The Search for a Unique Solution to Chronic Pain
The Precision Medicine Initiative is an ambitious new plan announced by President Obama to find more precise treatments for various illnesses, in part by leveraging recent advances in genetic science. The idea is to do away with “one-size-fits-all” medicine not only through genotyping but also by using existing large datasets that already containing a wealth of patient- and condition-specific information. The details – not to mention the funding by the U.S. Congress – are still uncertain. But precision medicine, if done right, could transform medicine and patient care, particularly for the millions of Americans who experience chronic pain.
Pain affects more than one-third of all Americans and costs more than $600 billions dollars annually, according to the Institute of Medicine. Treatments are marginal, and many patients continue to suffer serious disability and disruption to their lives. Opioids have been increasingly prescribed, but they are not very effective for many common types of pain, including migraine, low-back pain and neuropathic pain and can be dangerous in the wrong hands. Besides, opioids do not work equally well for all people, and genetic factors are a large reason why.
Pain needs an individual approach with precise treatments as much as or more than any other area of medicine due to the tremendous genetically influenced variability in how people feel pain and how they respond to pain-relieving medications. The same pain stimulus from the same origin can produce wide differences in how much pain is felt, how frequently the pain is felt, how long it lasts and whether prescribed medications work or not.
Some pain disorders are known to have significant hereditary contribution like low-back pain, lumbar disc degeneration, osteoarthritis and temporal mandibular disease. Migraines, interstitial cystitis and irritable bowel syndrome appear to have similar contributing genes.
Genetic variations can also affect the severity and chronicity of pain, as recent work with the HCN2 gene indicates. There are “pain-reducing” genes and “pain-enhancing” genes. There are also genes that help make the same drug effective for one person and intolerable — if not toxic — for another person.
Sensitivity to pain also varies. Women experience more pain than men. Some ethnicities experience more pain than others.
Precision medicine would mean tailoring the treatment to the patient and the disease. This would include genetic testing of the sort French researchers used to quickly determine which patients are among the 5-10% who will not respond to tramadol because they are “poor metabolizers.” Genetic testing may inform clinical decision-making on the best therapeutic options and predict outcomes. This can lead to improved care, fewer adverse effects and lower cost.
Drug development is where precision medicine could be transformative. Most drugs have been developed for the average person. However, there are no average people, only individual responses. Yes, our genes are operative, but our environments also influence what works for us. Genetic research is complex, and clinically relevant findings will take time and commitment. The goal should be finding the best treatment for an individual rather then developing a drug that works only partly well for most people and not at all for others.
But first Congress must fund the bill. If you live with ongoing pain or know someone who does, contact the representative for your congressional district and urge passage of this initiative. In addition to calling for precision treatments, urge that funds also be used to help find cures for persistent pain syndromes.
Finally, seriously consider volunteering to be part of the database proposed in the legislation. Only by studying large numbers of people with a variety of pain conditions can we identify target genes for further action. People in pain can and should participate in finding better treatments and, eventually, cures.