The Complex Problem of Pain

Introduction

Pain is conceptualized to be a response to an injury or a marker of illness. It can be a complex problem because it embraces physical, emotional and social components. While pain is a mechanism in which the body tells us that something is wrong, it can often be a useful way to measure healing.

This is both a challenging and exciting time to be working in the field of pain management. Through research, clinical study and patient experiences, a wealth of information has emerged which has helped us understand the pain process, how it progresses and what treatments might work best to relieve it. Yet, for many people, pain is a persistent, daily challenge to cope with. We strive to provide insight and

In this presentation, we will:

• Review some terminology related to pain. It’s important that when one clinician talks to another we share a similar language – this helps us to communicate about pain.
• Discuss the clinical differences between acute and chronic pain.
• Outline some treatment options.
• Mention some of the scientific advances in the field of pain management.

What is Pain?

It is now a widely accepted principal that pain is best understood as having both a physical and an emotional component. Dr. Harold Merskey, a professor of psychiatry, defines pain as “…an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”[1]

This is a very scientific and technical way to talk about pain, because it focuses on tissue injury. That is easy to understand.

Margo McCaffery, a highly recognized nurse and pioneer pain educator, defined pain as “…whatever the experiencing person says it is, existing whenever he/she says it does.”[2]
In other words, pain is personal. You, the person experiencing it, define it and translate it. A report from the patient is the single most reliable indicator of pain.[3]  So, tell your healthcare provider how you are feeling.

Basic Pain Terms

Nociceptive – pain that results from acute tissue injury. It is divided into two classifications: somatic and visceral. Somatic pain is best understood as pain of the musculoskeletal system and is described as pounding, throbbing, and well localized – affecting an isolated area. An example is a cut or a sprain. Visceral pain originates in an organ. It is not localized and can be experienced somewhere other than the source, being diffuse in presentation. An example is pain from a kidney stone.

Neuropathic – nerve injury or dysfunction affecting the central or peripheral parts of the nervous system involved in bodily feeling (the somatosensory system). It is often described as a burning, stabbing, tingling, electrical, or pins-and-needles type of feeling. It is most frequently used when describing a chronic pain condition.

Breakthrough – episodic pain. It’s an acute, sudden break in relief from pain medication, which spikes and then returns to “normal”. The term came from cancer pain literature, going from a “steady state” (when medicated) and then having a spike.

Referred – pain felt at a site other than where injury occurs; e.g., pain from the pancreas that can be felt in the back.

Psychogenic – associated with psychological factors. There isn’t a definable source, but there are multiple causes. An example is a headache, which could come from not having coffee, as well as stress, low magnesium level, etc. It’s not rooted in one physical problem.

Classifications of Pain

Acute Pain is limited in duration. This type of pain has a defined time period in which it occurs, and its presentation matches the pathology (that is, it has an identifiable cause).

Chronic Pain is now known as “persistent or complex pain.” This refers to pain that lasts longer than six months or beyond the timeframe of expected resolution. The pain may not match the pathology (for example, when the back is causing the problem when a patient presents with a knee problem). It might be intermittent – persistent but not constant, coming and going (such as migraine headaches). It is associated with other symptoms.

Treating Pain

There are a variety of ways to treat pain, depending upon the symptoms. The following are some general treatment strategies.

Acute pain should be treated with a multimodal approach. This includes the use of both pharmacologic and non-pharmacologic methods to relieve pain. Listed below are some options typically used to treat acute pain. Using nonsteroidal anti-inflammatory drugs (NSAIDS) and acetaminophen as first-line agents is now recommended. Opioids can be added to the plan using the lowest effective dose. Other medications like antidepressants and anticonvulsants are sometimes added to enhance the analgesic plan.

Remember – no drug is completely harmless! Check with your prescriber before taking any new medication.

Pharmacologic Treatments

• Acetaminophen (Tylenol): for some people, this is a wonder drug. However, it can be a problem to use regularly if taken in large amounts. The current recommended dose for an adult should not exceed 4g per day (4000mg per day). For elderly patients and those with liver disease, the maximum recommended dose will likely be lower than 3000mg per day (American Geriatric Society guidelines)
  
  Many medications combine acetaminophen with an opioid, like Percocet (which combines oxycodone with acetaminophen). The most frequent dose of this medication contains 325mg of acetaminophen. So, if you are taking an opioid like Percocet (5/325, 5mg oxycodone with 325mg acetaminophen), pay attention to the total amount that you take in a day (six tablets will equal 3900mg of acetaminophen – which is now considered a high dose). If you are taking extra strength Tylenol that contains 500mg of acetaminophen, it is recommended that you do not take more than six tablets per day. Acetaminophen is found in many over the counter products like cold and sleep medications. If you are taking acetaminophen regularly, for pain, fever, cold-like symptoms or sleep, the lower limit is considered safer.
   
