Chronic pain is a major social and economic problem that consumes numerous resources, affects millions of lives and is a major source of both physical and psychological disability. Just as it does today, pain has always played a prominent role in our society and it is interesting to look back and trace its manifestations and treatments at different times in our history.
Every civilization has passed on records documenting pain and painful experiences. Primitive man used such basic modalities as the cold of a stream, massage through rubbing or pressure to control his pain. There is evidence that he found relief by applying pressure along the pathways of nerves and veins, but didn’t understand the anatomical reasons for its effectiveness. At one time pain was thought to be an evil spirit that might be scared away by the wearing of rings, claws or charms; a medicine man or shaman dressed differently, empowering them to fight away these “pain demons.” With the advancement of religious beliefs, man’s ideas changed to that of pain being inflicted by an offended god to relieve the pain and suffering. The medicine man was replaced by a priest who relied on prayer. Shrines were built and sacrifices were made to appease and get the attention of the gods. With Christianity came healing through the “laying on of hands”, a still common practice. Pain was often considered good for the soul since it was a punishment from God. The idea of guilt and suffering crosses all religious and cultural boundaries and is not restricted to Jewish mothers!
The middle or dark ages brought a halt to virtually all scientific investigation and there was no advancement of man’s understanding of pain. The modern era of pain management was ushered in when Joseph Priestley discovered nitrous oxide in 1772 and observed its analgesic properties. The19th century witnessed the use of physical modalities for the treatment of pain and the first public demonstration of anesthesia at the Massachusetts General Hospital in 1846. In 1817, the active ingredient of opium was discovered by Frederick Sertuner who named it morphine after Morpheus, the Greek God of dreams. The injection of medications was developed in the 1840’s with the invention of hollow needles and syringes and with the subsequent discovery by Lister of antisepsis, the surgical treatment of pain spread rapidly as did the proliferation of pharmacological treatments.
ACUTE VS CHRONIC PAIN
Acute pain is an unpleasant response or experience that is brought on by an injury or acute disease. The pain usually disappears in days or weeks with either treatment or by the self-limiting nature of the disease. A broken arm or sprained back is expected to hurt for a period of time and then resolve. On the other hand, chronic pain persists beyond the usual course of the acute disease and may recur at repeated intervals. Many professionals have set six months as the demarcation point for chronic pain, however this is not always appropriate since some disease processes may heal in much shorter periods of time (4-8 weeks). Persistent pain complaints beyond that point then become labeled “chronic.”
As a rule we don’t expect to see chronic pain result from simple injuries such as ankle sprains, uncomplicated fractures or surgical procedures. However, the physical setting of an injury and a person’s psychosocial history frequently contribute to whether or not a mild or trivial injury progresses to a chronic pain problem. The more common types of pain seen at chronic pain center include:
- Lower Back Pain
- Neck pain
- Post- traumatic headaches
- Diabetic and alcoholic neuropathies
- Post-herpetic neuralgia
- Abdominal pain
- Phantom limb pain
RISKS OF CHRONIC PAIN
Although acute pain can cause temporary disability and has risks, the long term risks of chronic pain are much more significant:
Increased Psychiatric Disability: Chronic pain patients become increasingly anxious and depressed over time, decreasing their tolerance for pain and amplifying their symptoms. They are trapped in a merry-go-round of increasing pain causing increasing depression which then fuels and amplifies their pain complaints. These psychiatric symptoms are frequently the most disabling and are one of the explanations why the attempts of a solo practitioner to manage a chronic pain patient almost always results in failure.
Drug Dependence: The health care system responds to pain complaints with the administration of an increasing number of medications, tests and therapies. When the patient returns for a 10-15 minute follow-up visit, it is near impossible to uncover or deal with the psychosocial issues that may be driving the pain. It is easier to write a prescription. When carefully questioned, these patients rarely get satisfactory relief from any of these medicines or treatments since they have developed a psychological dependence on taking “something” for their pain. When they feel discomfort there is a desire to do “something”, whether it is helpful or not, for they have not been taught acceptable alternatives to drug use. We, not the patent, create many of these cases of drug dependence. Many of the medications that we prescribe are not without side effects and iatrogenic complications are not unusual. The best medicine is frequently to stop taking a medication.
Multiple Surgical Procedures
In the quest for pain relief the unknowing physician offers an unneeded surgical procedure as “something to do” or as a “last resort.” Dr. J.D. Loesser has remarked that, “offering a patient who is depressed and desperate another surgical procedure is an abrogation of the responsibility by the physician and the exploitation of the confused, discouraged and frustrated patient who will grasp at almost any straw offered, often without regard to the risks involved or indeed any chance of significant improvement.” Disability worsens and the pain cycle continues.
WHAT CAN WE DO?
Chronic pain requires that we re-examine our definition of success. We do not speak of cures or total elimination of pain. The actual cause of the discomfort may never be identified, although we do strive to eliminate the source of the pain when possible. More importantly, the patients are taught to live and function within the limits of their pain. This may include a vocational rehabilitation program with eventual return to work or may be limited to just performing normal household tasks. Over one half of the patients admitted to a pain program are dependent on opioid/narcotic medications and must be detoxified. At discharge from the program they should be free of all narcotics and taking a minimal amount of medication that may include an antidepressant since the treatment of depression associated with chronic pain is one of the primary goals of the program. Most patients have been to numerous doctors, therapists and clinics before entering a program. Another major goal is to discontinue their dependence upon the health care system and as a result to decrease the future cost of medical care. For many patients, going to the doctor or their therapist has become their job. It is what they do day after day. Their pain is the primary focus of their life.
To achieve these goals one must address secondary gain issues, both financial and social. Are there benefits that the patient receives as result of continuing in the sick role? Does he get out of responsibilities at home? Does she get more attention from her husband and children? The family must be treated simultaneously for one will always fail if the patient is returned to a dysfunctional setting that promotes abnormal pain behavior. If a spouse continues to be overly attentive to her husband’s pain complaints, then the pain behavior will be reinforced. At discharge a system that includes family, medical and community support must be provided to limit the chances of regression and failure.
WHO CAN BE HELPED?
The success of a chronic pain program depends upon proper patient selection. Not all pain patients are candidates for an intensive chronic pain program. Some may respond to simple single modality therapy such as nerve blocks or trigger point injections, but many will have complex issues that require more than a single practitioner. Most patients are referred after they have undergone numerous failed and inappropriate therapies that have resulted in prolonged suffering. They have developed pain behavior and drug dependence that interferes with their ability to function effectively at home, work or in the community. Which of these patients will benefit from an intensive chronic pain program? As a rule it is those with:
- Significant pain behaviors
- Disruption of their life both at home and work
- Drug dependence or persistent attempts to obtain medication
- Continued use and abuse of the disability system
We have to determine what barriers may exist toward success. Is return to work desirable and realistic? Is the patient motivated? Are there adequate funds to support the patient during and after the pain program? Is there active litigation that serves as an impediment to improvement? It is critical to answer these questions before enrolling the patient in a chronic pain program. Chronic pain is not an emergency! The time spent gathering information is well spent and contributes greatly to one’s chance of success.
Chronic pain is a national problem of epidemic proportion that is often inadequately or inappropriately treated. Multidisciplinary pain programs provide a cost-effective way of dealing with these patients. The key is not only screening the patients, but screening the programs to be certain that they truly are multidisciplinary, comprehensive and experienced.
Code of Hammurabi
“If a surgeon has opened an eye infection with a bronze instrument and so saved the man’s eye, he shall take ten shekels. If a surgeon has opened an eye infection with a bronze instrument and thereby destroyed the man’s eye, they shall cut off his hand.”