Living well with chronic pain

Acute Pain

We all know the pain we experience when we cut our finger. We are suddenly alerted that there is body damage. Our muscles tense as we jerk back our arm from the sharp edge that cut our finger. We may wave our hand about, say some choice words, and for some reason, the severe pain we initially feel is rather quickly blunted. Our brain is trained to release pain killers called endorphins in response to acute painful stimuli. Endorphins are our own natural defense against pain.

Chronic Pain

What about pain that we continue to feel after an injury or surgery has healed? Pain that outlives its usefulness is known as chronic pain. It no longer warns about the danger of a sharp object or to avoid over-using a damaged body part. It has a life of its own, and it compromises the life we want to live. If you have pain like this, you are not alone. It is estimated that one in six adults suffers chronic pain. That translates to more than 50 million Americans who live with chronic pain whether it be arthritis, back problems, headache, cancer, peripheral neuropathy, or pains that don’t have any identified cause. Chronic pain is the most common complaint that brings people to the doctor. Many physicians and patients have focused on curing, but have given short thrift to treating the suffering that can’t be cured.

Pain Treatment Shortcomings

People concentrate on medications or injections to treat chronic pain. This often works in the short-term, but the pain comes back. The recent public outcry over the overuse of OxyContin, and the withdrawal of Vioxx and Bextra from the marketplace, has increased the frustration of many looking for pain relief. However the notoriety of these medications has forced us again to appreciate that chronic pain must be attacked on many fronts. Medications and injections are important, but they are only one kind of weapon in the arsenal against pain. We have unrealistically expected too much from pain relieving drugs. They are not magic potions for pain control.

Complex Mind and Body Process

Chronic pain is a complex give-and-take between the mind and the body. The when chronic pain continues to alarm about body damage that no longer exists, up we tense in our muscles and we guard our postures. We favor the hurt and become less active. Less activity translates into muscle atrophy and weakness. When we are weaker, we are unable to perform activities of daily living without stimulating more pain. A vicious cycle develops with our body becoming exhausted by the constant stimulus of pain. Exhaustion and fatigue further limit our capacity to play, work, and enjoy life. Pain restricts serotonin, the natural anecdote to depression and anxiety. Depression, anxiety, and lack of physical activity disturb sleep. Disturbed sleep perpetuates the sense of fatigue and exhausts the rejuvenating supply of pain relieving endorphins. Ultimately changes occur in the peripheral and central nervous system. Pain nerves grow more populous and connect with other nerves, so that even a simple touch on the skin is painful. Chronic pain “rewires” our nervous system. Prolonged exposure to pain produces its own lasting damage. I have learned that when a patient with pain tells me that they “have a high pain threshold,” I immediately become suspicious that they have entered the vicious cycle of chronic pain.

Chronic Pain Cycle

This vicious cycle of chronic pain may start with a regional problem like back ache or headache, but ultimately many people who don’t experience relief develop chronic widespread pain. The pain cycle is easier to identify than you might imagine. The terrible triad of suffering with pain, terrible sleeplessness, and associated sadness or depression is a striking contrast from patients who present with new inflammation of their joints or osteoarthritis. The chronic pain patient will have a total preoccupation with pain that leads to irritability, depression, and loss of sleep that is proving as hard on their family as it is on the victim of pain. It can be difficult to redirect a patient who is still searching for a cause of their pain, and help them find ways of breaking their cycle of pain.

Studies have shown that a comprehensive or multidisciplinary program to control pain does better than pain medication alone. Many pain experts estimate that at most, pain medications and injections provide 40 or 50% of the relief. A successful pain management program is one that not only looks at medications and injections, but incorporates dietary management, physical therapy, massage, chiropractic, relaxation techniques, and psychological techniques that can make the journey to pain-free existence a realistic expectation. Pain management clinics are expensive; frequently more than $25,000 for a six-week course of therapy. Many patients may not require such aggressive or expensive therapy. Pain experts, while increasing in number, are not available for the vast majority of patients with chronic pain. It is incumbent on all primary health care providers to become more comfortable with the idea of chronic pain management as they are in the front line in the battle against pain. It is also important to recognize that without the patient’s cooperation, little can be accomplished.

Pain Medications

Nonsteroidal anti-inflammatory drugs like aspirin and ibuprofen are a first line of pain therapy, and have the added benefit of treating inflammation that may provoke or perpetuate pain. Pure pain relievers like acetaminophen/Tylenol are effective for many forms of chronic pain including osteoarthritis. Stronger pain relievers, narcotics or opiates, have fallen out of favor because of potential for dependence and addiction. However many recent medical studies have shown that these medications are usually well tolerated, and when used in appropriate patients, have low risk for dependence or addiction.

Adjunctive pain medications can help potentiate the pain relieving effect. These can include muscle relaxants, antidepressants, anti-anxiety medications, and anti-epileptic medications. On their own, they are frequently very poor pain relievers. But when they control the anxiety associated with chronic pain, or reduce the irritability, insomnia, and depression that can complicate chronic pain, they certainly can help. Anti-seizure medications are helpful for minimizing painful burning and numbness.

Psychologic Therapy for Pain

Many patients are reluctant to consider psychology or psychiatry treatments for their chronic pain. However chronic pain is a mix of mind and body. Functional imaging of the brains of patients who suffer from pain will light up areas involved in emotion. Learning to relieve fear, anxiety, and depression related to pain actually helps bring relief by activating the body’s own painkilling chemicals, the endorphins. Relaxation, breathing, and visual imaging techniques, massage, and biofeedback, allow patients to refocus their energies into healthful body reactions rather than maladaptive behaviors. It’s very empowering and done with out medication side effects.

Psychosocial supports, whether it is prayer, meditation, and the continued efforts at socialization with friends and family are critical ways to overcome the demoralizing effects of chronic pain. Chronic pain patients must constantly guard against using their pain as a way of controlling those around them. This is called secondary gain, or benefiting from the pain and it is a strong stimulus for chronic pain. It serves to drive a wedge between the patient who suffers from pain, and their loved ones or coworkers. Learning to reduce the language of pain that dominates the conversation for many chronic pain sufferers will also provide significant benefits.

Essential Exercise

The Arthritis Foundation has a new slogan, “Exercise Is the Arthritis Anecdote.” Once we dispense with the number one fear that activity will cause reinjury, we can move forward with exercise to restore function and raise spirits. Every individual will have their own brand of exercise that will produce benefit. I have seen patients do extremely well with a walking program, yoga, Pilates, or more structured forms of rehabilitation. Exercise enhances the body’s ability to produce endorphins.

Whose Problem Is It?

It should be clear that it takes more than a prescription or a shot to bring relief for chronic pain. This does not mean that you have to live with your pain. TV ads would suggest that dissatisfaction with your current pain reliever is simply solved by switching to a new and improved tablet. While it is unpopular notion in this age of daily scientific breakthroughs and medical miracles, there remains no guarantee of a pain-free existence. There are many programs and therapies beyond pills and shots that allow motivated people to live better with the pain that they have and by doing so making it a much smaller part of their life. Health-care providers do not have the ultimate cure for pain, but must be willing to offer direction and guidance on path to relief. To expect more is just a recipe for disappointment and more pain.