Thursday March 29, 2007
Managing Chronic Pain
By Rachel Stern
Signal Staff Writer
Sharp, burning, stinging, throbbing. Whatever you call it, it’s pain. We’ve all had it, and it all calls out for relief. Whether it’s migraine headache, arthritis, or low-back pain, there is generally an over-the-counter analgesic to take care of it, and, failing that, a prescription. But what happens when your pain simply won’t go away?
Nicolas Weider, D.O. (Doctor of Osteopathy), board-certified anesthesiologist and Physician-in-Charge at the Kaiser Permanente Panorama City Pain Management Clinic, explains that this is known as chronic pain, which comprises several different disorders.
“Chronic pain in general is pain that lasts more than three months,” said Weider. “there are many different types of pain disorders: for instance those due to congenital factors or to trauma. There are also specific pain disorders, like complex regional pain syndrome, when there is an activation of multiple parts of the nervous system.”
The ABC’s of Chronic Pain
More than 50 million Americans experience chronic pain, according to the American Pain Foundation, with back pain, headache and joint pain caused by arthritis being the most common conditions. Chronic pain costs the United States billions of dollars annually. According to Shahin Sadik, M.D., Board Certified in Anesthesiology, Pain Management and Pain Medicine, the U.S. is behind other major Western countries such as Canada, Great Britain, and the European Union in terms of palliative (pain-relieving) care. For a long time, pain per se received little attention or government funding, the situation is changing. Sadik, who has practices in Valencia and Palmdale, said part of the problem is the anti-drug message the government so assiduously dispenses.
“There is a stigma about opiate use,” said Sadik. “But prescribed and controlled, they are wonderful drugs. People are happier when their pain is down.”
Part of the stigma is among doctors themselves they are worried, said Sadik, that if their patients get addicted and want to stay on the medications longer than is necessary, they themselves will have trouble from the Drug Enforcement Agency, which oversees the dispensing of all controlled substances. But in his 14-year experience as a pain doctor, only approximately one to two percent of his patients have used their medications inappropriately.
“And these patients should be treated differently from street-drug addicts,” said Sadik. “Though they shouldn’t get narcotics anymore, we help them get into detoxification programs.”
Congress designated the years 2001-2010 as the “Decade of Pain Control and Research.” Among the goals of this initiative are the requirement that U.S. hospitals and nursing homes meet new standards of pain management, and that health-care professionals be more informed about the nature of chronic pain.
Physicians have learned that pain is much more complicated than had been previously thought, said Weider, involving many different mechanisms depending on the source of the underlying problem. In some cases, pain receptors begin to act on their own, with concomitant physical changes in the behavior of the nerves, making chronic pain very difficult to treat.
Sadik decided on pain management as a sub-specialty because he himself was a chronic pain patient, due to an automobile injury.
A Stuck Switch
Simple pain involves the transfer of basic information from the site of the injury to the brain. For instance when you get a sunburn, the initial injury is at the level of the skin, whose nerves send a signal to the spinal cord and from there to the brain. With chronic pain, however, there is an over-sensitization of the nerves so that they feel pain all the time. “In fact, the nerves create their own circuit that persists, even when there is no longer an ‘original’ injury,” said Weider. “This is caused by chemicals shuttled on the spinal cord, which effectively reset the suffering person’s pain ‘thermostat.’ The goal of treatment for chronic pain is to try to set that thermostat back.'”
This is how antidepressants and anti-seizure medications can alleviate chronic pain, said Sadik. They work directly on the nerves to stop them from “firing,” which is what causes the pain.
Treatment of chronic pain differs from most other medical techniques in that practitioners might essentially “throw the book” at the pain, whereas in general medical approaches are more fine-tuned mechanisms. Because the theory is that pain-inducing chemical signals are “wound up,” and the practitioner wants to break that cycle, he or she will often use whatever works, whether that involves neurochemical stimulation, medication, removal of disks for back pain, or exercise, for instance if the issue is that the patient lacks core strength.
“Or we might use all of them,” said Weider. “The traditional thinking in medicine is to try things systematically, whereas for chronic pain we might try remedies in parallel to see what works.”
What has changed in the past decade or so, is that pain is now being taken seriously as a chronic disease, said Weider, like diabetes, or any other chronic condition. The key insight is to see all pain as urgent, whether it is acute or chronic.
The Emotional Connection
It has long been understood by traditional cultures and by the psychotherapeutic community that emotions have a relation to pain. This is not the same thing as saying to sufferers of chronic pain that “it’s all in their head” – on the contrary, neurology is helping to explain the specific pathways whereby emotions exacerbate or mitigate pain.
“Your mind does not create the pain,” said Weider, “but it can create a tendency to focus on it.”
For instance, many pain patients find that their pain increases at night. Weider said that this is sometimes due to the fact that there are fewer distractions at night, and actually presents a therapeutic opportunity to use techniques like guided imagery to take their mind off their pain. This is especially helpful since using imagery is a skill that patients can develop on their own, and since part of the experience of pain is feeling out of control, the sense of control itself can alleviate some of the pain. In addition, there is abundant evidence, said Sadik, that chronic pain can cause other symptoms, like depression.
“Pain is both emotional and sensory,” he said. “Depressed people often have a lower pain threshold, which sets them up for more pain. It’s a vicious cycle and when we address the emotional component of dealing with chronic pain, the patient’s demeanor improves; they don’t feel so hopeless, whereas before they couldn’t see a future out of tunnel of pain. That’s part of our job too.”
Pain researchers are confident that future studies will further illuminate the relationship between emotions and chronic pain.
An Eclectic Approach
Because chronic pain has many causes, practitioners avail themselves of many remedies. These can be medications, like anti-inflammatories, anti-seizure medications, muscle relaxants and opiates like codeine, methadone and morphine. Other, non-pharmaceutical modalities like heat, chiropractic and massage are also used.
“We figure out what works, and whatever it is, we use that,” said Weider. Non-medicinal modalities are especially helpful for elderly patients, since they can be particularly bothered by the side-effects of muscle relaxants and pain medications, which can promote loss of balance and falls. This sets up a situation where the elderly become afraid to move, and their resulting inactivity, or even fear of movement itself, can make their pain worse. Though the kinds of conditions Weider and Sadik may see, e.g.: low back pain, muscle pain and arthritis, are common, the difference is in how they approach the problem and the patient.
“We see (patients) after they have been evaluated by a primary doctor or even by a specialist, when the outcome has not been satisfactory,” said Weider. “And they ask us to help them. It can be the most frustrating thing to handle, to have a pain that won’t go away but which doesn’t have a specific cause.”
Whether there is an objectively obvious cause, or whether the pain is subjectively perceived doesn’t matter, said Weider. The issue is that the patient has an unpleasant sensation regardless of whether there is an indirect or direct trauma. The proof is in the perception.
“In the past, we would say to a patient, in effect, ‘I don’t understand why you’re still in pain,’ or worse, ‘You really shouldn’t still be in pain now,'” said Weider. “Now we ask ‘What can we do to stop the pain?'”
What changed, he said, is the education doctors have received in pain management.
“Pain medicine has grown quite a bit,” said Sadik. In the future, he hopes, doctors will be able not only to understand their patients’ chronic pain, but to reliably alleviate it as well.
Annemarie Donkin contributed to the story.
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