Chronic Pain
What Is Pain?
When you first experience pain, it is a symptom of illness or injury in the part of your body that is having the pain. The sudden onset of pain is called acute
pain. It gets your attention and prompts you to take action to prevent further worsening of the condition causing the pain. This could be a simple action such
as the reflex that makes you jerk your hand off a hot stove, or it could be more complex such as cooling, resting, or elevating an injured ankle. Or the pain
could prompt you to see a doctor.
We take for granted that we will feel good most of the time. When pain strikes, we feel bad. Pain interrupts our work, our recreation, and our relationships with our families. Comfort, that is, not being in pain, is one of your goals if you are sick and should be one of the goals of treatment for the doctor who is treating you for any illness, but especially for an illness associated with chronic pain.
Once the cause of your pain is found and proper treatment is started, the pain may serve the useful function of keeping you at rest so that the injury or illness can heal. But if the pain comes from an illness that is incurable and will never heal, the pain loses its usefulness and becomes harmful. This type of pain keeps you from normal activity, and inactivity decreases your strength.
Why pain can become worse: There is a "wind-up phenomenon" that causes untreated pain to get worse. Nerve fibers transmitting the painful impulses to the brain become "trained" to deliver pain signals better. Just like muscles get better at sports with training, the nerves become more effective at sending pain signals to the brain. The intensity of the signals increases over and above what is needed to get your attention. To make matters even worse, the brain becomes more sensitive to the pain. So your pain feels much worse even though your injury or illness is not getting any worse. At this point, pain may be termed chronic pain. And it is no longer helpful as a signal of illness.
The goal in treating pain: When you consult a doctor, your goal is to be cured. That means that you want the cause of your pain to be found and cured so that you can resume normal life without needing medication or further visits to doctors.
Treating lifelong pain: Unfortunately, many illnesses do not have known cures. The treatment of illnesses such as diabetes and high blood pressure is often lifelong. In these chronic illnesses, as in the treatment of chronic pain, your goal is to live as normally as possible. Sometimes medication is needed for the rest of your life in order to achieve that goal.
A sensible view of addiction: In this respect, chronic pain is no different from diabetes or high blood pressure. If you need to be on pain medicine for the rest of your life, you should not be said to be "addicted" to pain medicine any more than a person with diabetes who needs to be on insulin for the rest of his or her life should be said to be "addicted" to insulin.
Use of pain medications: Some doctors are reluctant to use powerful pain medications known as opioids (also known as narcotics) to treat pain even when non-opioid medications have not worked. If your doctor is reluctant to prescribe opioids in this situation, and you have chronic pain, talk with another doctor or get a referral to a pain specialist.
Measuring Pain
The World Health Organization has a "pain ladder" with 3 steps. The steps are mild pain, moderate pain, and severe pain.
Mild pain: Mild pain is self-limited. It goes away either with no therapy at all or with the use of nonprescription medication such as acetaminophen (Tylenol), aspirin, or other nonsteroidal anti-inflammatory drugs (NSAIDs). There are lots of NSAIDs (examples are Motrin, Advil, and Aleve). Some are available without a prescription. You can try different kinds to find the one that works best for you.
Moderate pain: Moderate pain is worse than mild pain. It interferes with function. You may be unable to ignore the pain and go on with all of
the activities of daily living, but it goes away after a while and doesn't come back after it has been treated. Moderate pain may need stronger medications
than acetaminophen or nonprescription NSAIDs. Most NSAIDs, including ibuprofen (Motrin), have been found to be as effective at relieving pain as codeine. Your
doctor can work with you to find the type of NSAID, either prescription or nonprescription, that works best for you.
Severe pain: Severe pain is defined as pain that interferes with some or all of the activities of daily living. You may be confined to bed or
chair rest because of the severity of the pain. Often, it doesn't go away, and treatment needs to be continuous for days, weeks, months, or years.
For severe pain, the World Health Organization recommends strong opioids, such as morphine, oxycodone, hydrocodone, hydromorphone, methadone, or
fentanyl, as well as other medications (called adjuvant therapies) as needed for the particular kind of pain. A number of adjuvant therapies are
described in the previous section.
