Why is treating chronic pain such a challenge? The answer: We don’t have a lab test, an X-ray, or any other test that tells us how bad pain is. There is no pain meter. We have to rely on what the patient tells us.
It’s not only rare or terminal conditions that are painful and disabling. Even chronic low back pain can be awful.
Proper pain relief comes from an understanding of the duality of pain. One definition of pain is an unpleasant sensory and emotional experience, associated with actual or potential tissue damage. In other words, pain affects attitude, and attitude affects pain. And pleasant thoughts can significantly reduce the pain experience.
Your emotions can have profound effects on your perception of pain. How your physician, family, friends react also change the pain experience. If a friend says, “I believe you,” it elicits a positive response. If he says, “You’re a faker,” this elicits a negative response and it only makes the pain worse. The support of a friend, family member or your physician can be a powerful pain reliever.
The Tools of Pain Management
Today’s health professionals have numerous therapies at their disposal. Here are seven therapies frequently advised alone or in combination.
These include such nonsteroidal anti-inflammatory drugs, or NSAIDs, such as ibuprofen and naproxen. Inflammation plays a major role in many types of pain, so NSAIDs are often effective pain relievers. The main side effects of NSAIDs are stomach upset, gastritis and peptic ulcers. NSAIDs can also cause kidney damage.
Before the introduction of such antidepressants as fluoxetine (Prozac), duloxetine (Cymbalta), Paxil and Zoloft, collectively called selective serotonin reuptake inhibitors (SSRIs), there were tricyclic antidepressants, or TCAs. TCAs increase the body’s own inhibitory (anti-pain) mechanisms to modulate pain. For unknown reasons, having nothing to do with their depression-lifting properties, tricyclics can be highly effective against headaches and neuropathic pain. Meanwhile, the SSRIs can be useful against the depression that accompanies pain and also seem able to reduce pain even in the absence of depression.
The anticonvulsants were developed to treat seizures . However, in some abnormal pain conditions, the nerve fibers become hypersensitive and start producing what amounts to “mini-seizures,” sending waves of pain racing to the brain. Anticonvulsants, especially the latest additions to this class, gabapentin and pregabalin (Lyrica), slow down nerve impulses and may reduce pain even in the absence of nerve disease.
Many patients and some physicians are still reluctant to use morphine and its derivatives. This aversion is unfortunate because opiates are the only drugs that provide effective relief for many patients with pain. Studies have repeatedly shown that when prescription opiates are used under careful supervision, the risk of addiction for a patient with chronic pain is quite low, around 1 percent. Keeping the risk of addiction low requires careful evaluation of a patient before and after starting opiates. When used correctly, opiates should liberate, not stupefy, the patient. If the use of opiates increases a patient’s mobility, mood and motivation to return to activities he or she had abandoned because of the pain, then the drugs should be continued. To avoid spikes in blood levels of opiates, patients often prefer long-acting or time-release formulations, which decrease the chances of becoming overly sedated.
Because the mind-pain connection is so strong, psychological coaching and counseling can be valuable components of the pain management package. In particular, cognitive-behavioral therapy can help patients develop healthier and more productive thought patterns, emotions, and actions. Relaxation methods can help decrease tension and anxiety and decrease pain medication requirements.
Injections of local anesthetics into specific nerve bundles can suppress pain. The relief is usually temporary, but even the short respite helps patients regain mobility and participate in physical activities.
When pain doesn’t respond to the other six measures, certain devices can be implanted through the skin to provide relief. Patients report satisfaction with the implantable pump, which delivers a tiny dose of an opiate or other painkiller directly to the spinal cord where pain is processed.