WHAT IS CHRONIC PAIN?
Chronic pain can result from one or a combination of factors including stress, illness, nerve injury and surgical complications. According to John J. Bonica, M.D., an anesthesiologist known as the “founding father of the pain field,” chronic pain is any pain that persists more than a month beyond the usual course of an acute injury, process, or disease. In his book, Management of Pain, Dr. Bonica describes chronic pain as “A pathological process that causes continuous pain or the pain recurs at intervals for months or years.”
CHRONIC PAIN TREATMENT
In the ideal world, each person with chronic pain would have a thorough medical evaluation with a pain specialist and be treated with a combination of psychological, pharmacological and alternative therapies. “Unfortunately, many comprehensive pain management programs are going down the tubes because they are not cost effective. We are not lacking in strategies, but as a society there is not a push to get through the barriers that prevent real multi-disciplinary pain management,” says B. Eliot Cole, M.D., M.P.A., Administrator of the Pain Program Accreditation and National Pain Databank with the American Academy of Pain Management.
More and more practitioners are being trained in pain medicine, but access to care is an ongoing problem for patients with chronic pain. In a survey conducted by The American Pain Society, only 25 percent of patients with moderate to severe pain were evaluated by a specialist.
Most people with chronic pain receive treatment from their primary care physicians who, for the most part, are untrained in the field.
This is not necessarily the doctor’s fault. There is very little formal education on the topic of pain management. According to the American Medical Association, only four schools currently include end-of-life care in their curriculum. Furthermore, most residency training programs, with the exception of anesthesiology, do not require pain management rotations. Doctors learn to provide pain management in a very haphazard way. “There is a lot of practice variation because doctors are all trained differently. For example, anesthesia, surgery, neurology, primary care and psychiatry look at pain from very different perspectives,” says Dr. Cole.
While it is clear that pain is being undertreated in the U.S. health care system, experts are optimistic about the impact of new Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) pain management guidelines. As of January 1, 2001, the Joint Commission put in place new standards that create new expectations for the assessment and management of pain in accredited health care organizations.
As part of the new standards, JCAHO will require health care providers in hospitals, nursing homes, surgical centers, etc. to include pain as the “fifth vital sign.”
Under the new standards, patients will be asked about pain and the intensity of the pain. Doctors and nurses alike will be expected to treat the patients’ pain and continue to access treatment of the pain during and after hospitalization. According to June Dahl, Ph.D., professor of pharmacology at the University of Wisconsin Medical School, “These changes have the power to improve the quality of life for millions and millions of Americans.” She goes on to say, “This is a great victory for cancer patient in particular whose pain is often undertreated.”
While excited about the upcoming changes, some experts remain skeptical. Russell Portenoy, M.D., Chair of the Department of Pain Medicine and Palliative Care at Beth Israel Medical Center in New York City, says, “The JCAHO guidelines are going to help inpatient and hospital systems to treat pain. I am very optimistic that these guidelines will improve nursing home care and post-surgical pain management. However, the reality is that an overwhelming amount of pain management is done in the outpatient setting.”
Despite all of the aforementioned barriers, effective treatment for chronic pain has improved considerably in the last decade. Scientists continue to improve upon known treatments while searching for new ways to help people with chronic pain.
DRUG TREATMENT FOR CHRONIC PAIN
Medication is the most common choice of treatment for chronic pain in the United States. Drugs treat the symptoms rather than the cause of pain, and therefore offer a short-term solution. Side effects, drug interactions and overdose are potential concerns when using medication for pain management.
OPIATES: Opiates (also called narcotics) are drugs derived from the opium poppy and have been used since the days of ancient Rome. Opiates such as morphine effectively reduce pain by mimicking the body’s endorphins — natural painkillers produced in the brain.
Controversy surrounds the use of opiates in treating chronic pain for many reasons, one of which is the potential for misuse and addiction, strict federal regulations, and potentially dangerous side effects.
