Treatment Options Why do some patients fail to respond to these guidelines? Some pains don't respond to narcotics at all and some may require extremely high doses for pain control. Some patients may achieve pain control with a given dose of narcotic when they are lying quietly in bed, but their pain increases as soon as they are moved. This type of narcotic-resistant pain is called incident pain.
Besides physical reasons for not responding to the narcotic ladder approach, there are other reasons why patients do not get good pain control. Just as beliefs and experiences color the experience of pain, the beliefs and knowledge of caregivers, patients and their families influence whether patients receive appropriate pain care. Doctors may be uncertain about the role of narcotic therapy for patients with early pain or treatment-related pain. They may under-treat the pain because of a lack of knowledge of narcotic therapy, failure to assess the type of pain adequately or because they overestimate the risks of addiction. Your own and your family's beliefs about narcotic treatment, fears of addiction and under-reporting of pain may also lead to poor pain control.
If 90 to 95 percent of patients receive adequate pain control using the narcotic ladder, what about the 5 to 10 percent who do not have their pain controlled by these guidelines? Certain direct interventions by specialists can modify or block pain information from reaching the central nervous system. These interventions include "nerve blocks," alternative delivery systems—such as administering narcotics under the skin (subcutaneous) or into the spine—spinal local anesthetics or therapies that destroy nerves causing the pain. These invasive, interventional therapies may require the expertise and skills of a pain specialist to whom your doctor may refer you if needed.
