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Chronic pain.

January 31, 2012

Chronic pain is a big problem for a lot of people.  More people than most realize, I think.  It is also a frequently misunderstood problem and those of us experiencing chronic pain can face attitudes ranging from pity to disbelief to (sometimes) understanding.

When discussing pain, it is important to realize that there are different kinds of pain.  The cause of the pain determines appropriate treatment.  The American Chronic Pain Association website offers a wealth of information on various causes of pain and treatment options.  It’s a great resource to check out.  I’ll give a quick overview here, but that site covers things in much greater detail.

Generally speaking, chronic pain is pain that persists 3 to 6 months or more.  The pain may be from an injury or an ongoing process.  It may be from muscles, nerves, bones, or visceral organs.  Determining the cause helps with choosing an appropriate treatment.  In some cases, the causative factor can be treated and the pain relieved.  In many cases some level of pain persists despite the best treatment and pain medications or other treatments are necessary in order to stay functional.  Most times there are multiple sources of pain.  For example in my case, I have old injuries to a couple of joints, osteoarthritis in those joints plus several others, cardiac pain, and frequent migraine and tension headaches.  Examples of other causes of chronic pain are diabetic neuropathy, fibromyalgia, back or neck degenerative disc disease, peripheral vascular disease.  This is by no means a comprehensive list.

Joint pain is a common complaint as people age or in younger people with injuries or an ongoing inflammatory process like rheumatoid arthritis.  Often physical therapy can help with joint pain by strengthening the muscles which support the joints and improving flexibility.  Sometimes a surgical intervention may be called for to correct a joint abnormality.  In my case, I had to have surgery on my knee for an injury which tore the meniscal cartilage and ruptured two ligaments.  I had another surgery on my ankle to help arthritis pain caused by joint instability.  That actually reduced my pain to a much more easily tolerated level for several years.  Steroid injections to joints or visco-supplementation (injecting a synthetic synovial fluid into the joint capsule) can relieve or reduce pain.  Heat and/or ice is useful and an inexpensive treatment that can be done at home any time.  Finally medications are a big stand-by, especially anti-inflammatories such as the NSAIDS (ibuprofen, naproxen, etc.) or even steroids (prednisone, medrol, etc.).  For those unable to use NSAIDS due to stomach or bleeding problems, kidney problems, high blood pressure, or cardiovascular issues, or those with severe pain, opiates may be necessary.  Topical medications are also commonly used.  These include counter-irritants such as camphor, menthol, or capsaicin (found in Tiger Balm, Icy Hot, Ben Gay), salicylates (aspirin-like compounds), and NSAIDS (topical ketoprofen or diclofenac).

Nerve pain can be a more difficult problem to cope with.  This type of pain may be caused by damage to a nerve from an injury or surgery, peripheral neuropathy related to diabetes or some vitamin deficiencies, pressure on a nerve by bone spurs or neighboring structures such as bulging discs or inflamed tissues.  The pain is typically perceived as burning or tingling and maybe shooting.  Treatment may require surgery to free trapped nerves or reduce pressure.  Keeping diabetes under control helps diabetic neuropathy.  Treating vitamin deficiencies may relieve the pain if that is the problem.  If medication is needed, typically medications originally developed to treat seizures are used.  These include Neurontin, Depakote, Dilantin, Tegretol, Lyrica.  Certain antidepressants are used at low doses such as amitriptyline, nortriptyline, or trazodone.  Injections of steroids or local anesthetics may be used also in some cases.

Visceral pain originates inside the body in the internal organs.  Examples include that burning pain in the stomach and chest from gastro-esophageal reflux (GERD), chest pain from cardiac ischemia, abdominal and back pain from gallbladder problems or kidney stones.  The key to all of these is treating the underlying pathology in the organ if possible.  That may mean acid reducing medicine and diet changes for GERD, for example.  Cardiac ischemia requires revascularization by stenting blocked vessels or bypass and nitrates or other cardiac medications.

There are also pain syndromes such as fibromyalgia and reflex sympathetic dystrophy.  These require specialized treatment which may include physical therapy, aquatherapy, injections, or oral medications.  Tramadol has been found to be especially helpful for fibromyalgia pain.  Sometimes Tylenol or NSAIDS are used.  Medications for neuropathic pain such as Lyrica are used as well.