• Nonsteroidal anti-inflammatory drugs (NSAIDS) include COX-2 selective drugs, such as celecoxib (Celebrex). When you have an injury, the way your body responds is to inflame the surrounding tissue to stimulate the healing process. These drugs attack that inflammation and diminish its effects while still allowing the process to continue. NSAIDs can be over-the-counter – for example, naproxen (Aleve) and ibuprofen (Advil, Motrin) – or be given in prescription strengths. Side effects, especially in older populations, include stomach irritation, ulcerations and bleeding. It is recommended that you can take a medication like famotidine (Pepcid) or ompeprazole (Prilosec) to coat your stomach lining while taking NSAIDs. Consult your prescriber before using any NSAIDs. In addition to the gastrointestinal side effects, the use of use of NSAIDs has been associated with cardiovascular risks as well. Consult with your prescriber before using any NSAIDs to avoid potential harm.
  
  NSAIDs work well for acute pain. Besides pill form, they also come in patches, creams, or gels. Note that if you use the cream, don’t combine it with the pills – it’s the same effect but cream works more slowly. The only difference is the routing administration.
   
• Opioids – Medications like oxycodone, oxycodone/paracetamol (Percocet), hydrocodone/acetaminophen (Vicodin), hydrocodone/paracetamol (Norco), and tramadol are short-acting medications often prescribed for the treatment of acute pain. Once you take them, they begin to work in about 30 to 45 minutes and the analgesic effect usually lasts about 3 to 4 hours. Long-acting opioids, like controlled-release oxycodone (OxyContin), are not recommended to treat acute pain. Regular, consistent use of opioid medications has been associated with developing dependency on them. In the acute pain phase, they can be helpful in reducing pain but the potential for harm with long term use is real.
  
  If you have had surgery, keep in mind that as you recover, your need for opioids should decrease.
  
  Opioids can also be associated with side effects like constipation, even with limited use. If you are taking opioids for pain, ask your prescriber about how to best treat constipation. They might recommend drinking a lot of fluid, eating fruits and vegetables, or starting a bowel regime. Avoid bulk formers such as psyllium (Metamucil), as this can make your constipation worse.
   
• Anticonvulsants & Antidepressants. Medications in this classification can be helpful additions to a pain regime. They can help reduce anxiety and depression that can occur because of a pain condition. Many of these medications also seem to help reduce the intensity of pain, particularly nerve pain. Examples of these medications are duloxetine (Cymbalta), an antidepressant, pregabalin (Lyrica) and gabapentin, an anticonvulsant.
   
• Corticosteroids are given via intra-articular injections (for example, cortisone) or orally (for example, prednisone).
   
• Disease-modifying anti-rheumatic drugs (DMARDs), for example, cyclophosphamide (Cytoxan), were developed for rheumatoid arthritis.
   
• Nutraceuticals – A food or part of a food that allegedly provides medicinal or health benefits, including the prevention and treatment of disease. A nutraceutical may be a naturally nutrient-rich or medicinally active food, such as garlic or soybeans, or it may be a specific component of a food, such as the omega-3 fish oil that can be derived from salmon and other cold-water fish.[4] These agents are commonly used today although their risk/benefits as a classification of pharmacologic treatment remains unclear.

Benefits and Risks of these Medications

• Opioids
  • Benefits: Opioids do relieve acute pain. These medications come in many formulations, including injections, sprays, pills, patches, liquids and suppositories. Opioids should be used to relieve moderate to severe pain. They are not considered a first-line agent for mild pain. They help reduce the degree of pain intensity and therefore allow for movement and function. They don’t eradicate the underlying problem, but they do allow you to gain some control over your pain.
     
  • Risks: Oversedation and dependency are two significant risks of opioid therapy. Using these medications as directed is essential to help avoid substance dependence. The use of alcohol as well as benzodiazepines – for example alprazolam (Xanax), diazepam (Valium) – in conjunction with these mediations is dangerous and should be avoided.
    
    A major side effect of opioids is constipation. You will need to take something (for example a stool softener), particularly as you get older. Other effects include sedation, nausea (your doctor will often give something prophylactically to settle your stomach); slowed thinking (making you less sharp); and increased tolerance to the medication. Note that tolerance does not mean that you will become addicted; addiction hinges on craving, while tolerance does not. Be sure to tell your doctor what you’re taking and how often you are taking it so your dosage can be adjusted accordingly.
     
• NSAIDs
  • Benefits: Nonsteroidal anti-inflammatory drugs relieve pain and inflammation, but they will not help you heal.
     
  • Risks: They do not affect the course of the disease. They can cause gastrointestinal distress, ulcers and bleeding.
     
