Pain happens. It’s a prime symptom of most injuries and illnesses. When the pain fades, you know that you’re getting better.
But what happens when the pain does not go away–when it lingers for months or even years? Some define chronic pain as pain lasting six months or longer; others say it’s pain lasting longer than expected. It can occur from a number of causes: sports injury, car accident, arthritis, shingles, sciatica, chronic fatigue syndrome, fibromyalgia, headaches, cancer and cancer treatment. Chronic pain is closely associated with depression, both as a cause and an effect. In many cases, doctors cannot really find a satisfactory explanation for the pain.
Pain begets pain. Frustration related to chronic pain leads to stress, and stress causes more pain. Pain that keeps you awake at night makes you feel tired and painful the next day. And the increased pain makes it even harder to sleep the following night. When you’re hurting, you don’t feel like exercising–or moving at all. Your muscles stiffen, and you feel even worse.
The most obvious way to deal with pain is to pop a pain-killing pill–aspirin, ibuprofen, naproxen. While these are perfectly safe over-the-counter medications for occasional use, they are not intended to be taken at high doses for long periods, as many patients use them.
NSAIDs Raise Heart Risk
All nonsteroidal antiinflammatory drugs (NSAIDs)–both over-the-counter and the stronger prescription medications–increase the risk of gastrointestinal bleeding–often severe.
COX-2 selective inhibitors were introduced in the 1990s in order to reduce this risk. Clinical studies found they were very effective at doing so, and they were hailed as a major advance for patients suffering chronic pain.
That optimism quickly faded, however, when studies found an unequivocal association between COX inhibitors and the risk of heart attacks.
And in the fallout from this discovery, large meta-analyses found they were indeed no more nor less dangerous to the cardiovascular system than traditional NSAIDs. The Food and Drug Administration now requires that all NSAIDs carry a boxed warning about their cardiovascular risks. They should be used with caution by anyone with risk factors for heart disease.
Since heart disease is the number one killer of Americans, those findings take a good proportion of chronic pain patients out of the running for NSAID pain medication.
A recent meta-analysis [The Lancet, May 30, 2013] found that the effects of different regimens of NSAIDs could be predicted, a finding “which may help physicians choosing between alternative NSAID regimens to weigh up which type of NSAID is safest in different patients,” the lead author wrote. This study also found that naproxen was associated with less risk than the other NSAIDs when prescribed at high doses.
In the meantime, researchers have gained greater knowledge of chronic pain and how it develops. Using brain scans, researchers at Northwestern University found that the architecture of the brain changes in response to persistent pain.
While the severity of the injury or illness may determine the severity and nature of the pain over the short term, chronic pain is determined more by changes that take place in the brain and central nervous system.
Through a process known as “central sensitization,” the initial pain from an injury or illness can gradually become chronic. If the pain signals are not adequately treated, they are sent again and again, causing changes in the central nervous system. Eventually, even the slightest touch becomes painful.
Clearly, “toughing out” pain is not the answer; early treatment is the key to long-term success.
Most patients, and even doctors, find it hard to think of the pain as something separate from the underlying cause. It’s important to treat the underlying cause, and that will usually make the pain subside. In some cases, though, the pain continues even after successful treatment. Long-term pain management then typically requires seeing a pain expert as well as your regular physician.
Most pain experts take a holistic approach that involves treating both mind and body. Patients are encouraged to think less about their pain and more about what they want to do that they can’t do because of their pain. The goal is to find ways to do those things even if the pain never completely goes away.
One of the best treatments–nearly all agree–is exercise or physical activity. It improves circulation and muscle tone, distracts the mind from the pain, elevates mood and stimulates the production of natural pain killing neurochemicals.
At one time, back pain patients were routinely advised to stay in bed; now, they are told to maintain their normal activities as much as possible. Studies show that almost any type of activity helps...as long as it doesn’t aggravate an injury or a painful joint.
Traditional pain killing drugs–even NSAIDs–are still used for short-term relief from pain caused by inflammation. Recent research suggests, though, that even tendinitis rarely involves significant inflammation.
The next level, for severe or persistent pain, involves narcotic medications such as codeine, fentanyl, morphine and oxycodone. These work directly on the pain receptors in nerve cells. Contrary to belief, there is only a small risk of addiction with such drugs if prescribed appropriately for patients with no risk factors for addiction.
There are other approaches: 1) anticonvulsants such as Lyrica, Neurontin or Tegretol; and 2) antidepressants such as Elavil, Pamelor, Norpramin or Cymbalta. These have been found effective whether the patient is depressed or not, usually at lower doses than needed to treat depression.
Non-drug treatments include TENS (transcutaneous electrical nerve stimulation), biofeedback, relaxation therapy, hypnosis, massage, acupuncture, nerve blocks and trigger point injections. In some cases, surgery (such as removing a tumor) can give relief.
Chronic pain patients who get counseling can learn coping skills and are more likely than others to follow through with their treatment.
Dealing with chronic pain is never easy and nearly always requires more than one approach or treatment. A good pain management team can help you reduce your suffering even if the pain is never entirely eliminated. And, more important, they can help you learn to go on with your life.
REFERENCES:
Pauline Anderson, “New research confirms spinal cord is key to chronic pain,” Medscape Medical News, April 15, 2013.
Pauline Anderson, “Few differences between chronic and acute lower back pain,” Spine, 2011;36:320-331.
Jeanie Lerche Davis, “Chronic pain relief: new treatments,” WebMD Feature, reviewed by Brunilda Nazario, M.D.
R. Morgan Griffin, “Myths about treating chronic pain,” WebMD Feature, reviewed by Brunilda Nazario, March 9, 2011.
Peter Jaret, “Fighting chronic pain,” AARP Bulletin, April, 2013.
Susan Jeffrey, “Risk for CVD events with NSAIDs can be predicted,” Medscape Medical News, May 30, 2013.
Sue Hughes, “Chronic pain common after mild to moderate stroke,” Medscape Medical News, April 23, 2013.
Christopher Lettieri, M.D., “The association of obstructive sleep apnea and chronic pain,” Medscape Pulmonary Medicine, May 24, 2013.
Fran Lowry, “Chronic, noncancer pain boosts suicide risk,” Medscape Medical News, May 28, 2013.
Fran Lowry, “Freezing nerves controls chronic pain,” Reuters Health, April 23, 2013.
Esther T. Maas, “Cost-effectiveness of minimal interventional procedures for chronic mechanical lower back pain,” BMC Musculoskeletal Disorders, 2012;13(260).
National Institute of Neurological Disorders and Stroke, “NINDS Chronic Pain Information Page,” last updated May 22, 2013.
Geneva Pittman, “Osteopathic back manipulation may help relieve chronic pain,” Reuters Health, April 1, 2013
09/29/2013
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