Recent data disputes tightly held beliefs about the addictive nature of narcotics in the general population. In his research David Jorenson, MSSW, Director of the Pain and Policy Studies Group at the University of Wisconsin Medical School in Madison, found the rate of narcotic abuse was unchanged despite a significant increase in the amount of opioids prescribed by doctors in the United States from 1990-1996.
Although beliefs about using opioids for pain management are changing, many pain experts feel that these drugs are underused and patients are suffering unnecessarily. As Russell Portenoy, M.D., points out, “There are a tremendous number of barriers to physicians prescribing and patients using narcotics such as fear of federal regulation and chemical dependency.”
B. Eliot Cole, M.D., M.P.A., says, “The biggest trend in medical management of chronic pain is the movement toward earlier introduction and use of opioid medications. There is new evidence that says opioids are not as dangerous as we thought.” Mike Royal, M.D., Medical Director of the Pain Evaluation and Treatment Center in Tulsa agrees and adds, “If people take medications for the treatment of pain, not for psychological reasons, the likelihood of addiction is very, very small. People should not be afraid of getting addicted if they are taking the appropriate drug.”
NON-STEROIDAL ANTI-INFLAMMATORY MEDICATIONS: NSAIDs like aspirin, ibuprofen and naproxen are used to treat a variety of conditions including muscle pain, tension headaches, and osteoarthritis. Injury causes a release of chemicals into the body (called prostaglandins) that make nerve fibers more irritable and can increase the experience of pain. NSAIDs interfere with the production of prostaglandins and reduce the feeling of pain. Side effects of long-term NSAID use include stomach, kidney and liver problems.
In 1999 the FDA approved two new NSAIDs that inhibit COX-2, an enzyme that plays an important role in pain and inflammation. Studies showed Celebrex and Vioxx are as effective as other NSAIDs in reducing pain, but do not cause gastrointestinal side effects like peptic ulcers.
STEROIDS: Steroids are hormones that reduce pain by blocking the synthesis of prostaglandins. Experts say they are the best anti-inflammatory medication, but many people cannot tolerate the associated side effects including decreased immune system function, osteoporosis and psychosis.
ANTIDEPRESSANTS: Antidepressants such as tricyclic antidepressants (TCA) and selective serotonin reuptake inhibitors (SSRIs) are effective in treating some types of chronic pain. These drugs increase the level of neurotransmitters (serotonin and norepinephrine) in the body, which cause the release of endorphins.
ANTICONVULSANTS: Anticonvulsants such as Neurontin and Tegretol are used to control seizures and can help treat severe muscle pain. They work by stopping the abnormal electrical discharges in damaged nerves that causes neuralgia, peripheral neuropathy and phantom limb pain.
MUSCLE RELAXANTS: Muscle relaxants help to calm muscle spasms by sedating the central nervous system. These drugs are especially useful for the short-term treatment of back and neck pain.
TRIPTANS: The FDA recently approved a new family of drugs called triptans for the treatment of migraine headaches. These drugs have revolutionized the treatment of migraine headaches by significantly reducing the associated pain and nausea.
NEW MEDICATIONS OFFER HOPE One new treatment found to help is the toxin known as BOTOX. It is a highly purified form of botulinum toxin type A that is approved for treating muscle spasms and for experimental use by dermatologists.
Mike Royal, M.D., J.D., Medical Director of the Pain Evaluation and Treatment Center in Tulsa, Oklahoma, is conducting innovative research using botox to treat patients with low back pain and myofascial pain. Botox prevents the release of acetylcholine at the neuromuscular junction, and stops muscle spasm, thereby reducing pain. Dr. Royal reports improvement in 70 percent of patients in his study group who received botox.
ZICONITIDE, a promising new drug for pain, is in the final process of clinical trials for FDA approval. This very potent drug is made from a toxin found in marine snail venom called conotoxin. Edgar Ross, M.D., Director of the Brigham and Women’s Hospital Pain Management Center in Boston, recently completed clinical trials testing the effectiveness of Ziconitide. He said that it is several thousand times more potent than morphine for pain, and appears to be safe when used long-term. In the trials Ziconitide, a protein, was injected into the patient’s spine in combination with morphine.