• Pharmacology
  • Corticosteroids risk: Long-term use can reduce your body’s ability to use calcium to build bones, which could promote osteoporosis.
  • DMARDS risk: These work slowly and can suppress the immune system.
  • Nutraceuticals risks: Always tell your doctor if you are intending to use these (including rose hips, fish oil, etc.), as they are not regulated and can interact negatively with other medications.

General medication tips:

• If your medication has no apparent effect, talk to your health care provider.
• If you are having side effects from the medication, talk to your health care provider.
• Consider the schedule – you may need to take it at night instead of noon, etc.
• Consult with your health care provider before stopping your medications.
• Ask your provider about how to safely taper and come off the medications if you have been taking them regularly
• Keep your medications is a safe place, clearly marked – in their original containers.
• Remember the medication ordered is for you. Don’t share it with another person.
• Dispose of all unused opioid medication properly. Unused medications are best disposed of at a take back facility or pharmacy.

Nonpharmacologic options

Your body is like a walking pharmacy. You have chemical agents in your body that, when stimulated with activity, produce a healing effect. Options include, but are not limited to, meditation, supportive therapy, acupuncture, exercise (which releases endorphins in the body), and TENS (transcutaneous electrical nerve stimulation). TENS uses a portable device which sends electrical signals to the nerve fibers leading to the brain, which then releases natural pain-relieving substances.

Also, assistive devices increase safety, decrease stress on joints, compensate for unstable or weak joints, and increase independence. These help you by taking stress off the body.

Options for Acute Pain Relief

The main objective when relieving severe pain is the use of multimodal analgesia, which refers to a combination of solutions for pain relief; these include pharmacological and nonpharmacological sources.

• Use thermal therapy – applying hot and cold compresses. If you’re running and your joints are hurting, use ice. If you have arthritic pain and bones are hurting, consider using heat.
• Rest – this is a healing activity. Fatigue can enhance the feeling of discomfort and be demoralizing. Take rest periods as needed to restore energy.
• Nutrition – what you eat and absorb can impact on your immune system and overall well-being. Consider a nutrition evaluation to facilitate healing and recovery.
• Nerve blocks, performed by anesthesiologists, can numb the affected area by applying anesthetics.
• Physical therapy – movement increases strength and confidence
• Assisted devices
• Stay connected! Engaging in as many of your normal activities as you can, talk to people

Recent Developments in Understanding Chronic Pain

• Biological studies have given us insights into the neurotransmitter system (chemical messengers that pass nerve signals). Old theories about how pain signals travel through the body are being modified. Recent findings have shown that the pain pathways are more complicated and are effected by many different types of stimulation.
• Neurobiologic studies through MRI imaging are looking into pain and emotion. They have been able to visually identify pain in the brain and emotional responses to pain. So, when someone says the pain is in your head – well, it literally is. Epigenetics – gene therapy is providing insights into the how genetic impact pain
• Psychosocial research shows that your feelings about your pain are more important in many ways than what caused the pain. How you respond is important. Self-determination, realistic expectations and goal setting are major components in coping with pain.
• Chronic pain research has shown numerous things:
  • Smokers tend to be more sensitive to painful stimuli.
  • Smokers are more prone to depression.
  • Individuals exposed to nicotine are at increased risk to develop back pain and other pain related problems.[5]
  • Behavior impacts on pain.

What does this all mean?

Today we have a much better appreciation of the mind-body connection and how it effects pain. They work together to help us respond and cope with pain.

As we learn more, we work with patients to offer insight into painful conditions and how to deal with them. With greater utilization of both pharmacology and nonpharmacologic treatment, there are more pain management therapy options for patients than ever before.

So, the best things you can do to improve your own ability to understand and manage pain is to stay connected, stay educated, and ask questions. We will do our best to help find the answers.

At of the time this article is being updated (see below), Barbara Wukovits has 31 years of working in the Anesthesia Department at HSS, and 28 years working in pain management.

 

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References

1. Merskey, H. (1979). Pain terms: a list with definitions and notes on usage. Pain 6:249-252.

2. McCaffery M. (1968). Nursing practice theories related to cognition, bodily pain, and man-environment interactions. Los Angeles: UCLA Students Store.

3. Acute Pain Management Guideline Panel: Acute pain management:operative or medical procedures and trauma. Clinical practice guidelines. AHCPR Pub No 92-0032, Rockville MD, Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, Feb 1992.

4. Definition of Nutraceutical – Medicine net.com April 27, 2011

5. Warner, David O. (2010). Smoking and Pain: Pathophysiology and Clinical Implications. Anesthesiology. 113(4):977-992.

Summary by Steve Rudolf, SLE Workshop Intern

Authors