Conditions and Diseases: Chronic Pain

Conditions > Conditions and Diseases: Chronic Pain

One of the conditions and diseases that many North Americans suffer from is chronic pain. There are many things that can be the cause of chronic pain. Many of the conditions and diseases that also affect aging may have some affect on the joints and bones of the body and cause chronic pain for one reason or another. Other causes of chronic pain, beyond conditions and diseases, is nerve damage that is the result of an injury that doesn’t heal. Chronic pain can be caused by one or more of the following conditions:

Obesity
Curvature of the spine, which is a congenital condition
Any traumatic injury to the body
Poor physical condition
Sleeping on a poor bed

There are other conditions and diseases that can be the cause of chronic pain. Two of these diseases are osteoarthritis and Rheumatoid arthritis. Other conditions that can affect chronic pain include stomach ulcers, AIDS, multiple sclerosis, cancer, or gallbladder disease. Basically it is hard to determine what conditions and diseases are the causes of chronic pain. Following are some of the treatments of chronic pain that have proven to be helpful:

The use of drug therapy using both prescription and nonprescription drugs. This method of treating the conditions and diseases of chronic pain is sometimes only helpful for a short period of time.Specific drugs such as soma are targetting specific muscle injuries by relaxing the affected muscles They should not be used for general aches and pains.
Trigger point injections. The treatment is used to target specific areas of pain, such as the muscles.
The use of surgical implants. This treatment of the conditions and diseases of chronic pain is attempted when other methods of drug and physical therapy has failed.
Physical therapy. This method of treating chronic pain is proven quite effective if the patient is consistent with the therapy. Keep in mind that physical therapy will only relieve some of the pain associated with chronic pain and is not a cure.
Mind-body therapies, acupuncture, therapeutic touch. All three of these methods of dealing with the conditions and diseases of chronic pain are less heard of than more conventional treatment, however, there have been some great results in controlling pain.

Prescribing Opiates: Are Physicians Right To Worry?

By Garry Moore, MD

This article is not intended to explore all the issues surrounding chronic pain; my only goal is to convince the readers that it’s okay to be an“opiophobe”.

I’m not talking about the elderly patient or one seriously limited by conditions such as poly-arthritis, malignancy or fatally debilitating disease. I’m talking about the patient who is balanced in life with its vicissitudes but has some bio-psycho-social event that tips them out of balance, and they decompensate. The decompensation is most obviously demonstrated by the symptom of pain. Not a lot of signs, (except perhaps pressure at a few scattered points might cause pain, if you consider that a sign) just pain, not evidence of any particular loss of function, just pain.

If that patient sees the typical primary care doctor we will look for a physical condition that needs to be‘fixed.’ We won’t find anything, then after a few weeks of frustration we refer them to a pain medicine doctor.

By definition, the pain medicine doctor wants to relieve pain. Among their ranks are some truly wonderful people. Mother Theresa, Albert Schweitzer and your local board certified anesthesiologist turned pain management specialist, they could be a team working seamlessly together.

With my obvious sarcasm, I don’t mean to disparage pain management, but is chronic pain really an opioid deficit? There is no other rational explanation for the long term use of narcotic pain relievers. We all know it is a one way street for the vast, vast majority of patients who get on long acting, high-potency opiates.

So what, getting on Synthroid, insulin, lisinopril or Zocor is a one way street too, right?

Isn’t chronic pain fundamentally different than hypothyroidism or hyperlipidemia? Is it likely that a patient coping with life, has an event that causes minimal tissue damage but depletes their body of endorphins so profoundly that for the rest of their life they have to have opioid supplements?

I don’t think so. I think it’s more likely the “event” has become an excuse for the patient. The symptom they present with is relatively easy and gratifying to treat (perhaps only the dermatologist has a more grateful patient population, at least for the first few months) and the opiophiles say it’s safe. Alternatives are extremely time consuming, difficult to code for, (patients have a blind trust in a prescription but have to be convinced to try something non-pharmacologic) so why not?

We remember the best part of being a doctor is to relieve suffering, and opiates have got to be one of Gods greatest gifts to humanity for that purpose, but there is that other part of medicine— do no harm.

If narcotics just fill a physiologic need, why aren’t the patients better when given the opiates? Better of course becomes hard to define since there wasn’t a lot of obvious concrete deficits to begin with, we only have two things to measure: Where did it go on the pain scale? (From a 9/10 to a 5/10 would be considered a success). The second is function. My practice is limited to workers’ comp, but from what I see narcotics never improve function!

From my experience in San Antonio, if a patient is referred to a pain management specialist their chance of returning to the same level of functioning as they enjoyed before their work related event is almost zero.

Of course there are a lot of selection bias issues to discuss, but the question why aren’t patients better, i.e. more functional, after treatment with opiates is still valid. One of the conclusions of a large Danish study of pain stated,“However, it is remarkable that opioid treatment in long term/non-cancer pain does not seem to fulfill any of the key outcome opioid treatment goals: pain relief, improved quality of life or improved functional capacity.”

