How Much Pain Relief is "Enough"?

Patient Expert

As chronic pain patients, we dream of complete relief from pain.   However, the sad fact for most of us is that total freedom from pain is probably an unrealistic goal.   If that's the case, what then is a realistic goal?   Just how much pain relief is it reasonable to expect?   And a perhaps equally important question is, what outcomes other than a decrease in pain intensity are important to us?

For the past seven years, a multidisciplinary group of international experts has been meeting and working to develop recommendations for improving clinical trials of pain treatments.   One important focus of this group - called the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) - has been on how effective treatments for chronic pain can be defined, measured and translated into meaningful outcomes for patients.  
Measuring Improvement in Pain Intensity

Not surprisingly, the primary measure of a treatment's effectiveness has been pain intensity.   The most frequently used tools to evaluate a patient's pain are:

-  Numerical Rating Scale (NRS) - Patients are asked to rate their pain by a number between 0 (no pain) to 10 (worst pain imaginable).   This is the scale most often used in doctors' offices and hospitals.   (See _Using the Pain Scale Effectively _.)  
-  Visual Analog Scale (VAS) - Patients are asked to mark their pain intensity along a line 100 mm long, with 0 (no pain) at one end and 100 (worst pain imaginable) at the other end.

The IMMPACT group reviewed several studies and found that patients evaluate the success of a treatment by the following criteria:

Substantial improvement - 4 or more points reduction on the NRS, or 50% or more reduction on the VAS;
Moderately important improvement - 2 points NRS reduction, or 30 - 36% VAS reduction;
Mimimally important change - 1 point NRS reduction, or 10-20% VAS reduction.

From that it was surmised that most patients consider a treatment satisfactory or successful if they experience at least a 50% reduction in the level of their pain.  
How These Studies Apply to You

Before beginning any pain management plan, I think it's important for the doctor and patient to discuss expectations and agree on realistic goals.   If the patient is expecting complete pain relief but the doctor considers the treatment a success if there is a 50% reduction in pain, both are going to be dissatisfied.   The patient will end up feeling like the doctor doesn't care about her pain and the doctor may start to think the patient is just looking for more drugs.

It's also a good idea to periodically reassess your pain management plan, evaluating your progress (or lack of it) and possibly setting new goals.   When you first began pain management, you were probably happy with any degree of pain relief you could get.   But after a while, you may feel that a 30% reduction in pain is just not enough to allow you to function as you need to and you want to try for better pain control.   You doctor needs to know if your goals have changed so you both are aiming for the same target.

Other Measures of Treatment Success

I think most of us would agree that significantly reducing the intensity level of pain should be the primary goal of any pain treatment.   However, chronic pain also causes numerous other problems that shouldn't be overlooked when forumlating a pain management plan.

In order to determine which aspects of life were most significantly and negatively impacted by chronic pain, the   IMMPACT group, together with the American Chronic Pain Association, surveyed 956 chronic pain patients.   Nineteen areas were identified as having the greatest negative impact on patients' lives.   Below is a list of the 19 areas in their order of importance, as determined by the patients surveyed.   Following each item is a number that indicates where that item fell on the scale of importance, with 0 representing "not at all important" and 10 representing "extremely important."

Enjoyment of life - 8.8
2.   Fatigue, feeling tired - 8.8
3.   Emotional well-being (feeling sad, depressed, less motivated) - 8.6
4.   Physical activities (walking, climbing stairs, bending, squatting, lifting) - 8.4
5.   Weakness - 8.3
6.   Staying asleep at night - 8.3
7.   Difficulty concentrating - 8.0
8.   Household activities (cleaning, cooking, running errands) - 7.9
9.   Falling asleep at night - 7.8
10. Relations with family, relatives or significant others - 7.7
11. Participating in family events/activities - 7.7
12. Participating in recreational and social activities - 7.7
13. Employment - 7.6
14. Difficulty remembering things - 7.6
15. Relations with friends - 7.2
16. Taking care of family such as children, spouses, parents or other relatives - 7.1
17. Hobbies - 7.1
18. Planning activities - 7.0
19. Sex life - 6.6

It's also interesting to note that the ranking of these 19 areas was remarkably consistent for all of the chronic pain conditions studied, which included migraine, rheumatoid arthritis, osteoarthritis, low back pain, neck or shoulder pain, fibromyalgia and neuropathy.

Now the question becomes, how much does chronic pain affect these other areas of life?   We can't necessarily assume that relieving the intensity of the pain will automatically eliminate the other problems.   In most cases, it will certainly help.   But depending on the individual and the particular chronic pain condition, some of these problems may remain.   For example, a key symptom of fibromyalgia, in addition to pain, is extreme fatigue.   Reducing the pain may not significantly impact the level of fatigue.   That doesn't mean that the pain treatment wasn't successful; it just means that the   fatigue needs to be treated separately.

While I don't think these other areas should necessarily be measured in clinical trials to determine the success of a treatment designed to reduce the intensity of pain, I do think they need to be considered when evaluating an individual patient's pain management plan.   Regaining the ability to function in life is important to the patient and, therefore, should be an important consideration in developing and assessing a treatment plan.

Now I'd like to know what you think.   What are your expectations from a pain management plan?   How much pain relief is "enough"?   How do you think your pain affects the 19 other areas listed?   Please click "Comment" below and tell me what you think.

Dworkin RH, Turk DC, Wyrwich KW, et al. Interpreting the clinical importance of treatment outcomes in chronic pain clinical trials: IMMPACT recommendations. J Pain. 2008;9:105-121.
Turk DC, Dworkin RH, Revicki D, et al. Identifying important outcome domains for chronic pain clinical trials: an IMMPACT survey of people with pain. Pain. 2008;137:276-285.

Credit: Thinkstock