of living. None of the medical interventions, including surgery, medications, severing the nerves, are not able to stop the intractable pain. The result of which is feelings of frustration, depression, hopelessness and thoughts of suicide to end the pain, in the patient.

Patients with intractable pain will have occasional spikes in heart rate and blood pressure along with extremely high levels of cortisol, which is a stress hormone. This is the body’s physical reaction to the pain which the person is feeling.

• Pain is excruciating and constant. 
• Due to the pain, the patient is not able to eat or sleep.
• The patient suffering from intractable pain can become chair- bed- house-bound if adequate management of pain is not started.
• Intractable pain patient experiences depression, confusion, attention deficit, frustration and suicidal tendencies.
• The underlying cause of intractable pain is non-removable or incurable and does not respond to any pain therapies.
• Patient suffering from intractable pain has increased pulse rate and blood pressure.
• There are immune and serum adrenal hormone abnormalities.

• Degenerative spinal disease post-surgery (commonest cause of intractable pain).
• Non-operable degenerative spinal disease (commonest cause of intractable pain).
• Fibromyalgia can also cause intractable pain.
• Migraine-vascular headache.
• Neuropathies.
• Congenital skeletal disease.
• Headache after an injury.
• Reflex sympathetic dystrophy.
• Osteoporosis.
• Systemic lupus erythematosus.
• Interstitial cystitis.
• Abdominal adhesions.

Diagnosis of intractable pain in a patient is made when the patient fails to respond to the traditional treatment methods for acute and chronic pain, which include medications such as anti-inflammatories, non-opioid analgesics, mild opioids, muscle relaxants, antidepressants and anti-seizure medications. Patients with Intractable Pain also do not respond to corticosteroid injections in and around the peripheral nerves or spinal column. Exercise, physical therapy and psychological interventions also prove to be of little benefit, as the patient is not able to participate in all this because of the excruciating nature of the pain. The only treatment till now which has shown to relatively control and manage intractable pain is lifetime therapy of potent opioids. This line of treatment should be done as a last resort or end-stage because of its expense and complications.

Goals of Treatment: The aim of treatment for intractable pain is extension of life of the patient and giving the patient an improved quality of life as much as possible. The aim of treatment of patient with intractable pain is for the patient to become ambulatory so that the patient can leave their home to, socialize, shop and even work. Treatment is decided based on the cause of the intractable pain, the type of pain, the location of pain, and the triggers which worsen the pain.

In many cases, the patient who is suffering from intractable pain is very ill and chair or bed bound. The hygiene, diet and ambulation of the patient are also neglected in many cases. So, this should be first corrected.

Medications to Treat Intractable Pain: Some of the medications used for managing intractable pain include opioids, non-opioid painkillers, muscle relaxants, antidepressants or anti-seizure medications.

It is important to determine the opioid which is effective in the patient. This opioid should be prescribed in such a dosage and frequency which gives the patient some measure of relief by preventing emergency room visits, enables the patient to take proper diet, allows the patient to ambulate, and gives the patient some chance to return to normal activities of daily living.

Pain Monitoring: Monitoring of the intractable pain and its intensity is important. This can be done by using a pain scale, which notes the severity of the pain from 0 (no pain) to 10 (severest pain). This will help in controlling the intractable pain.

Treating the Cause of Intractable Pain: Patient may have a terminal disease like cancer, which is causing the intractable pain; whereas in some cases, the cause could be a non-terminable condition. In some cases, there is no identifiable cause found. Degenerative spine disease is the commonest cause of intractable pain.

Treating Associated Physiologic Conditions in Intractable Pain Patients: Other physiologic problems, such as hypertension, tachycardia and changes in the concentrations of the adrenal hormone should be managed. These problems serve as biologic markers which help in gauging the effectiveness of the treatment.

Treating Associated Psychiatric Conditions in Intractable Pain Patients: Treatment of psychiatric conditions such as depression and suicidal tendencies should be done immediately. Patient should be able to lead an improved quality of life as much as possible.

Surgery: Specialized surgeries, which will block the nerves in the affected region, can be done. Patient can also benefit from counseling or working with a mental health specialist, as the pain can worsen if there is decline in the patient’s mental health. This becomes a vicious cycle.

It is important to document that the patient has intractable pain on his/her chart. This should be done by the physician and clinical staff. Documentation of intractable pain is important not only for legal purposes, but also because the medical management of intractable pain is a lifetime treatment, which needs potent medication, which can have potentially detrimental complications.

The documentation should include the medical records, which show the presence of a painful and incurable condition, which has failed treatment attempts with traditional therapies for recurrent, chronic pain. A detailed history of the onset of intractable pain in the patient along with subsequent failed treatment methods should be provided by the caretakers and family members. Physical examination is conducted to identify the physical evidence of the cause of intractable pain along with neuromuscular abnormalities which are incurable, fixed and irremovable.

If the intractable pain is not controlled or managed, then usually physiologic or laboratory abnormalities can be seen, as the intractable pain causes over-excitation of the autonomic, cardiovascular, and hypothalamic-pituitary-adrenal systems. Some of the common physical signs and symptoms include hypertension, tachycardia, dilated pupils, hyperreflexia, depression and anxiety.