One reason the narcotic treated patient is not much more functional is that the drugs are CNS depressants. Some enterprising pain doctors then treat the dull lethargy associated with opiates with amphetamines! Honest they do, or they might use Ritalin or Provigil, but does that make sense?

Opiates relieve suffering, maybe they don’t improve function, but are they doing any harm? In the general population 10 to 12 percent have true addictive disorders. In the chronic pain population it is at least that high. Does it seem okay to prescribe drugs where you know 10 percent of the patients will have a true addiction and be struggling against a drug stronger than they are for the rest of their lives?

To put it in perspective, the FDA considered the .005 percent of patients taking Rezulin who suffered liver damage to be unacceptable, so that drug was removed. More recently .1 percent of Zelnorm users have had cardiovascular side effects. That was considered too high a risk, so now Zelnorm is gone. Yet the opiates are okay with at least a 10 percent serious addiction problem? (I suspect we all accept the risk and want these strong opiates available because we fear that some day we too will be in serious pain.)

I had a family member taking OxyContin 40 mg three times a day for her neuropathic pain. It and other drugs literally stole four years from her; eventually she suffered painful withdrawals and then got on with her life coping with her pain without narcotics. She was definitely worse off than she was before the narcotics.

As a National Guardsman, I was involved in the aftermath of both Katrina and Rita. I witnessed many sad cases of evacuees wandering about desperately looking to satisfy their iatrogenic narcotic addiction.

The mortality associated with these narcotics is difficult to quantify but consider, in 2002 there were more deaths in the U.S. due to prescription opiates than to cocaine and heroin combined.

The drugs were prescribed to mostly peri- and post-menopausal women, but the deaths were in younger men. So, what violence must the women have suffered for the drugs to go from them to the men? Imagine if the ladies had also been prescribed amphetamines to counteract the narcotics.

There are many cases in history where mainstream medicine tried to relieve suffering but ended up making it worse. I see it all the time on a smaller scale with excessive use of slings and braces. Another common one is steroids in multiple sclerosis.

In the old days, everything was treated with bed rest, and we now know how counterproductive that can be. I suspect some chronic pain starts with all the other neuroactive drugs we use, from SSRIs to benzodiazepines, before the event occurs. Imagine after a neuron has been damaged by some event and it can not remodel and regulate its receptors normally because there are outside pharmacologic influences, so chronic neuropathic pain ensues. If we leave neurons alone they will repair and remodel for us just as they did in our grandparents’ time.

Is it just a coincidence that chronic pain sufferers are three times more likely to be smokers?

I think there is a lot we do not know about this kind of chronic pain. I strongly suggest the caring provider consider non-narcotic treatments, from acupuncture, to talk therapy to tai chi. That is the best way to do no harm, and it has a better chance of actually helping a patient enjoy life.

Palliative Care: Easing the pain of chronic disease

by Dennis S. Pacl, MD

In my hospital-based practice of Palliative Medicine I am often explaining my specialty to patients, families and even colleagues. It doesn’t fit nicely into an organ system. I can’t say I am a heart specialist or kidney specialist. A pulmonary doc once explained to me that they always try to “stay in my organ.” While to me it sounded a bit odd to hear, I can understand the respect conveyed for the expertise of other specialists who may be involved with a patient’s care.

After giving that statement a lot of thought, the best approximation that I could come up with for my specialty is that the organ of focus for Palliative Medicine is the soul. Easing the pain requires an understanding of the personal experience of chronic disease for that individual with the diagnosis and the families who care for them.

Board certification in Palliative Medicine requires expertise in the management of pain and non-pain symptoms (i.e. nausea, dyspnea, constipation, etc.). Excellent communication skills and extensive experience with collegial interdisciplinary care coordination are paramount for effective relief of suffering.

An important principle in easing the burden of advancing illness is the concept of “total pain,” which is a model that views the overall burden of illness in four major domains. The domains include the physical effects of illness, pain and other symptoms. Secondly, the diagnosis of a life-limiting illness usually results in suffering within the social domain. One may feel marginalized, no longer be able to hold down a full time job or maintain active relationships with friends and colleagues.

The feeling is one of no longer being relevant. Chronic illness will also create a strain on our families and loved ones due to changing roles or a variety of other factors, which leads to conflict or distress in the interpersonal domain. A fatal illness in a child carries with it an exceedingly high divorce rate, for example. Last, but certainly not the least, is the effect of disabling disease and life-limiting illness in the spiritual domain. Not just questioning one’s faith in God (Why me Lord?), but more importantly it leads to questions about purpose and meaning in life…existential questions.

By recognizing the experience of the disease for your patient, it is possible to heal relationships, help patients identify true purpose and meaning in their lives and ease the burden of advancing illness. Intractable symptoms may no longer be so intractable. I often tell patients and families that treating pain and physical symptoms is really the easy part. Improving the experience for all who are affected by a loved one with serious illness and disabling disease is quite a bit harder, for it takes a lot of time and effort to understand the patient experience. But when done well, I can’t imagine a more gratifying clinical outcome.