MEDICAL MANAGEMENT OF CHRONIC PAIN

JAMES K. ROTCHFORD, MD, MPH

Author's Note: This handout was written in about 1995. Some of the concepts are as a consequence a little dated but it will remain a good primer on chronic vs. acute pain.

AUDIENCE: This paper is directed toward patients who have a chronic painful condition which is likely to be with them for the foreseeable future.

Check out the New Tennis Elbow article, for more information on Chronic Pain.

BACKGROUND: The best results in treating chronic pain arise from markedly different practices from those methods used for treating acute pain.

WHY MUST CHRONIC MANAGEMENT DIFFER FROM ACUTE MANAGEMENT WHEN PAIN FEELS THE SAME?

This is a good question and there are no quick answers. The following is a simplification:

Acute Pain

Hurt equals Harm (This is a true message)

Hurt equals warning signal to rest

Pain is a guide to healing

Chronic Pain

Hurt doesn't mean harm

False message about what is going on

Rest is worst thing to do

Pain regulatory mechanisms are generally assumed to be "abnormal".

I believe there are solid physiological reasons why chronic pain management needs to differ from acute pain management. These physiological reasons stem from normal -- as well as sometimes unhealthy -- adaptive processes. This concept of adaptation is helpful to look at in answering the above question. Here an example might be helpful: If a person starts to

smoke on a regular basis their body adapts to the nicotine and the smoking.

Even though smoking isn't necessary and can be considered harmful to one's health, the body's systems eventually adapt to the point where the individual has difficulty in stopping. Many cases of chronic pain can be looked at as an example of a bad habit that needs to be broken. This bad habit is chemically and neurologically "real", just as addiction to nicotine is chemically and neurologically "real." It makes sense that to help someone stop smoking the approach will vary depending on whether the person just started or has been smoking for several months. Similarly, breaking the "habit" of chronic pain requires specific interventions other than those employed for "acute" pain.

BASIC PAIN PHYSIOLOGY 101

Patients need to understand that all pain is in their head. Let me explain: when tissue is damaged, the information is transferred to your brain via nerves and the spinal cord. If the information never reaches the brain there is no pain. Some researchers have divided pain up into three parts: the first is called "nocioception", which is the signal transmitted into the spinal cord from tissue damage or irritation; the second component is called "pain" and represents the arrival of the signal to the brain; and the third part is "suffering", which represents how the brain deals with and interprets the "pain". In this model, morphine or other oral narcotic pain medicines don't help with "pain" -- they just treat the "suffering". Indeed, many patients who have had surgery and are adequately medicated with morphine will tell you that they can still feel the pain but they are comfortable because they don't care about the pain. I know this might sound confusing, but you can see the value, I think, of being clear about what we mean when we say someone is in pain. We now know with certainty, both through human and animal studies, that pain is not just a function of tissue damage and input into the brain. If regulatory mechanisms in the brain or brainstem are disturbed, patients can feel pain even though there is no tissue damage or input from the body.

Regulatory mechanisms in the brain and the brainstem are quite complicated. In part, these mechanisms involve chemicals called neurotransmitters which affect how one nerve talks with the next nerve. Neurotransmitters called enkephalins, serotonin, CPK, substance P, are just a few of the different neurotransmitters in your central nervous system that are involved in pain transmission and modulation.

WHAT FACTORS HAVE BEEN SHOWN TO HELP THE BRAIN BLOCK OUT PAIN AND SUFFERING? Here we start to get into the solution. Four factors can be experimentally shown to play a role in the transmission and modulation of pain: affect (one's emotional state), attention, expectations, and sleep disturbances. All can affect pain thresholds. Serious and sudden fear can actually make pain go away. Anxiety, uncertainty, depression, low grade fear, and even frustration can increase pain. If one is able to distract oneself, usually there is less pain. I think we all have experienced seriously cutting ourselves while playing or working and not noticing it. On the other hand, a pinprick at the wrong time can be exquisitely sensitive. Expectations also play a role. Studies have demonstrated that our brains can create pain (that is, pain with no tissue damage) if one sufficiently anticipates it. Perhaps the most important contributing variable I see in my medical practice are sleep disorders. If one doesn't sleep well or long enough, clearly one is going to have more pain. Regularly, I tell my patients: The sun rises in the east and sets in the west... likewise if I am able to help you with your sleep I will have helped you with your pain and suffering.

Other evidence supports the notion that if one reduces disability one, in effect, reduces suffering. The point to remember is that how disabled you are at present is not simply a matter of how much pain you have or how severely you have been injured. A more accurate picture of disability is what has been called the "DIAL".

