Why do people have so much trouble getting treated for their chronic pain? It's this simple: "We don't have a lab test, an X-ray, or any other test that tells us how bad pain is. We have to believe the patient," says Peter Staats, M.D., director and chief of the Division of Pain Medicine at Johns Hopkins University.
For people who suffer from fibromyalgia, myofascial pain syndrome, migraines, neuropathic pain, reflex-sympathetic dystrophy syndrome and a myriad other conditions, there simply is no way to positively prove the pain is real.
It's not only rare or terminal conditions that are painful and disabling, says Dr. Staats. A full 50 percent of the people visiting his Hopkins clinic suffer from "simple" low-back pain. Even such a common condition can destroy lives, he says. One patient of his used to play professional baseball but because of chronic low-back pain, he hasn't been able to play in years.
For Dr. Staats, proper pain relief comes from an understanding of the duality of pain. "Pain has been defined as an unpleasant sensory and emotional experience, associated with actual or potential tissue damage," he says. In other words, pain affects attitude, and attitude affects pain.
For example, pleasant thoughts can actually cut the pain experience in half. To demonstrate this principle, Dr. Staats and colleagues had college students immerse their hands for as long as possible in a tub of ice-cold water. Think that's not painful? Try it. Half the group was instructed to say positive words to themselves, and they were able to hold their hands in the water for twice as long.
Clearly, your emotions can have profound effects on your perception of pain. "If a physician says, 'I believe you,' it elicits a positive response. If he says, 'You're a faker,' this elicits a negative response and it only makes the pain worse." Simply having a physician's support can be a powerful pain reliever, Dr. Staats says.
The Seven Basic Tools Of Pain Management
Today's pain management specialists have numerous therapies at their disposal. Here are the seven therapies Dr. Staats considers most effective. They are used alone or together and should be used in combination with rehabilitation.
Anti-inflammatory drugs: These include such nonsteroidal anti-inflammatory drugs, or NSAIDs, as ibuprofen. Inflammation plays a major role. But NSAIDs can have serious side effects such as stomach upset, ulcers or liver damage. The newest class of anti-inflammatory pain relievers, the COX-2 inhibitors, are hitting the market and should offer an improved side effect profile for people with arthritis.
Antidepressants: Before the introduction of such antidepressants as Prozac, Paxil and Zoloft, collectively called selective serotonin reuptake inhibitors (SSRIs), there were tricyclic antidepressants, or TCAs. TCAs increase the body's own inhibitory (anti-pain) mechanisms to modulate pain. For unknown reasons, having nothing to do with their depression-lifting properties, tricyclics can be highly effective against headaches and neuropathic pain. Meanwhile, the SSRIs can be useful against the depression that accompanies pain.
Anticonvulsants: The anticonvulsants were developed to treat seizures. However, in some abnormal pain conditions, the nerve fibers become hypersensitive and start producing what amounts to mini-seizures, sending waves of pain racing to the brain. Anticonvulsants, especially the latest addition to this class, gabapentin, slow down nerve impulses.
Opiates: There is a huge stigma attached to the use of morphine and its derivatives on the part of both the public and physicians. This aversion is unfortunate because obiates are the only drugs that provide effective relief for many patients with pain. Studies have repeatedly shown that when prescription opiates are used under careful supervision, the risk of addiction for a patient with chronic pain is quite low, around 1 percent. Keeping the risk of addiction low requires careful evaluation of a patient before and after starting opiates. When used correctly, opiates should liberate, not stupefy, the patient. If the use of opiates increases a patient's mobility, mood and motivation to return to activities he or she had abandoned because of the pain, then the drugs should be continued. To avoid spikes in blood levels of opiates, Dr. Staats provides patients with time-release formulations, which decrease the chances of a patient becoming overly sedated or high. If a primary care physician is inexperienced or uncomfortable with prescribing opiates for long-term use in chronic pain, a pain specialist should be consulted, says Dr. Staats.
Behavioral Therapies: Because the mind-pain connection is so strong, Dr. Staats advocates psychological counseling as an important component of the pain management package. In particular, cognitive-behavioral therapy can help patients develop healthier and more productive thought patterns, emotions, and actions. Relaxation methods, including biofeedback, decrease anxiety and foster a more pain-free existence.
Nerve Block: Injections of local anesthetics into specific nerve bundles can suppress pain. The relief is usually temporary, but even the momentary respite helps patients to get actively involved in physical therapy and regain mobility.
Implantable Devices: When all else fails, pain specialists may resort to implanted devices. One type delivers a low-voltage electrical current to the spinal cord, which suppresses pain impulses. Patients also report great satisfaction with the implantable pump, which delivers a tiny dose of an opiate or other painkiller directly to the spinal cord where pain is processed.
Finding The Right Pain Specialist:
Many primary care doctors are either unwilling or unable to adequately manage patients with serious pain. Here are the steps Dr. Staats recommends to ensure that your pain is brought under control:
1. Talk to your primary care doctor about your pain. Give him or her a diary of how you suffer, when the pain is worse and what makes it worse. Provide objective numbers - 0 is pain-free, and 10 is the worst pain.
2. Make sure your doctor knows exactly where you hurt. The pain may be associated with another serious disease.
3. If despite your efforts your primary care doctor can't get your pain under control, ask for a referral to a pain specialist who is board certified by the American Academy of Pain Medicine or by the American Board of Anesthesiology, with a subspecialty in chronic-pain management. Last updated February 01, 2000
( This article is no longer available at the website, where I found it.)