September 20, 2018

Chronic Pain: What can we do about it?

By dryeongs

Photo by mwangi gatheca on Unsplash

Last week, I wrote about the definition of pain, and some of the physiology behind it.

Today, I’m going to talk a little about some of the management strategies for chronic pain.

Chronic pain is hard to treat. As I said last week, chronic pain patients are difficult to treat for doctors because often there are no physical symptoms or signs that anything is wrong. Doctors are used to investigating, diagnosing and prescribing– we look for the physical ailment and we try to figure out ways to fix it. In chronic pain, the physical ailment is elusive. It is tempting for doctors to think that the pain is “all in the patient’s head”- and many chronic pain patients have heard this or some variation of this during the course of their illness.

In a way, it really is “all in the patient’s head”- in that the subjective experience of chronic pain is related to neural pathways and processes. Furthermore, mental health is intricately related to, and affects one’s experience of pain. It should come as no surprise that untreated depression- whether as a preceding event, or caused by the chronic pain, makes everything worse.

So the first step on the management plan is patience. Patience by the patient when approaching the doctor, and patience on the side of the doctor when listening to the patient. Treatment of chronic pain is not as simple as prescribing a pill, and hoping for the best. It is a wholistic, long term, and often multidisplinary and requires the cooperation of the patient just as much as it requires the management team. The patient needs to be an active player and empowered to make decisions and participate in their health care.

The next step is developing treatment goals and expectations. An important part of this is acceptance by both the patient and the doctor that achieving a completely pain free state may not be possible. Instead, more realistic goals such as being able to participate in social activities or being able to go for a daily walk can be developed together.

The RACGP’s “4 P’s approach” to pain management:

  1. Physical
    Depending on the patient’s physical state, a tailored exercise program can be really helpful for pain management. Gentle stretching, a walking program or other guided exercise can help to improve mobility, mood, and facilitate the release of good neurochemicals that can improve the pain experience. This is best done under the guidance of a physio or exercise physiologist.
  2. Psychological
    As mentioned above, mental health is intrinsically related to the experience of pain. Often years of chronic pain can result in depression or anxiety and other mental health issues, and addressing these can improve both the patient’s quality of life as well as their pain experience. This can be facilitated by a trained clinical psychologist.
  3. Pharmacological
    There are some specific pain medications that can be used according to the type of chronic pain. For example, medications such as Lyrica can assist in neuropathic type chronic pain. The major concern when it comes to pain medication is a patient developing dependence on the medication- both psychological or physical. For some doctors, it can be very tempting to give opioid or opioid type medications (such as morphine or codeine), because these medications are very good at getting rid of pain. However, once started down this path, it can be very difficult to get patients off the medications, due to their addictive potential and the other effects they have on mood. The main concern with that is, of course, that eventually they will need higher and higher doses to produce the same effect, increasing the risk of side effects, and especially- overdose. There are some studies that suggest long term use of opioids can actually increase sensitivity to pain, making the chronic pain syndrome worse. They may also have a detrimental effect on the immune system and on the hormonal system. So pain medications have to be used judiciously and under the close supervision of your treating doctor.
  4. Procedural
    There may or may not be some procedures that could assist with relieving the pain, such as steroid joint injection, nerve block procedures, or even surgeries such as knee replacement for arthritis.

Chronic pain may not be completely curable, but it can be managed, and many of these patients, if appropriately treated, can go on to live happy, functional lives, not crippled or bed-bound by their pain. But it starts with taking the first step, and seeking help.

If you or someone you know has a chronic pain syndrome, you can come and see me in my practice for a bulk billed consultation and development of a chronic pain management plan. We have an exercise physiologist and a psychologist, both of whom would be able to assist in your management.