Disability = Injury + Attitude + Lifestyle

With chronic pain as with many other health problems, attitudes and lifestyle are key factors between those who suffer and those who thrive with identical physical problems.

BUT DOC IT HURTS HERE, AND LOOK AT MY X-RAYS, HOW CAN YOU SAY THAT THE PAIN IS ALL IN MY HEAD? Unfortunately many of my colleagues have fostered the belief that pain resides in a joint or a bone, or that an x-ray can tell you precisely why a patient has pain. In acute painful conditions an x-ray often can be of help in ruling in, or out, a possible source of the pain. Conversely, x-rays rarely tell the whole story when dealing with chronic pain. Two people with the same findings on x-ray can experience very different levels of pain. Even the same individual with the same x-ray findings will find that his pain can vary widely from day to day. In these cases of x-ray abnormalities associated with chronic pain, I encourage you to remember that the pain can be alleviated without changing the x-ray. Almost always, I recommend against surgery in patients with non-cancerous chronic pain. If, however, the surgery is likely to correct muscle weakness, loss of sensation, or improve other functions then it should be considered as a last resort. There are, however, exceptions to every rule ... especially in medicine.

BUT DOC, WHY ALL THIS COMPLICATED TALK? WHY DON'T YOU JUST GIVE ME PAIN MEDS AND LEAVE ME ALONE? The simple answer is that in the long run, it rarely works. The side effects from the medicines become noteworthy, especially if they taken in dosages required to abolish pain. The biggest problem medicating chronic pain is that the narcotics interfere with the normal, natural pain regulatory mechanisms which I'm vigorously trying to help the patient heal. For patients with chronic pain, I'll only give narcotics in small amounts, and then only on a non-pain contingent basis. For example, the patient is not to take the pain medicine as needed for pain but because it's bedtime or four in the afternoon. The reasoning for this will be given below. Most often the best approach is to avoid narcotics for patients who are not terminally ill.

DR. ROTCHFORD'S POLICY WITH REGARD TO NARCOTICS IS AS FOLLOWS:

1. We'll set things up at the first, and then there is to be no discussion except when to reduce dosage.

2. Prescription lasts one month, no early refills.

3. Dose does not increase.

4. Don't expect exceptions.

5. Misuse of medications is not acceptable. Misuse includes receiving narcotics from other sources including other doctors, selling your medications, and the abuse of alcohol. Continued requests for early refills is an abuse of medication and may result in the discontinuation of the medication.

6. Refills can be arranged by the nurse. Please call ten days prior to running out.

7. Refills will not be honored unless patient is adhering to the prescribed schedule of appointments with Dr. Rotchford.

DOC WHY ALL THIS TALK? WHY DON'T YOU JUST FIX ME?

In order for someone to be helped with chronic pain, the traditional doctor-patient relationship needs to change. In most cases when a patient goes to the doctor, the patient expects to receive a diagnosis and a prescription which will remedy the problem. This approach rarely works with the patient suffering from chronic pain. The physician needs to take on the role of a teacher, counselor, and coach, rather than one as a diagnostician and prescriber. There is a lot to learn about effectively managing chronic pain. That is why this handout was written. Your physician may recommend a pain clinic for you. The best pain clinics are often multi-disciplinary, involving a number of specific health-care providers working together to provide optimum care. Pain clinics will often have on-staff specialists in pain management, anesthesiologists, neurologists, psychiatrists, psychologists, orthopedic surgeons, neurosurgeons, social workers, physical therapists, biofeedback specialists, pharmacologists, acupuncturists, etc. Often some, or all of these practitioners can contribute to the care of a given patient. I see these pain clinics as places where patients can go to get a clearer idea of what structural and regulatory mechanisms are interfering with their getting better.

I also see pain clinics as intensive learning experiences for the patients. There is much to learn about managing chronic pain and it shouldn't be surprising that an intensive educational experience away from family and other distractions could well be of help. Because of the expense of these clinics, many insurance companies do not pay for them. If your insurance company pays for you to attend a chronic pain clinic, I recommend you seize the opportunity.

Chronic pain is best approached as a chronic illness. That is, you might never be cured, but with proper care, the patient can expect little disability from their illness and can hope for a happy and full life. Diabetes is an example of a chronic disease similar to chronic pain: when one manages diabetes well, the disabilities associated with the disease can be minimized.

WHAT THINGS CAN I DO TODAY TO HELP MYSELF HAVE LESS PAIN? We've talked already about attitudes and lifestyles being important in the control of pain. These issues are clearly under the control of the patient. This is why self management is such an important component in the treatment of chronic pain. It is only after you decide to take charge of your life that you will gain control over your suffering.