Addiction: People with chronic pain worry about addiction, but it turns out that for most adults, if they do not already have a substance (alcohol or drug) abuse problem, addiction is not much of an issue even when opioids are used on a long-term basis.
A study was done in which 12,000 nonaddicted people who needed opioids were followed up to see if they had become addicted. Four out of 12,000 showed
addictive behavior (less than one tenth of 1%).
Generally, the only people who develop addictive behavior after being given opioids had an addiction problem before the opioids were given for pain. Most
people take opioids until the pain goes away. Then they stop taking them because they do not want to feel dizzy or drowsy. Once the pain goes away, the toxic
side effects of dizziness and drowsiness come back.
Most medications have a maximum dose. Usually, the maximum dose is one that you cannot exceed without suffering harm. In the case of most pain medications, taking more than the maximum dose will not increase the pain relief but may cause toxic side effects such as stomach ulcers, kidney damage, liver damage, chemical imbalance in the bloodstream, or death.
Strong opioid medications are slightly different in this regard, and this is fortunate for people who suffer from severe pain. With strong opioids, the dose depends on the amount of pain. These medications should not mixed with acetaminophen or other non-opioid drugs when used to treat chronic pain. People with intense pain can take very high doses of opioids without getting side effects. Some people with intense pain get such high doses that the same dose would be fatal if taken by someone who was not suffering from pain. In the pain patient, that same high dose can control the pain and still allow the person to be wide awake enough to do his or her activities of daily living.
Long-acting opioid: The best way to treat chronic, severe pain is by keeping it under control all the time. Your doctor can do this by using a long-acting opioid to keep the pain under control and a short-acting opioid to deal with those few times during the day when the pain breaks through. So, if you are on morphine, you would get a slow-release tablet that would keep your pain under control most of the time, and a short-acting tablet or liquid for those times when your pain breaks through.
Bad opioids: Some opioids are not recommended for chronic pain.
Demerol (meperidine), which is used often for acute pain after surgery, is a poor drug for chronic pain. It is not absorbed well when taken by mouth, and it causes dysphoria (feeling truly lousy) and seizures if used for more than a few days.
Talwin (pentazocine) is also bad for chronic pain. It has a ceiling effect. There is a maximum dose after which raising the dose gives no further pain relief. It also causes withdrawal symptoms when given to someone who is also taking another opioid.
The opioid/acetaminophen or opioid/NSAID combination drugs are fine for short-term use, but acetaminophen is poisonous to the kidneys and liver when used for a long time or in high doses. Many NSAIDs are toxic to the kidneys and stomach when taken for a long time or in high doses.
Complications of opioids
Nausea and vomiting
Dizziness and sleepiness
Constipation
Respiratory depression: The most dangerous complication of opioid therapy is respiratory depression. Everyone knows that some drug addicts have been known to get pure heroin or fentanyl and then die with the needle still in their arm because they fell asleep and didn't breathe. That happens because of a huge overdose in a person who is not in pain. Pain is a potent stimulator of the respiratory center in the brain. So if you have pain, and your doctor increases the dose of opioids carefully until the pain is controlled, and then stops raising the dosage, you will not get respiratory depression.
Fortunately for people with pain, large doses of opioids can safely be used if they are necessary to combat severe chronic pain.
Controlling Pain
It is not always possible to completely get rid of chronic pain. Your goal may be simply becoming able to do more of your normal activities of daily living
than before.
•Your doctor may ask you to rate the pain on a scale from 1 to 10.
•You also need to report whether it is possible to go to work, go shopping, exercise, sleep, or have sexual intercourse.
•Sometimes, the only measure of effectiveness of treatment is that you can do certain things that were not possible before the treatment started. This is what your doctor needs to know in order to make decisions about your treatment.
•If nothing else works for your pain and your doctor is unwilling to use opioids to control your pain, consider asking for a referral to a pain specialist or a pain clinic