This is not meant to be a comprehensive review.  There are many possible treatments I have not been able to cover yet.  Next time I’ll talk more about the use of opiate medications and common misconceptions and attitudes encountered by those with chronic pain.

One Comment leave one →
  1. Melissa permalink
    February 1, 2012 11:11 am

    2/1/12

    Thanks so much for opening the door to chronic pain!
    As a chronic pain sufferer and survivor, I have come to learn a great many things about the subject, and about myself as a chronic pain sufferer. Chronic pain has ruled my life at times, and caused me to become a fierce self-advocate in the face of a medical system fraught with misunderstandings and outright discrimination when it comes to pain.
    Long ago, in my RN training, I heard of some pain related statistics– that roughly 75% of all patients enter the inpatient and outpatient medical systems with the main complaint of pain. That is to say, that PAIN is the reason that the majority of us seek medical help, it is our overwhelming symptom of illness.
    Ironically, lack of medical attention to pain relief is the one biggest complaint of patients upon exit polling. (These numbers and statistics ought not be difficult to track down.)
    Why then, in the new world of outcome-oriented patient care, does this dichotomy exist? Well, I have a few ideas about that.
    First, we must look a few years back into the history of doctor-patient relationships.
    At the advent of antibiotics and preventive inoculations, before which many people died of “ordinary” infections such as pneumonia, suddenly people were living through these diseases. Doctors rose to near god-like status in the eyes of the public, and were afforded god-like respect and unquestioning devotion. One never questioned the judgment of one’s physician. With ongoing incremental upticks in medical technology and the subsequent ability to save more and more lives, the god status of doctors was maintained. The relationship of doctor and patient was clearly that of Parent to child.We
    Perhaps it has been Ralph Nader’s popularization of consumerism and the self advocacy spurred by the women’s movement, in addition to the availability of academic information and instant communication via internet that have changed the patient-doctor relationship most. Now we are able to study up on our illnesses and injuries, the treatments available, the potential outcomes, and alternative therapies. We come armed with knowledge to our doctor appointments. We challenge the notion that physicians must not be questioned. We stand ready to defend our experiences of illness and our perceived needs. We have tipped the scales.
    While medical schools and individual doctors and practices, as well as (and particularly) nursing practices have risen to become partners with us in our medical care, others have reacted by building walls against uppity patients. How dare we challenge ten or so years of grueling medical education? Many patients are more comfortable with the old paradigm, but a growing population is clearly not.
    Enter- chronic pain! Add attitudes about addiction, questions about who’s in control in the doctor’s office, and patients who just won’t be quiet about their ongoing suffering.
    From a purely “business” point of view, concerted pain management saves and makes money. From a humanitarian stance, it is imperative! Unfortunately, though, from a law enforcement perspective it is both an opportunity for more control and abuse, due to grand misunderstandings of addiction.
    Addiction is simply defined as a compelling physiological and psychological dependence on substances or activities. Examples might be- heroin addiction, valium addiciton, gambling or sex addiction, cigarette and/or caffeine addiction– all potentially either substances or behaviors that rule one’s life, and that cause great physical and psychological disturbance when removed from the addict’s life and body. These folks may start out using their activity or substance for relatively innocent reasons– “just for fun”, “to wake me up in the morning”, or “ to relax me at night.” At some magical point the getting of and taking of the substance or doing of the behavior becomes more and more compelling. The budding addict becomes obsessed with finding their stuff, using it, and planning how to get more. As time goes on their lives fall apart. Families kick them out, they lose their jobs, the addict becomes socially isolated, and may feel that no one can help them. They may feel ashamed and in constant fear.
    They begin to need more and more for the same effect, or maybe they desire more and more of the effect. When they run out, they have withdrawal effects– often shaking, runny nose, diarrhea, vomiting, terrifying nightmares, cold sweats. They begin to live from substance/activity event to event, the situation known commonly as being “strung out.” Some people are so desperate as to prostitute themselves or resort to larceny and fraud in order to keep supplied. Some people die from overdoses, or from complications of withdrawal, or from illnesses, infections and organ failure due to their drug of choice. Alcohol is one of the most common of the substances, and one of the most deadly. This is the kind of path that many people, including medical folks, think about when patients need opioid medications for pain control.