1. Come to accept more fully your condition. Whenever you are dealing with a chronic illness, acceptance goes a long way to reduce suffering. To accept a painful and disabling condition is tough going. Ask for help. I believe there is an important paradox here: the more you can accept your condition, the easier it is for your body to heal and to reduce the pain and suffering associated with it. A different slant on this same principal goes as follows: if you come to expect that the pain will be with you, the suffering is optional and you will do better.

2. In the early 70's, research by Dr. Fordyce at the University of Washington demonstrated that helping patients behave normally was actually effective in helping them function better. With all your behavior make an effort to not have it contingent upon the symptom of pain. An example I give is the actual schedule of office visits I give to the patient. I tell patients I want to see them regularly for a while rather than have their visits contingent upon the presence or absence of pain. The implications of this suggestion are enormous. Another example of adhering to this principle is not to take pain medicines when you hurt. If you feel you need pain medicines you should take them contingent upon a time of day rather than on pain per se.

3. Look for strong emotional support. If one is having problems in their family, marriage, or work situation, it can clearly interfere with normal pain regulatory functions. I believe past emotional pain can equally interfere with the brain's ability to respond properly to present emotional or physical pain. If you are angry or resentful about something, seek help to let go of these feelings. Often my patients are quite angry about a system that has been unable to help them. Labor and Industry patients are typically angry, and I must often say rightfully so. Nonetheless, these feelings interfere with normal pain-regulatory mechanisms in a number of ways, and I suggest you seek help in letting go of these feelings.

One suggestion about dealing with anger has helped some patients. Rather than direct the anger at yourself, your family, an institution, etc. try directing the anger at the pain itself. "Dog gonnit I'm not going to let this damn pain get the best of me," is a pretty healthy attitude. Eventually we want to see the anger dissipate.

4. I recommend that all patients stop drinking any alcohol or taking any mind-altering medication or drug such as marihuana. These drugs can and do interfere with normal pain-regulatory mechanisms. If you have any reservations about stopping one of these drugs, please discuss this with your physician.

5. Learn and practice a relaxation response twice a day for 15-20 minutes. Your physician should be able to help you find the help you need in this regard.

6. Examine your beliefs and be sure they aren't interfering with your getting better. Example might be: "I should have no pain." For most people, this is an unrealistic and unobtainable goal. Pursuit of this goal will lead to frustration, endless disappointments, and loss of control of your life.

WHAT IS THE ROLE OF ACUPUNCTURE IN HELPING PATIENTS WITH CHRONIC PAIN?

Despite the lack of conclusive scientific evidence in this regard, my experience and that of others in the field, is that in some cases it can help significantly. I've had patients suffering for years with chronic pain who, after the first one or two acupuncture treatments, experienced significant relief. Acupuncture is relatively safe, so I believe one should almost always give it a try to see whether it helps. Please don't expect it to be a cure-all; just hope that it helps your system regulate the pain better. In some cases, it might even help your physician more fully appreciate what set you up for the pain in the first place.

In all cases, however, acupuncture in the context of chronic pain should be looked at as adjunctive therapy, rather than definitive therapy. Appropriate self-management remains the corner stone of chronic pain management.

Some Last Words:

It is very important to realize that normal people can become extremely disabled when they have chronic pain. It can erode a person's life in the same way that a steady stream of water can break down the strongest rock. Given enough time, the daily struggle with pain and the frustrating search for solutions can wear anyone down. The Pain Rut is the end result of a process by which a person's entire life has become focused on avoiding or minimizing pain. It is caused by a series of normal reactions to pain which you have learned, which have likely been reinforced by doctors, and which seem to be based on plain common sense. There are "curve balls" in the care of chronic pain. Please be kind to yourself and allow yourself to ask for support and guidance.

The following two references are helpful self-management tools. I plan to have the manual by Caudill available for patients at the office.

References:

1. Managing Pain before it Manages You, M. Caudill, MD, PhD Guilford Press, N.Y. 1995

A Harvard clinician with practical solutions for dealing with chronic pain.

2. Mastering Pain, A Twelve-Step Program for Coping with Chronic Pain, Richard A. Sternbach, First Balantine Books, 1988

A classic self-help book with broad and helpful suggestions.

3. Paradox & Healing, Medicine, Mythology & Transformation, Michael Greenwood. Meridian House, 1980 Cromwell Rd., Victoria, B.C. v80 1R5 Available from Publisher.

This book is a great one in appreciating how complex issues around chronic pain management can be. It's directed toward the more literary audience.