An Introduction to Chronic Pain
Chronic pain is an enormous topic and much has been written regarding its causes and management. An Introduction to Chronic Pain is Part One in a series of upcoming posts which will highlight injuries and conditions associated with chronic pain, look at their impact on future care, and identify some of the strategies used in long term management of these often complex conditions.
Pain affects millions of individuals each year, and is seen as a common theme in many types of claims. Pain affects more Americans than diabetes, heart disease and cancer combined and has been referred to as the most costly health problem in America. It is estimated that 50 million Americans are either partially or totally disabled due to chronic pain. Economically, for the individual, this translates into lost income and emotional / financial burdens. For the employer, the reduced annual productivity is estimated to be between $60 and $100 billion.
The American Society of Anesthesiologists defines chronic pain as “pain of any etiology not directly related to neoplastic involvement, associated with a chronic medical condition or extending in duration beyond the expected temporal boundary of tissue injury and normal healing, and adversely affecting the function or well-being of the individual.” (2010)
Chronic pain differs from acute pain or recurrent acute pain. Acute pain is due to actual or pending tissue damage as seen with fractured bones, lacerations, or post surgical pain. An example of acute pain from pending tissue damage would be Chest pain (angina) due to lack of oxygen to the heart muscle. In this case, if circulation is not restored to the heart muscle, the involved area eventually dies resulting in infarction or heart attack. Acute pain improves as healing occurs. Acute recurrent pain refers to episodic pain associated with chronic conditions such as migraine headaches in which one may experience intense, sometimes disabling pain which then resolves and recurs with the next episode. Although acute pain can be intense, the perception and behavior associated with it tends to be short-term. Chronic pain, described above, tends to be long-standing and refractory to treatment.
Marchand (2009) noted that the mechanisms believed to be associated with the development and persistence of pain involves changes which occur at all levels of the central nervous system (CNS) when pain signals are transmitted from the body’s periphery (everything outside the CNS). Evidence-based research suggests that when acute pain does not resolve within a few months, continued activation of the nerves which transmit pain impulses may result in changes to the spinal cord and brain, eventually leading to the development of chronic pain and chronic pain syndrome. In addition, when our brains receive pain a message, the information is associated with the emotion and processed. Our resulting sensation therefore, has both physical and emotional components.
The “Terrible Triad”
Chronic intense pain can be overwhelming, interfering with work and normal activities. Often times the individual becomes so preoccupied with the pain, their appetite decreases. Physical activity exhausting and individuals sometimes fear it will worsen or aggravate the pain. As a result, they avoid activity, becoming more and more sedentary. Depression and irritability soon follow leading to insomnia. Lack of refreshing sleep causes fatigue; which can trigger more irritability, depression and pain.
This cyclic state is referred to as the “terrible triad” of suffering, sleeplessness, and sadness. Many individuals become so distraught and desperate that they will do anything to stop the pain. This can lead to drug-dependents; searching for multiple opinions, repeated surgeries and/or seeking relief via unusual or bizarre cures. Does this scenario sound familiar?
Many factors contribute to the cause of chronic pain. These can include a variety of disorders such as arthritis, spinal compression fractures, fibromyalgia, faulty or poor posture, nerve injuries, cancer, irritable bowel syndrome and peripheral vascular disease, just to name a few. Some authors have suggested that a chronic pain syndrome represents a learned behavioral syndrome that begins with a noxious stimulus that causes pain. This pain behavior is reinforced either by external rewards (attention from family and friends, socialization with the physician, medications, compensation and/or time off work etc) or internal reinforces which provide relief from personal factors (guilt, fear of work, sex, responsibilities).
Richard A Sternbach, a researcher and program director at the Pain Treatment Center of California’s Scripps Clinic and Research Foundation, refers to the 6 D’s of Chronic Pain Syndrome. These include:
- Dramatization of complaints
- Drug misuse
- Dysfunction/disuse
- Dependency
- Depression
- Disability
When dealing with chronic pain, the burning question remains… Why do some individuals with serious injuries do so well that they defy the odds; while others experience prolonged recovery and /or long-term disability after seemingly minor injuries?
Weighill (1983) and Hanson-Mayer (1984) identified the following factors which contribute to delayed recovery: unconscious psychological conflicts; personal predisposition; pre-existing psychological disability; low work satisfaction; poor attitudes toward work and social responsibilities; family system homeostasis under threat; the accident as a “solution” to current life problems, no incentive for light duty; unions encouraging additional time off and others.
