Chronic Pain

On this topic, which is highly controversial, I will start with the science behind it in order to get to explain it better. After I am done with the science I will try to give the alternative medicine solution and also my own personal opinion.

“The management of pain is a cornerstone of the compassionate practice of medicine. The knowledge exists to ameliorate pain in most of our patients. We now require the will to do so.”
--Schecter, Berde, Yaster, 2003

What is Pain?


“An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage, or both.”

International Association for the Study of Pain (2001)

Nociceptive pain
Is pain from pain receptor stimulation ( we all have receptors for pain throughout our bodies, when one of these receptors gets stimulated, we feel pain ).

Neuropathic pain
Is due to changes due to damage to the peripheral or central nervous system.

Psychogenic pain:
This is pain felt at the brain with no body pain correlation. It doesn't mean the patient makes it up. Psycogenic pain is as real for the patient as any nociceptive pain ( for example, a thumb being "whacked" with a hammer ).

Idiopathic pain
Is pain without a known cause, and is not a diagnosis of psychogenic pain.

Accurate assessment of the type of pain will allow more accurate selection of appropriate medications. Pain may be multifactorial and require multiple approaches to treatment.


What is Acute Pain?

Acute Pain

The Federation of State Medical Boards (2004), a non-profit organization of 70 regulatory boards from across the country, defines acute pain as, "The normal, predicted psychological response to an adverse chemical, thermal, or mechanical stimulus..."

It is generally time limited and is responsive to antiinflamatory and opioid medications as well as other approaches. Inadequate treatment may delay full recovery and increase healthcare costs.

Acute pain may be due to trauma ( motor vehicle accidents, for example ), or an acute medical ( heart attack pain , for example ) or orthopedic problem ( broken bone, for example ). Postoperative pain, acute exacerbations of pain associated with chronic medical problems (e.g., cancer), and pain associated with medical procedures are also considered to be acute pain.

The treatment of acute pain should be as effective as possible to prevent the formation of prolonged or unusually severe pain episodes that can have negative psychological and physical effects.

Should acute pain NOT be treated conveniently, it will can lead to prolonged hospital stays and delayed recovery, both of which ultimately drive up healthcare costs and adversely affect medical and social outcomes.

What is Chronic Pain?

"A state in which pain persists beyond the usual course of an acute disease or healing of an injury, or that may or may not be associated with an acute or chronic pathologic process that causes continuous or intermittent pain over months or years. “

The Federation of State Medical Boards (2004)

It is estimated that approximately one third of the population suffers from chronic pain and up to 9% of adults suffer from moderate to severe non-cancer related chronic pain (American Pain Society [APS], 2002).

In addition, chronic pain is estimated to affect 15% to 20% of children (Goodman & McGrath, 1991).

The Wisconsin Task Force on Pain Management defines chronic pain as persistent pain, which can be either continuous or recurrent and of sufficient duration and intensity to adversely affect a patient’s well being, level of function, and quality of life.

The economic impact of pain is significant. In 1986 back pain alone cost over 20 billion dollars in healthcare and related disability costs. It is estimated that U.S. business and industry loses about $90 billion annually to sick time, reduced productivity, and direct medical and other benefit costs due to chronic pain among employees. Thus, chronic pain is a major cause of healthcare consumption and disability.

Chronic pain and its related causes are the greatest single source of healthcare consumption and disability during an individual’s working years.

Indequate Pain Treatment Can Lead To:

Lost productivity
Excessive healthcare expenditures
Needless suffering
Domestic and occupational problems
Increased thoughts and risk of suicide
These factors have driven estimates of the economic burden of chronic pain as high as $100 billion annually.

(American Pain Society, 2001: National Conference of State Legislatures, 1999)

Chronic pain lasts at least 6 months after your body has healed. Sometimes, when people have chronic pain they don't know what is causing it. Along with discomfort, chronic pain can cause low self-esteem, depression and anger, and it can interfere with your daily activities.

Pain Management Goals

Pain reduction
Improved functioning
Improved quality of life

Treatment goals should be SMART (Specific, Measurable, Achievable, Realistic, Time based).

If treatment goals are not easily achieved or the primary healthcare provider does not have adequate time to devote to pain management, consultation from, or referral to, a pain management specialist is in the patient’s best interest. A multidisciplinary approach is recommended and may be required for optimal treatment. The primary healthcare provider may then continue to give the best continuity of overall care for the patient. Appropriate consultations, referrals, diagnostic tests, accurate record keeping, and timely follow-up are the cornerstones of good pain management practices.

The primary care provider is a key part of any pain treatment team. Much of the treatment of chronic pain can and should, with adequate resources, occur in the primary care setting. they are often held accountable financially and otherwise for referrals, pharmacy costs, specialty care and other aspects in the continuum of care, and as such, need to be advised of any changes or developments by the involved specialists and ancillary care providers as much as possible.

Who are Pain Management Specialists?

These are practitioners that specialize in the diagnosis and treatment of the entire range of painful disorders. Because of the vast scope of the field, pain management is a multidisciplinary subspecialty. The expertise of several disciplines is brought together in an effort to provide the maximum benefit to each patient.

