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PARADE

Relief From Chronic Pain
By Dr. Ranit Mishori
Published: September 28, 2008

The No. 1 reason patients come to see me or any doctor is pain-pain in all its forms: sharp, dull, tingly, burning, itching, aching. All any patient suffering pain asks of me is something obvious and simple: Make it stop.

But pain can be mysterious. Everyone experiences it-and yet you can't see pain, measure its intensity, or even reliably describe it. How people experience discomfort is as varied and subjective as how they experience beauty or happiness. The person who hurts is essentially alone with his anguish, which is part of what makes pain even more painful.

In many cases, we know the source of pain-a broken arm, for example, or a twisted ankle. Other times, pain warns of something more serious, such as cancer, appendicitis, or heart disease. Then there's the pain that seemingly has no explanation, the kind that can linger for months or even years after an injury. Such chronic pain becomes a condition in itself.

Some 76 million of us live with chronic pain, according to the American Academy of Pain Medicine-more than the number with diabetes, heart disease, and cancer combined. This unwanted, constant companion can afflict anyone. Says Dr. Penny Tenzer, vice chair of the department of family medicine at the University of Miami Miller School of Medicine: " It crosses the spectrum of cultural, ethnic, and socioeconomic backgrounds."

The most common type of chronic pain is lower-back pain, according to a survey by the National Institutes of Health. Next are headaches and migraines, neck and facial pain. There's also the chronic pain of arthritis, fibromyalgia, and cancer, as well as post-surgical pain, limb pain from diabetes, and pain following shingles.

Still, it can be difficult to convince others-doctors, co-workers, family members-that one's pain is "legitimate." Sufferers often complain that they're told, "It's all in your head." Physiologically, notes Dr. Tenzer, this is correct: "Pain is all in your head." As the center of the nervous system, the brain receives and sends pain signals to and from the rest of the body. We now know that these signals can get amplified or distorted, activating pathways not originally involved in the injury and causing pain to persist long after the injury occurred. Some sufferers also may have lower levels of endorphins, our body's natural painkillers, or a heightened sensitivity to pain.

The annual cost of chronic pain in the U.S. is $100 billion-in health-care expenses, lost income, and diminished productivity, says Dr. Todd Sitzman, the former president of the American Academy of Pain Medicine. Pain also affects an individual's self-esteem and self-image, notes Dr. Tenzer, leading to frustration, anger, sleep disturbances, anxiety, and depression. Many feel they have little control over their pain.

So what can be done to ease the pain? "There is no magic bullet, usually no single cure," says Dr. Michael McCeney, a pain specialist from Fort Collins, Colo. But there are options that, used in combination, can help relieve some pain some of the time. Talk with your doctor about what may work for you.

STIMULATION
Electrical stimulation is a popular treatment for chronic pain, even though there isn't substantial scientific evidence to support it. Spinal-cord stimulation-mostly used to treat chronic back and leg pain-involves implanting a small wire in the back to carry current to targeted areas in the spinal cord. When it's activated, patients feel tingling sensations instead of their usual pain. The patient uses a remote control to turn the current up or down. The effects can linger for hours. While pain specialist Dr. Michael McCeney calls it "the fastest-growing and most-promising treatment available for certain types of pain," the medical literature still is inconclusive about the treatment's benefits.

Another popular technique is transcutaneous electrical nerve stimulation, or TENS. While a recent review of hundreds of studies showed limited benefits, some patients still use it for lower-back, muscle, arthritis, and post-surgical pain. TENS consists of a device that produces electrical currents. When put on the skin via a patch, the currents stimulate nerves-mostly superficial ones-and can cause some reduction in pain. Here, too, the individual controls the frequency and intensity of the device.

DRUGS
Relief in pill form-often the first option people try-can come from over-the-counter analgesics. These pain-relievers are good at what they do, but only to a point. Take too much, and you risk side effects-internal bleeding with too much aspirin, ulcers or kidney damage with too much ibuprofen, liver damage with too much acetaminophen.

Opioids are another class of drugs that are effective pain relievers. These powerful narcotics, including codeine, oxycodone, and morphine, require a prescription, but doctors often are reluctant to prescribe them-and patients to use them-for fear of addiction. Patients build up a tolerance, needing higher and higher doses to get the same pain relief. Every doctor has tales of patients desperate for refills who tell creative stories to get drugs or visit several doctors to establish a steady supply.

But addiction and abuse are not inevitable when opioids are administered appropriately. Many patients now sign agreements stating the goals of treatment and exact dosages and designating a single physician who may write prescriptions and one pharmacy that may dispense the drug.

Meanwhile, new drugs are appearing that target specific brain pathways, chemicals, and receptors-an attempt to minimize dependence and bypass the side effects (including sedation, dizziness, nausea, vomiting, and constipation) that make opioids intolerable to many. Researchers also are working on manipulating genes that can produce naturally occurring opioids.

Anti-depressants and anti-seizure medications also have been shown to relieve certain types of chronic pain. Using small amounts of several classes of medications together often can provide relief. But you have to work with your doctor to make sure the drugs don't interact badly with each other.

Because of a cultural tendency to "suck it up," some people wait until their pain is nearly too much to bear before taking drugs. Here is what I tell my patients: There is a whole arsenal of pain meds out there. Use it. If pain is dealt with early and regularly, it is much easier to treat. It's also usually more effective to take medications "around the clock"-that is, every few hours-t han to wait for an episode of pain before the next dose.

ALTERNATIVES
Complementary therapies-including acupuncture, massage, magnet therapy, hypnosis, and other nontraditional treatments-have a role in the management of chronic pain. In some patients, says Dr. Penny Tenzer, "alternative therapies can be quite effective."

Some of these treatments, such as acupuncture and biofeedback, have scientific evidence to back their claims of providing pain relief. In many cases, however, this relief is short-lived.

With biofeedback techniques, patients learn to control their breathing, muscle tension, heart rate, and blood pressure-all of which are closely tied to how we experience anxiety, stress, and pain. Research has found that biofeedback treatments can reduce the frequency and duration of headaches and may even work as well as some medications in relieving chronic pain.

PSYCHOLOGICAL HELP
'Chronic pain goes hand in hand with depression and anxiety," says Dr. Todd Sitzman. Most doctors agree that pain is a complex experience that is influenced by the patient's emotional state. Stress and anger can intensify pain and increase the body's sensitivity to it, according to some studies.

Psychological treatment, therefore, should be an integral part of managing chronic pain. You don't have to spend years on the couch. In cognitive behavior therapy-a targeted treatment often short in duration-patients attempt to see what role their emotions and behaviors can play in controlling their pain. They also learn coping skills, such as relaxation and distraction techniques.

Finally, says Dr. Tenzer, it's important to realize that "pain doesn't live in a vacuum. It's an ongoing journey," with hills and valleys, in which you need the support of doctors, friends, and family. To those in that circle of support, Dr. Sitzman urges, "Believe them when they tell you they are in severe pain. And be compassionate."

PARADE Contributing Editor Dr. Ranit Mishori is a family physician and a faculty member at the Georgetown University School of Medicine.

http://www.parade.com/health/2008/09/chronic-pain