A poisonous frog from Ecuador has helped scientists to discover a pain medication 200 times as effective as morphine, but without the side effects. Stephen Arneric, Ph.D., leads the research group at Abbott Laboratories that created ABT-594, a non-toxic drug that is chemically similar to the frog poison. Clinical trials are underway to test the effectiveness and side effects of ABT-594, and initial results are positive.
According to Russell Portenoy, M.D., Chair or the Department of Pain Medicine and Palliative Care at Beth Israel Medical Center in New York City, there have been great advances in the delivery systems for drugs that treat pain. Extended release tablets, skin patches, and continuous release systems implanted in the arm are helping patients to manage their pain more effectively.
A research team led by Edgar Ross, M.D. at the Brigham and Women’s Hospital in Boston was recently involved in clinical trials on the drug PREGABALIN. The drug that reduces the pain and fatigue caused by fibromyalgia. While Dr. Ross says the results appear extremely promising, clinical trials have been temporarily put on hold due to some complications discovered in animal studies. A few of the mice from the early studies developed tumors which caused concern among the manufacturers of the drug and the FDA. Dr. Ross says the mice used in the study were a strain of mice at higher risk for tumors.
While most drug companies have stopped using this type of mouse for their studies because of this reason, they were still used during the pregabalin studies. Dr. Ross says he remains optimistic about the drug’s potential.
PAIN RELIEF WITH ANESTHESIA
NERVE BLOCKS can relieve pain by stopping the impulses that travel along nerves in the body. The physician injects a local anesthetic along the course of the nerve or nerves associated with the pain.
SPINAL INFUSION involves the delivery of low doses of medications like morphine through a catheter inserted in the spine.
SURGICAL TREATMENT OF CHRONIC PAIN
Most experts say that surgery is a treatment of last resort. For many patients surgery can magically cure their pain, but, the risks are high. Surgery can destroy other sensations in the body or become the source of new pain.
IMPLANTED DRUG DELIVERY SYSTEMS are used for patients with very resistant pain. These systems are expensive but offer a more convenient, portable and efficient way to take medications.
IMPLANTED DORSAL COLUMN STIMULATOR is a device that allows a patient to stimulate spinal nerves with mild doses of electricity, producing relief by short-circuiting pain impulses. This method is being used to treat pain caused by nerve damage and angina.
JOINT REPLACEMENT is the surgical replacement of a joint with a prosthesis. This procedure can be a successful treatment for rheumatoid arthritis and osteoarthritis.
SYMPATHETIC BLOCKS cut some of the sympathetic nerves, reducing pain for some patients.
ABLATIVE SURGERY cuts one or more sensory nerves and blocks sensation from the parts of the body affected by that nerve.
NON-INVASIVE CHRONIC PAIN TREATMENTS
PHYSICAL THERAPY helps patients with chronic pain to improve flexibility, strength, endurance and conditioning thereby reducing the disability caused by chronic pain. Techniques include postural correction for patients with back pain, hot and cold therapy, ultrasound and massage.
TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) uses mild electrical impulses delivered to the skin by hand held device. It is a popular method of relieving joint and muscle pain. TENS works by increasing endorphins and stimulating the nerve fibers, altering the balance of painful stimuli entering the spinal cord. It can be worn in a pocket and transmits an electrical impulse through electrodes taped to the body in the area of pain.
CHRONIC PAIN AND THE MIND/BODY CONNECTION
Pain, depression, anxiety, and insomnia are intimately connected. Patients have found that making behavioral changes to support a healthier lifestyle can dramatically reduce their pain and improve their mood. Changes in diet that result in weight loss can have a positive effect on back pain and arthritis. Exercise increases the level of natural painkillers produced in the brain (endorphins) and can help reduce anxiety, depression and weight as well as stress.
