The System Profits From Your Pain | The Pained Brain, Chapter 12

Polypharmacy · Chronic pain

Polypharmacy and Chronic Pain: What Your Medication List Measures

Most people with chronic pain take five or more medications, and a list that long often grows through cascades in which a new drug treats the side effect of an earlier one. Bring the list to your physician for a structured review, ask for measurements of the body underneath it, and never stop a medication on your own.

A chart can hold a dozen procedures and seven prescriptions and still contain no measurement of the body underneath the pain. The length of the list is a signal worth reading.

Polypharmacy and chronic pain travel together so reliably that researchers call it the rule rather than the exception. In a Quebec cohort of 1,342 adults with chronic pain, five or more medications were the norm for 71.4 percent, and ten or more for 25.9 percent. A list that long is a measurement in its own right: it records how many problems were answered with a prescription, and how few were answered with a question. The Chapter 12 video of The Pained Brain, from Dr. Gurpreet Singh Padda, MD, MBA, MHP, and Dr. KrisJay Fucanan, MD, argues that a system built to count procedures and prescriptions will keep producing longer lists. The useful response is to start counting different things.

What does polypharmacy look like in a chronic pain chart?

The book opens its twelfth chapter with a composite: a sixty-one-year-old man on his ninth epidural in three years, each at the same spinal level, each good for about six weeks. Between injections he takes seven prescriptions, and three exist to handle side effects of the other four. He has had imaging, a nerve study and a surgical consultation. What his chart lacks is just as telling. Nobody has checked his fasting insulin. Nobody has asked what he eats or how he sleeps.

Dr. Padda is blunt that he has given that injection himself and will defend it as a bridge, a few weeks bought so a person can rehabilitate, sleep, move and change the terrain under the pain. The ninth injection, with nothing planned on the far side, is not a bridge. It is a routine, and routines do not generate measurements.

What causes polypharmacy in chronic pain?

Long lists grow through cascades, where a new prescription answers a side effect of an earlier one. In 23,544 nursing-home residents who began a gabapentinoid, a loop diuretic was added within ninety days for 4.2 percent, at a median of 36 days, a sequence consistent with treating the swelling the first drug can cause. Among older hospital inpatients who had chronic noncancer pain and polypharmacy, 24.5 percent were taking an opioid together with a sleeping medication. In United States survey data, adults whose pain interferes with work faced 1.47 times the odds of an emergency visit with every five added medications.

None of those studies proves a single prescription wrong. They show the list itself carries risk that deserves a structured review with the physician who writes it. Never stop or change a medication on your own.

What gets counted, and what does not

The system counts some things very well. Epidural injections in traditional Medicare grew by 103 percent per 100,000 enrollees between 2000 and 2010. In commercial claims covering 196,332 patients, the busiest tenth of providers performed 36.6 percent of all spinal procedures. Since 2019 those curves have bent downward, yet the counts carry no reason for the procedure and no outcome, so a smaller number cannot show whether patients now have plans or simply fewer appointments.

What almost never gets counted is the terrain. Two biological drivers sit under most long lists: metaflammation with insulin resistance, and the side-effect load of the drugs themselves. The third driver is the incentive: when the service count is what gets rewarded, a chart fills with procedures and stays empty of measurements. The patient can change that third driver by asking for numbers.

What should be measured when your medication list is long?

Measura [Cardiometabolic and Autonomic Health Analysis] measures; it does not treat or prescribe, and findings go to your physician. These are the gaps a chart like his leaves open:

Laboratory panels: blood markers of metabolic health, the category the composite patient never had drawn
Bioimpedance body composition: muscle and fat compartments rather than weight alone
Cognitive assessment and vestibular and balance testing: a baseline for memory and steadiness, worth raising when a list combines sedating medications
Autonomic nervous system testing: how the involuntary nervous system is regulating heart rate and blood pressure

A baseline earns its place because it can be repeated. A plan that works should move a number you can see; a routine moves only the next appointment date. For background, read chronic pain and metabolic health and why body composition is not the same as weight.

Proof that a lifelong label can move

One landmark trial opened by calling type 2 diabetes a disorder needing lifelong treatment, then assigned primary care practices to run a structured weight-management program. After twelve months, remission had been reached by 46 percent of the program group and 4 percent of usual care, and by 86 percent of people who lost 15 kilograms or more. After twenty-four months the split was 36 against 3 percent, and diabetes medication was still being taken by 40 percent of the program group against 84 percent of controls. Some people relapsed, and the trial studied diabetes, not pain. Its lesson for a long list is that the medications followed the terrain.

Pain programs point the same direction on a smaller scale: in 134 older adults finishing interdisciplinary rehabilitation, medication use fell across every drug class by discharge.

What should I ask my doctor about my medications?

Which medications on my list were started because of another medication?
What measurement will show this plan is working, and when do we repeat it?
Has my fasting insulin ever been checked?
Given what I take, would a balance or memory baseline help?
What should be different before the next procedure?

The studies behind every figure here, with their limits, are in the Chapter 12 companion. The next question in the series, whether the needle lands where it is aimed, is taken up here, and the physician version of this topic is measuring before the next procedure.

Frequently asked questions

What counts as polypharmacy?

In chronic pain research, polypharmacy usually means five or more medications taken together, and excessive polypharmacy means ten or more. In one cohort of 1,342 people with chronic pain, most met the first definition and about a quarter met the second. Counting includes over-the-counter products, so bring everything you take, not only prescriptions. Here is what happens before your appointment.

What is a prescribing cascade?

It is a chain in which a side effect of one medication is treated with a second medication instead of being recognized as a side effect. Swelling after starting a gabapentinoid, followed by a water pill, is a well-studied example in nursing-home residents. Asking which drug on your list treats another drug is a fair question for any prescriber. See questions worth asking your doctor.

Can Measura testing tell me which medications to stop?

No. Measura measures metabolic, autonomic, vascular, body-composition, cognitive and balance function; it does not prescribe or deprescribe. Results go to your physician, who weighs them alongside your medication list and history. A measured baseline can make that review more concrete, but only the prescribing physician should change a medication. Read what a test result can and cannot tell you.

Why measure body composition if the problem is pain?

Weight alone cannot show how much of the body is muscle and how much is fat, and The Pained Brain argues that chronic pain sits on the same metabolic terrain as diabetes. Knowing the compartments gives you and your physician a starting number to track as sleep, food and movement change. The test itself is described on the bioimpedance body composition page.

How often should these measurements be repeated?

That depends on what is being tracked and what your physician expects to change, so there is no single schedule. The point is that a plan names a measurement and a date to look again, so progress shows up as a number instead of an impression. A general guide is available on how often to repeat cardiometabolic testing.

What are the risks of polypharmacy?

A long list carries risk of its own. In United States survey data, adults whose pain interferes with work had 1.47 times the odds of an emergency visit with every five added medications. Among older inpatients with chronic noncancer pain and polypharmacy, 24.5 percent took an opioid together with a sleeping medication, a combination that makes a memory and balance baseline worth raising with your physician.

How can polypharmacy be reduced?

Start with a structured review of the whole list with the physician who writes it, and ask which drugs were added to treat another drug. Pair that review with measurements of the body underneath the pain, so the plan moves a number you can see. In 134 older adults finishing interdisciplinary rehabilitation, medication use fell across every drug class by discharge. Never stop or change a medication on your own.

Put numbers behind the plan

Ask your physician about a Measura baseline, then request testing so the results can be reviewed alongside your medication list.

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References

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