While healthcare providers from a wide variety of specialties may be called upon to treat acute or chronic pain, appropriate pain management is such an involved science that it is often considered a subspecialty.

Pain management specialists provide a consultation and referral resource for all healthcare providers who are having difficulty achieving the desired pain control or who need advice on a particular patient.

Treatment

Pharmacologic

There are several pharmacologic options available for the prescribing physician when treating acute and chronic pain.

Anti-inflammatory analgesics: NSAIDS such as Ibuprofen, Naproxen, etc.
Opioid analgesics: They come in short acting ( low potency ), and long acting ( usually high potency ).
Antidepressant therapy: Some antidepressants such as Cymbalta and Elavil have pain perception modification properties.
Muscle relaxants: Such as Ciclobenzaprine, baclofen, tizanidine, etc.
Pain perception modifiers (e.g. anticonvulsants: Such as Topamax, Carbamazepine and valproic acid.

Usually a combination of these is required for effective pain management.

Problems with Opioid Pain Management

1. Tolerance
The American Academy of Pain Medicine (AAPM), the American Pain Society (APS), and the American Society of Addiction Medicine (ASAM) define tolerance as "a loss of drug effectiveness due to physical adaptation over a period of use."
Significant tolerance to opioids can develop rapidly during sustained or prolonged analgesic treatment and should be accounted for in the dosing and prescribing process. This means that a narcotic at a given does WILL LOSE EFFICACY controlling pain over time.

2. Physical Dependence

“...a state of adaptation that is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug and/or administration of an antagonist. “

American Academy of Pain Medicine, American Pain Society,
American Society of Addiction Medicine, 2001

Physical dependence is not addiction. A withdrawal syndrome is to be expected after prolonged opioid therapy if there is sudden severe dose reduction or treatment cessation. The presence of a physical withdrawal syndrome does not in itself establish the diagnosis of addiction.

3. Addiction

Addiction includes one or more of the following hallmark behaviors:

loss of control over drug use
compulsive use
continued use despite harm to self and/or others, and
physical and psychological craving.
American Academy of Pain Medicine, American Pain Society,
American Society of Addiction Medicine, 2001

The risk of addiction is low if appropriate medication levels are attained. An addiction medicine evaluation or a Pain Management consult should be obtained if fear of addiction is causing physician apprehension and undertreatment.

Non-Pharmacologic Pain Treatment Options

Physical therapy, massage, body/energy work
Physical therapists are widely used and available for addressing pain with hands-on-techniques and for instructing patients in establishing a home exercise program (HEP).
Occupational therapy helps people function at the highest possible level, concentrating on what’s important to them to rebuild their health, independence and self-esteem.
Licensed massage practitioners are trained in soft-tissue manipulation for muscle/fascial release. Myofascial trigger point and other techniques have been shown to be effective for pain reduction in certain conditions.
Energy healing and instructions in self-disciplines such as Pilates and yoga can improve general sense of well being and induce needed relaxation responses in chronic pain patients.


Acupuncture
Acupuncture has been demonstrated in clinical trials to be effective in treating acute and chronic pain with wide ranges of etiology
Treats a wide variety of pain types with low incidence of adverse effects, as well as treating the causes of pain
May be used in conjunction with pain medications and other treatments
The National Institutes of Health has stated that acupuncture is effective in treating pain (NIH Consensus Statement, Vol. 15, #5, 1997).

Chiropractic, naturopathic care
Chiropractor adjustments may aid in musculoskeletal mobilization to reduce pain and improve function
Naturopathic physicians address pain with holistic approach that includes botanicals, nutrition, and nutraceutical supplements

Behavioral medicine, mental health treatment, biofeedback
Addresses the psychological aspects of pain
Helps recognize and reduce psychological and behavioral complications to pain
Assists in identifying behaviors or underlying disorders that contribute to pain and undermine treatment

Invasive Treatments for Pain

TENS units
Nerve blocks
Implanted nerve stimulators
Intraspinal delivery systems
Neuroablative procedures
Healthcare providers may utilize a number of non-pharmacologic interventions to reduce pain, including transcutaneous nerve stimulators, nerve ablations or blocks, and other procedures designed to interrupt or reduce the pain signals.

Interventional treatments can be utilized with pharmacologic and other treatments and may help reduce medication use and side effects.


Other Alternative treatments for pain

Movement therapy
Myofascial work
Yoga
Tai-Chi
Pilates
Qi-gong
Guided imagery
Energy work
Visualization
Reiki
Meditation
Craniosacral work
Biofeedback
Feldenkrais method
Music therapy
Alexander’s technique
Aromatherapy
Rolfing
Mind-body techniques
Trager approach
Antiinflammatory herbs

What is the author's opinion?


A. Pain treatment is a necessary symptom to be addressed in office visits.

B. Pain treatment doesn't necesarily mean opioids.

C. Opioids in cancer or terminal condition patients is warranted and useful.

D. Opioids in other patients need to given on a patient to patient basis. Although formal addiction is rare, tolerance, pseudoaddiction, physical dependance will happen and can offset the help that pain medication could do.

E. Pain needs to be treated in a multidisciplinary way, with a pain management referral, behavioural therapy, alternative medicine, etc.