Pain: Part Two-The Toolbox for Treating Chronic Pain
A colleague once said to me: “chronic pain causes so much suffering. I wish we had better medications for suffering.” I have never forgotten this simple observation which captured so much about living with chronic pain. In this article, we will focus on chronic pain and what we might be able to do to help reduce your suffering.
Before we start, it might be helpful to read Pain: Part One to familiarize yourself with some definitions. As a reminder, chronic pain is defined as pain that lasts longer than three to six months. The Cleveland Clinic puts it nicely: “this type of pain can continue even after the injury or illness that caused it has healed or gone away. Pain signals remain active in the nervous system for weeks, months, or years. Some people suffer chronic pain even when there is no past injury or apparent body damage.” Columbia University adds: “Sometimes pain evolves into a poorly understood condition known as chronic pain syndrome. Unlike acute pain, this condition doesn't go away after your initial injury or illness has healed. It's marked by pain that lasts longer than six months and is often accompanied by anger and depression, anxiety, loss of sexual desire, and disability.”
If you have experienced the chronic pain syndrome, you might recognize a sad pattern that we as family doctors often observe. Pain starts to take hold after an injury, or even out of the blue, and it won’t let go. The pain interferes with your work and your relationships and your sense of well being. Doctors start to order a series of tests looking for physical causes for your pain and your hope builds as you wait for each test that might reveal a treatable cause and then sags when no fixable cause is found. We offer medications and treatments, methodically following our guidelines. You meet physiotherapists, radiologists, pain specialists and pharmacists and still, your pain persists. You feel overwhelmed and struggle to convince others of what you are feeling and you suspect that people underestimate your suffering. The medications we prescribe may help a little, but they often cause side effects and the cost is significant. You start to lose hope that anyone can help and explore options suggested by friends or advertised online. Your trust in the healthcare system frays and you feel increasingly bleak. You sometimes wonder if it is worth booking another appointment. Perhaps it might be helpful to know that we recognize this pattern and that we do have ways of helping.
Let’s look at some of the tools in our toolbox. Most of the time, we are going to have to use several tools to help you reduce your suffering from chronic pain.
No medication is perfect and all of them come with costs and possible side effects, but we have many different options to choose from. These range from simple painkillers like acetaminophen (tylenol) to more potent medications like morphine or hydromorphone. It is important to note that there is lots of evidence that the stronger painkillers should be minimized or avoided in the treatment of chronic pain (for those who want to learn more about this, have a look at Choosing Wisely or watch this video from the Mayo Clinic). Here is a nice overview of the different classes of medications used in the treatment of chronic pain from Hamilton Health Sciences.
Interventional pain management:
This is a discipline of medicine devoted to the diagnosis and treatment of pain related disorders. Interventional pain medicine utilizes a multidisciplinary approach, in which a team of health care professionals works together, to provide a full range of treatments and services for patients suffering from chronic and/or acute pain. We are lucky to have a group of colleagues in Kelowna who specialize in procedural, medical and rehabilitation services at the Bill Nelems Pain and Research Centre. We refer patients to this clinic for procedures and injections that can be very helpful in coping with pain. Their website hosts a number of pain management tools that you might find helpful.
We work in partnership with physiotherapists, chiropractors, massage therapists and acupuncturists in helping patients who are living with chronic pain. A great overview of the role of each of these practitioners can be found in this guide from Pain BC.
Harvard Health Publishing summarizes the relationship between emotion and pain nicely:
“Pain, depression, and anxiety travel through similar pathways along your nervous system and share many of the same biological mechanisms. One of the areas in the brain that receives pain signals — specifically, the limbic region — shares many of the same messengers as the mood signals. We know from research studies using neuroimaging that the parts of the brain controlling emotion and sensory features of pain are altered in people with chronic pain.”
“The medical community has come to appreciate a direct correlation between improvement in one’s emotional well-being and their experience of pain (and vice versa). Chronic pain increases the risk of depression and anxiety, and depression and anxiety strongly predict the development of chronic pain. This association is seen in conditions like fibromyalgia and irritable bowel syndrome, where behavioral and psychological treatment strategies have shown benefit in reducing symptoms.”
Some of the techniques used to help with chronic pain are mindfulness, meditation, psychotherapy, cognitive behavioural therapy and acceptance and commitment therapy (ACT). For patients who want to read more on this topic, a good overview from Alberta Health Sciences can be found here. You might also want to check out Pain BC for information about self management tools, pain coaching and support in our community.
Exercise and well being:
I wish that we could say that exercise will always help patients with chronic pain, but research says that “physical activity may reduce pain and improve function for some adults with chronic pain, while having few adverse events.” Have a look at a summary of research findings here. We believe that exercise is so important for well being and good health that we would encourage you to try to exercise, within the limits of your pain. Please consider having us write you an exercise prescription or refer you to one of our kinesiologist colleagues to help design a personalized exercise program.
Sometimes using heat or cold packs can help with managing pain. The Cleveland Clinic has a nice guide here. Some of our patients use creams and rubs that cause “counter irritation” of the nerves in areas of the body that hurt. The theory is that nerves that are busy carrying signals of heat or prickly sensations are too busy to carry pain messages to our brains. TENS machines use a gentle electrical current applied to the skin. Research suggests that “...there is little evidence of the effectiveness of TENS in treating chronic pain,” but when used appropriately, this treatment does not appear to cause harm.
We hope that some of these tools will help you in coping with and overcoming your chronic pain.