    OK, now let’s look the path of a patient who is fortunate enough to have a doctor who is well educated and experienced in the art and science of good pain management. (Remember that the patient and doctor are partners in this symptom management project.)
    Here’s our hypothetical patient: a middle aged woman with a long history of osteoarthritis in her hands, arms and shoulders that makes it painfully difficult for her to continue at her job as a word processor/secretary at a large company. She is getting worse and worse job evaluations, and is now on probation and will be fired if she does not improve her productivity. She’s been taking lots of aspirin to try to control her pain, but it just doesn’t work that well, and she’s been vomiting blood occasionally as her stomach gets irritated and is starting to develop ulcers from the medication. She’s noticing, too, that her hips and knees are giving her increasingly severe pain just from walking to and from the bus stop each day, and she can’t walk the 30 minutes per day that her doctor has prescribed to help her maintain her heart health. Further, her back has given her intermittent trouble since she was in a car wreck several years ago. Sometimes she spends her entire weekend in bed, able only to get up to the bathroom or make a quick meal. Her family doctor is treating the stomach problems, has taken her off of aspirin, and has now referred her to a pain specialist clinic to see if she can get some relief in order to maintain her job and her physical mobility.
    Until the family doctor madet the referral to the pain specialist, this scenario could have gone a number of different ways. Our woman could have been left to fend for herself pain-wise and ended up drinking alcohol every day to try to deal with her pain, or perhaps gotten some valium from a friend to try to at least relax a little so she wouldn’t be as affected by the pain, or maybe she would’ve become depressed at feeling abandoned by the medical system. Feel free to think up your own possible scenarios.
    If she had then returned to the medical system with an additional diagnosis of, say, alcoholism or liver failure, or of valium dependence, she most likely would’ve been branded as a “drug seeker.” Remember, though, she’s still having a lot of pain, and perhaps by now, she’s lost her job. She’s desperate for pain relief. Her pain has gotten worse because she doesn’t have any medical support, or any psychological support. She keeps being spurned by her doctor when she mentions her pain.
    “Lots of people get along with this kind of pain,” replies the doctor, “You just need to suck it up, like the athletes! No pain, no gain!”
    She might then go away, to take too much valium, washed down by too much alcohol. She might die. She might become a repeatedly under-treated traveler of the medical system. Her local emergency room might label her as a “problem patient, a “GOMER” (Get Out of My Emergency Room patient), and a drug seeker.”
    On the other hand, if she is able to get that pain clinic referral, her life might be saved. In most pain clinics, patients are carefully screened and examined to determine all kinds of things, like: What kind of pain– what are the characteristics of your pain? How is pain affecting your life- are you able to work, to wash yourself, to make your meals? How far can you walk? What medications have you tried- do you take any over the counter or recreational drugs? The list goes on. The patient has all kinds of opportunities to express what their pain is like, how it affects them, and what works or doesn’t. The pain doctor, perhaps a physical therapist, an acupuncturist, a massage therapist, or music therapist, along with the patient, put together a plan to help the whole person, a comprehensive care plan. It will, for our particular patient, probably involve medication, physical therapy and alternative therapies that also help the pain directly and indirectly. She might actually get to keep her job if she doesn’t hurt so much. She might just avoid the whole addiction cycle. Her life might be saved.
    She’ll go back to the pain clinic regularly to fine tune the care plan. Her family doctor will be pulled into the loop, at the very least, informed of her progress and of things her or she can do to enhance the plan. She will be educated as to the symptoms of addiction and monitored for those symptoms and treated if addiction becomes a problem. If she’s on opioid medication, she and her doctor will expect some gradual need to increase the dose of the medication as time goes on– and will understand that this is a normal reaction to the legitimate use of these medications. If and when she needs to stop the medication, for any reason, her pain doctor will orchestrate the withdrawal so as to minimize withdrawal symptoms.

    In the best of all possible worlds, we all ought to be given the choices in care that lead to optimal function and mental and physical health. In the current unstable world of medical economics, choice becomes more and more elusive. My hope is that we the people can find information and medically adept doctors and nurses to partner with in achieving our goals, and in supporting the process that gets us there. We must be more vocal in public ways, we must have input into the medical insurance realm, and in the realm of medical education. Nothing less than our survival is at stake.
    Thanks to you who have braved this long post, and many thanks to ChronicConcerns for giving me the opportunity to say my piece.
    Love,
    frykwoman

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