The Illness of Chronic Pain

By Nancy Wurtzel

A sprained ankle can be a real pain.  But injuries like sprains, bone fractures, pulled muscles, cuts, and even minor burns are everyday pain and a normal part of life.  While the pain may be acute, it’s not lasting, and the discomfort eventually subsides and resolves over time.

On the other hand, if pain lingers for more than three months without lessening, it is considered neuropathic or chronic — pain that won’t go away on its own.

Unlike acute pain, which is the body’s way of communicating that something is wrong, this chronic pain isn’t a benefit.  Instead, it’s a signal that something has gone amiss in the body, causing pain signals to get crossed or misinterpreted.  The federal Centers for Disease Control and Prevention (CDC) estimates 11% of adults in the U.S. experience daily pain.

Some conditions and diseases that cause neuropathic or chronic pain include fibromyalgia, osteoarthritis, multiple sclerosis, migraine, diabetic neuropathy, shingles, and specific types of back pain, such as spinal nerve injury or nerve root compression.

Those who live with chronic pain often describe their condition as omnipresent.  However, some chronic pain will come and go, with no trigger or warning.  Either way, the effect can be devastating, causing the person living with pain to experience long-term psychological effects.

According to a groundbreaking 2011 report and subsequent book, Relieving Pain in America, A Blueprint for Transforming Prevention, Care, Education and Research, chronic pain now affects more than 100 million adults in the U.S.  Additionally, the economic price – from direct medical treatment cost and lost productivity – now totals at least $635 billion annually.

The report’s findings conclude that chronic pain is a disease in itself.  The authors write: “Pain results from a combination of biological, psychological and social factors and often requires comprehensive approaches to prevention and management.”

Furthermore, the best outcomes result from a combination of interdisciplinary assessment and treatment.

For a long time, the medical community was stymied when faced with pain that didn’t go away and resisted treatment.  Doctors either expected their patients to ‘tough it out’ or they opted for a Band-Aid approach and immediately prescribed strong prescription painkillers, which has led to rising addiction rates, including opioids.

This all or nothing approach was mostly ineffective, and a huge shift is underway in the healthcare industry to treat and manage chronic pain differently.

Physicians and other providers are now encouraged to use a patient-centered approach when treating issues related to chronic pain.  This is especially important as everyone perceives and deals with pain differently, and what works with one person does not mean it will be successful with the next.

While physicians used to automatically reach for their prescription pad when patients complained of pain, they now encourage non-pharmaceutical interventions as a way of providing relief.

“Each diagnosis needs to be approached systematically,” explains Dr. Christine Lee, anesthesiologist and pain specialist at UCLA Medical Center in Los Angeles.  “Trying to find the source of pain and using a multi-modal approach can help start the process.”

Early intervention is also critical.  Pain allowed to fester becomes increasingly difficult to manage.

Lee suggests a wide range of alternative interventions before powerful medications.  For example, some people living with pain will find success using biofeedback, physical therapy, acupuncture or even yoga.  Others benefit from cognitive interventions, such as meditation, cognitive behavioral therapy, or individual and group therapy.

Technology is also helping to make significant advances in pain management.  While they have been available for decades, new generations of medical devices, such as spinal cord stimulators, can deliver precise electrical pulses to the spinal cord, thereby blocking the pain signals before they reach the brain.

Patients often find relief by using alternative therapies combined with nonprescription medications.  Even so, some pain proves elusive and can never be eliminated.

What happens then?

Some people elect to live with their pain, while others may decide they need prescription medications, often called painkillers, to ease their suffering.

However, taking powerful medications, like opioids, does not guarantee a pain-free life.  Often chronic pain sufferers, for instance, experience episodes of break-through, where the pain is not totally suppressed with strong medications or the medications wear off before the next dose.  Patients can also build up a tolerance to painkillers, thereby requiring stronger doses to suppress their pain, sometimes leading to addiction.

To assist primary care providers, who account for half of the prescription opioids dispensed, the CDC recently issued guidelines, as well as a warning, about prescribing opioids for chronic pain.

First, the guidelines make clear that prescription opioids should always be considered a short-term treatment, and never a long-term solution.  While there are short-term benefits to the use of opioids, the long-term harmful effects are very real and sobering.

Also noted were sobering statistics and outcomes associated with long-term opioid use:

• Nearly two million Americans, age 12 or older, either abuse or are dependent on prescription opioids.
• Up to one quarter of patients receiving prescription opioids long term in a primary care setting struggles with addiction.
• Since 1999, opioid prescriptions have quadrupled, and over 165,000 people have died from prescription opioids

“The CDC hopes the guidelines will help physicians determine when to begin or continue opioids for chronic pain, which type of painkiller to choose, how long to administer the drugs, and how to weigh their risks,” Lee says.

These guidelines are designed to inform clinical decision-making and improve communication between health care providers and their patients.  Primary care providers are encouraged to educate their patients about the short-term benefits as well as the dangers of long-term use of prescription pain medications.  Additionally, throughout the course of treatment, physicians are strongly encouraged to be on the look-out for signs of any abuse.

“When opioids are used, start low and go slow, meaning doctors should increase the dose of medication slowly, and only when necessary, and monitor patients closely for signs of abuse,” Lee says.