End Stage Chronic Pain (ESCP): Naming Complex Suffering in the Opioid Crisis Era

The "opioid crisis" stemming from overprescribing of prescription opioids describes an iatrogenic situation which has resulted in a rise in opioid use disorder (OUD) and overdose deaths. Many of these patients suffer from chronic non-cancer pain syndromes (CNCP) who have been injudiciously treated with opioids. Some patients with CNCP are treated successfully with opioids in accordance with modern guidelines. There is a very complex, small group of patients with CNCP who require higher than recommended dosages of opioids when other modalities and treatments have failed. We describe such a patient and believe that there is a subset of patients with unremitting suffering from chronic pain which we have called end-stage chronic pain (ESCP). These patients, despite receiving expert chronic pain care, often require high doses of opioids and suffer a dramatic decline in quality of life (QOL), function and an increase in their suffering when their opioids are tapered or discontinued. We have responded to the treatment of this group of patients by critically examining our approach to the use of opioids for their pain and attempting to reconcile high dose opioids in the setting of the Center for Disease Control (CDC) guidelines. We describe a patient with severe chronic pain from congenital spinal disease who experienced increased pain and suffering when his opioids were tapered. We will discuss our approach to this patient and in doing so discuss the concept of ESCP and proposed criteria for the use of high dose opioids in such patients.