Headley (1989) notes that no personality cluster has yet been identified which, when subjected to an injury, produces delayed recovery. Hence “A” + “X” + “injury” = Delayed Recovery is too simplistic a formula by which to identify or intervene to decrease undesirable behavior. Instead, Headley recommends a biopsychosocial approach to understanding delayed recovery. She notes that a specific lack of certain coping skills; when combined with the physical aspects of pain (which are often unclear), social, industrial and medical factors, influence human functioning.
Chronic pain syndrome can be difficult to manage because of its complex natural history, unclear etiology and poor response to therapy. If at risk individuals can be identified, a proactive approach with early intervention, multidisciplinary treatment and an individualized care plan can made a difference. Consider the involvement of a qualified medical case manager. Although not appropriate for every situation, they can help to facilitate compliance, coordinate care and act as an intermediary between the involved parties so that these individuals don’t get lost in the system, treatment moves forward everyone is kept in the loop.
Overall the treatment goals need to be realistic and focused on the restoration of normal function to the extent possible, improved quality of life, reduction of medication and prevention of relapse. Efforts should be directed at making the individual with chronic pain self-reliant.
As we all know, despite the best efforts, some individuals will remain stuck in the cycle of chronic pain. In cases such as these life care planning for the future often occurs after pain clinic and surgical interventions have failed. When considering long term conservative care, multidisciplinary treatment programs can offer valuable resources. Typically the needs of the patient will require multiple measures to maximize the outcome of the patient’s ability to manage his or her own condition after a period of six months to a year. Most outpatient programs include a brief 1- to 2-month period of intense evaluation and management followed by a middle period of 3 to 6 months of continued weekly or monthly monitoring associated with the establishment of a management program tailored to fit the needs of the individual (Weed, Berens 2010). Identifying a primary treating physician who can provide ongoing long-term monitoring is optimal. Once the formal program is completed, long term cost estimates will include provisions for periodic reevaluation to assess and modify the program so that it remains appropriate and can address changing needs associated with aging. In addition, costs of medications and replacement/repair of any durable medical equipment should be evaluated and included.
Ultimately, the overall success of treatment is influenced by the individual’s compliance and ability to adopt new lifestyle measures and adjust and/or habituate certain aspects of their daily routine (i.e. Biofeedback, relaxation). The goal of chronic pain planning is not to reduce the pain to the level it was before the injury, as this is not always realistic, but to modify the pain and provide strategies which enhance quality of life and maintain a reasonable degree of function.
In treating one’s pain with medications, several options exist. First, we must try to differentiate between acute and chronic pain as length of time and types of medications differ. Acute pain is commonly treated for a short duration and with acetaminophen, NSAIDs (Ibuprofen) or even topical adjuncts (Capsaicin) for a short period of time. The treatment of chronic pain poses a greater challenge as it is commonly undertreated and medication usage may produce toxicities or addictive side effects when taken for long periods of time.
References
1. AAPM Facts and Figures on Pain. The American Academy of Pain Medicine.
2. National Centers for Health Statistics, Chartbook on Trends in the Health of Americans 2006, Special Feature: Pain. Nov 2006
3. Low Back Pain Fact Sheet. National Institute of Neurological Disorders and Stroke, National Institutes of Health. Updated Feb 18, 2011
4. Practice Guidelines for Chronic Pain Management. An Updated Report by the American Society of Anesthesiologist Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology 112:810-33. Apr 2010.
5. Marchand, Serge. “The Physiology of Pain Mechanisms: From the Periphery to the Brain.” Rheumatic Disease Clinics of North America 24 2 (2008): MD Consult. Elsevier, Inc. 5 Feb. 2009
6. Weighill VE. ‘Compensation neurosis’: a review of the literature.
J Psychosom Res. 1983; 27(2): 97-104
7. Hanson-Mayer TP. The worker’s disability syndrome. Journal of Rehabilitation, 50(3), 50-54, 1984
8. Headley BJ. Delayed Recovery: Taking Another Look. Journal of Rehabilitation, Vol 55, 61-66, 1989
9. Weed R, Berens D, Life Care Planning and Case Management Handbook: Third Edition, Chapter 17, Life Care Planning for People with Chronic Pain. CRC Press, Boca Raton, FL, 2010.
Please stay tuned for Part Two: Failed Back Syndrome. Also as part of our Chronic Pain Conditions Impact on Future Care series, William Bell, Jr. BSPharm, MBA, MSCC, Gould and Lamb’s Senior Clinical Pharmacist will weigh in on Pain Management Pharmacotherapy.
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