Chronic pain can be a difficult medical problem for both doctors and patients. Often, there is no one diagnosis that can account for the pain, and the treatment is often complicated, long term, and sometimes unsatisfactory. This page will deal with chronic non-cancer pain, and is broken into sections detailing:
Chronic pain is defined as pain that is present for more than three months, or for four weeks longer than would be expected as part of a normal recovery. The management of chronic pain can be difficult for both patients and doctors because it is often difficult to find an exact cause that can be treated leading to frustration from both groups.
While you may think that all pain is the same, the anatomy and physiology of pain is actually very complex and there are two major groups of pain that feel quite different. The pain we are most familiar with is called 'nociceptive' or 'somatic' pain, and is due to activation of pain receptors due to real or perceived injury. This is usually quite localised, constant or worse with movement, and of an aching or throbbing quality.
The other type of pain is called 'neuropathic' pain and is due to damage to the nerves that sense pain, or even the part of the brain that deals with pain. It often follows an injury, but not always, and feels different to somatic pain. Neuropathic pain typically occurs in certain patterns and is often described as being a 'burning' pain, or even like electric shocks are being sent to the area. This can be accompanied by changes in the sensation of the area supplied by the nerve.
Before a doctor can treat someone for chronic pain, it is important that they ask a few questions so that they can work out the best course of treatment. Some of the things they may try to find out are:
That pain is the primary problemWhat 'type' of pain is it, how bad is it, and what are the symptoms of the pain?What is causing the pain?How is the pain impacting your life?Is there anything else that is making the pain worse?After this assessment has been made, then the doctor might set some 'goals' for your treatment, that you should feel are significant but achievable. These will depend on just how bad your pain is. For example, in some cases being able to sleep through the night or walk to the shops may be the 'goals' as these will greatly improve the quality of life of the person with chronic pain. Your GP may also decide to send you to another health professional to help out with your treatment and there are numerous different people who can help with the care of someone with chronic pain. Rheumatologists (joint doctors), physiotherapists, occupational therapists and specialised pain doctors can sometimes be a great help in dealing with chronic pain.
Once a full assessment has been made, then the first step is to try and make some changes to your lifestyle that are easy to do, will also improve other aspects of your health, and can greatly reduce pain:
Weight Reduction: Reducing weight can greatly reduce the pressures exerted on joints, and thus lessen the pain that is associated with movement.Exercise: an exercise program should be included in the treatment plan of all people suffering from chronic pain. Obviously, the plan must be individualised taking into account what each individual is capable of.Cognitive-Behavioural Therapy: CBT can be a great asset in the treatment of chronic pain, improving their feeling of well-being, reducing pain scores and allowing for an improved quality of life.Mindfulness and other relaxation therapies can also be of some benefit, helping to focus patient's minds on things other than their pain and thus allowing an improved quality of life.Paracetamol: Paracetamol is a good first choice in the treatment of chronic pain, as it is very safe and also very effective for the relief of mild to moderate pain.Non-steroidal anti-Inflammatory agents: NSAIDs can be highly effective in the treatment of chronic pain, especially if there is an inflammatory character. While there is a risk of adverse effects when used for a long period of time, most notably bleeding from a stomach ulcer, this can be reduced with the use of other 'selective' NSAIDs (e.g. Celebrex) that cause less of this problem.Opiods: If the chronic pain persists, or is increasing, then in addition to the non-opioid agents, an opioid regimen with a medication such as codeine, oxycodone or tramadol should be started. If these agents are also ineffective at relieving the chronic pain and it is of a moderate to severe severity, then agents such as systemic morphine, hydromorphone, fentanyl (e.g. Durogesic) or methadone can be used.Tricyclic antidepressants: TCAs such as amitryptyline (Endep) have been shown to be useful in treating neuropathic chronic pain. While people are unsure as to how they actually work, it does more than just improve depression as the pain relief requires a much lower dose, and starts long before it helps with depression. They are also sometimes used to increase the effectiveness of opioid agents like those described above. Anticonvulsants and antiarrhythmics: these are usually used for conditions like epilepsy, but have also been shown to reduce neuropathic pain. Pregabalin (Lyrica), gabapentin and carbamazepine are all used for their membrane stabilizing properties and have been shown to be effective in neuropathic pain. Gabapentin is less likely to be effective when there is no objective finding of nerve injury. Lignocaine Patches: Lignocaine 5% patches have been shown to be effective in the treatment of neuropathic pain, presumably due to their membrane stabilising actions.Beyond the medications mentioned above, there are also more invasive options available for those suffering from chronic pain:
Corticosteroid Injections: given into the site of the pain, especially joints, can be very useful, and give rapid and reasonably long-term relief for those suffering chronic pain.Nerve Blocks: this involves the injection of an anaesthetic agent directly into the site of the pain, into the nerve supplying the painful area, or centrally into the spinal cord. Catheters can be inserted into the epidural or subarachnoid spaces, providing excellent pain relief.Neurostimulation: This involves the placement of electrodes around areas of the nervous system that are responsible for the painful stimulus. These electrodes can be placed in the spinal cord, on a peripheral nerve, or even into the brain.Spinal Cord Stimulation: Like neurostimulation, this involves the strategic placement of electrodes into the spinal cord, which artificially stimulate the nerves to the painful area. This usually involves the placement of a spinal cord stimulation device which come in various forms.Brunton, S. Approach to assessment and diagnosis of chronic pain. The Journal of Family Practice, 2004; 53(10 supp): S3-S10.Colvin L, Forbes K, Fallon M. Difficult Pain. BMJ, 2006; 332:1081-1083Fields H, Martin J. Pain: Pathophysiology and Management. Harrison's Principles of Internal Medicine. McGraw-Hill, London, 2007.McCarberg, B. Contemporary management of chronic pain disorders. The Journal of Family Practice, 2004; 53(10 supp): pS11-S22.Murtagh, J. General Practice (Third Edition). McGraw-Hill, Sydney, 2005.
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