For many people, stress contributes to both physical and mental illness. It has been linked to migraine headaches, back pain, and peptic ulcers. Stress causes the muscles in the body to tense up and worsen the pain. Many people find pain management easier when they reduce or eliminate stress in their lives.
STRESS MANAGEMENT TECHNIQUES such as deep breathing, progressive muscle relaxation, autogenics, and imagery can be effective.
BIOFEEDBACK teaches patients to monitor the level of tension in the body. When used in conjunction with relaxation techniques, biofeedback can help people to manage chronic pain caused by muscle tension and spasm.
COGNITIVE BEHAVIORAL THERAPY
“Actually, all pain is in our heads, as the brain mediates pain signals. Even though pain is not just in our minds, we need to use our minds as part of the solution to this problem that is as old as human civilization.” -Anne-Marie Deutsch, Ph.D., psychologist.
For the past 20 years pain experts have incorporated the mind into the comprehensive treatment of pain. Success is greatly enhanced when the patient’s emotional and psychological response to pain is addressed.
Since pain is a perception, many psychologists believe that it can be modified using various psychological interventions. The goal of cognitive behavioral therapy (CBT) is to help people change irrational thinking, misperceptions and negative thoughts. According to Anne-Marie Deutsch, Ph.D., a psychotherapist specializing in the treatment of pain, “Cognitive behavioral therapy is quite effective in reducing the intensity of pain and in reducing ‘pain behavior,’ but it needs to be continued periodically as effects have not been found to be long term.”
Hypnosis is a technique in which an individual’s susceptibility to suggestion is increased. The role of hypnosis in treating chronic pain is uncertain. Some studies have shown that 15 percent to 20 percent of hypnotizable patients can manage their pain with hypnosis. Other studies report that hypnosis reduces anxiety and depression, and therefore helps to diminish pain.
ALTERNATIVE THERAPIES FOR CHRONIC PAIN
ACUPUNCTURE is an ancient method of pain and disease control discovered in China as early as 3000 B.C. This treatment involves the insertion of fine, disposable needles into tiny places on the skin called acupuncture points. The needles are sometimes twirled or accompanied by mild electrical currents or lasers.
Acupuncture is believed to regulate the flow of positive and negative energy along channels in the body called meridians. When the normal flow of energy is blocked, this Chinese theory says, physical and mental problems result until the balance is restored. Acupuncture is believed to work because it stimulates better circulation to the tissues, releases tension in the muscle surrounding the acupuncture point, and releases endorphins into the spine and brain. Acupuncture is used to treat:
MASSAGE is probably the oldest method of relieving muscle pain, swelling and stiffness. Massage relaxes tense muscles, and reduces pain by dilating the blood vessels and stimulating circulation. An increase in blood flow to muscles helps carry away the chemical by-products produced by inflammation, and thus soothes nerve endings. A study in Norway found that massage increases levels of endorphins by about 16 percent, and may help to increase serotonin as well.
MAGNET THERAPY is a billion dollar business based mostly on anecdotal evidence and very little scientific research. Advocates believe that magnets increase circulation and stimulate the body’s natural healing process. But, in an article published in the Washington Post, Robert Park, Ph.D., a physicist from the University of Maryland, found no plausible explanation for how magnets could relieve pain. Park says that magnet therapy is, for the most part harmless, but it is not recommended for people with pacemakers or metal implants.
On his Web site, Andrew Weil, M.D., a best-selling author and advocate for complementary medicine discusses several alternative treatments for chronic pain.
Weil recommends the use of ginger as [a natural promoter of a healthy inflammatory response], and Arnica Montana as good homeopathic remedy. Yoga, he says, can help to manage chronic pain because it reduces stress, strengthens the back muscles, and promotes flexibility.
In the past, chronic pain has been undertreated and poorly managed in the United States. Over the last 10 years, significant improvements in the treatment of chronic pain have brought this issue into the forefront of American health care. Experts feel that real change will not happen until patients demand better care for their chronic pain. In addition, optimal pain care cannot be delivered until financial concerns of patients in a managed care system are addressed.