Cop­ing with the bur­den of chronic pain

The Dominion Post - - Well & Good - Dr Cathy Stephen­son GP and mother of three

Icome across a pa­tient suf­fer­ing from chronic pain nearly ev­ery week. What strikes me most about this group of peo­ple is how im­pact­ing on their lives this con­di­tion is – of­ten lead­ing to re­la­tion­ship or fam­ily break­down, de­pres­sion and anx­i­ety, low self-es­teem, and re­duced abil­ity to work or con­trib­ute in other ways.

I have no doubt it is in­cred­i­bly hard for suf­fer­ers and their fam­i­lies, and yet we know very lit­tle about why some peo­ple de­velop chronic pain and oth­ers don’t and, worst of all, as doc­tors we aren’t very good at man­ag­ing it ef­fec­tively.

So what is chronic pain, and what can you do if you or a loved one are un­lucky enough to be in this po­si­tion?

The word ‘‘chronic’’ in medicine doesn’t have any­thing to do with sever­ity, but is about du­ra­tion – any­thing de­scribed as chronic is on­go­ing, as op­posed to short-lived. So chronic pain re­ally means pain that has been there for a long time, some­times de­fined as more than 12 weeks. I pre­fer an al­ter­na­tive, less spe­cific, def­i­ni­tion, which states that pain per­sist­ing for longer than the body should have taken to heal or re­cover can be con­sid­ered chronic in na­ture.

I think of chronic pain as the body ‘‘adapt­ing’’ to hav­ing pain, then per­pet­u­at­ing the pain long af­ter the ac­tual trig­ger has gone, hence pain it­self be­comes the prob­lem, not the pri­mary cause.

We of­ten think of chronic pain in re­la­tion to backs, but ac­tu­ally it can oc­cur any­where in the body – other com­mon sites in­clude the head, neck, pelvic area, and gen­i­tals (es­pe­cially in women), ab­domen, and limbs. The pain can vary hugely too, from a burn­ing type of ‘‘neu­ro­pathic’’ or nerve pain, to a low con­stant ache, and ev­ery­thing in be­tween.

We don’t re­ally know ex­actly how com­mon it is, but prob­a­bly around 20 per cent of us will have a de­gree of chronic pain at some point – a huge fig­ure if you think how dis­abling it can be for those at the se­vere end of the spec­trum. Chronic pain usu­ally fol­lows an in­jury or an acute (that is, short-lived) episode of pain from something such as an in­fec­tion or op­er­a­tion. Most of us will re­cover in the time ex­pected, but oth­ers will go on to have chronic pain and all the is­sues that can lead to. We don’t know how to pre­dict who will or won’t de­velop chronic pain, but there are fac­tors that make it more likely – con­cur­rent phys­i­cal or men­tal ill health, low in­come, obe­sity, a fam­ily his­tory, and a phys­i­cally de­mand­ing job.

One thing we do know is that the ear­lier it is sus­pected, and the ear­lier good in­ter­ven­tions can be put in place, the eas­ier it is to treat. Chronic pain that is left for months or years be­comes a deeply com­plex is­sue – and ends up be­ing far from just a phys­i­cal prob­lem, with psy­cho­log­i­cal, so­cial and eco­nomic con­se­quences for the suf­ferer.

Most ar­eas of New Zealand now have ac­cess to some sort of spe­cialised ‘‘pain ser­vice’’ – although these aren’t usu­ally places you can di­rectly ac­cess your­self, it is worth talk­ing to your GP if you are wor­ried that the pain you, or a loved one, has is go­ing on for longer than ex­pected.

GPs will be able to as­sess you to make sure noth­ing phys­i­cal has been missed, and will be able

Chronic pain that is left for months or years be­comes a deeply com­plex is­sue.

to sug­gest treat­ments that might be re­ally ef­fec­tive in the early stages. If things aren’t im­prov­ing, or you have had pain for years and it isn’t re­solv­ing, ask for a re­fer­ral to a lo­cal pain team – they should be able to talk through some of the man­age­ment op­tions below:

❚ Firstly, keep ac­tive. I know that sounds dif­fi­cult if you are in pain, but ac­tiv­ity of any sort (as long as it isn’t ex­ac­er­bat­ing an in­jury) is help­ful. Be­com­ing in­ac­tive leads to loss of mus­cle tone and fit­ness, hence in­creased pain and dif­fi­culty when you do start to move again, as well as im­pact­ing on your men­tal well­be­ing, hin­der­ing re­cov­ery. You may find you can’t do your usual type or level of ac­tiv­ity, but think out­side the box – any­thing wa­ter-based tends to be amaz­ing for joint and mus­cle pain, and stretch­ing and strength­en­ing ac­tiv­i­ties such as pi­lates or yoga are great for im­prov­ing flex­i­bil­ity as well as help­ing re­duce stress and anx­i­ety lev­els (as­so­ci­ated with higher lev­els of ex­pe­ri­enced pain). Even talk to a physio or good per­sonal trainer to help de­sign a pro­gramme that will fit your needs.

❚ Se­condly, be in­volved in the man­age­ment of your pain. It is likely to be mul­ti­fac­to­rial (that is, have many causes con­tribut­ing to it), so your doc­tor won’t be able to wave a magic wand. They can help, but so can you, so tak­ing a proac­tive part­ner­ship ap­proach will give you a much bet­ter out­come, as hard as that may feel when you are sore and dis­tressed. That in­cludes seek­ing sup­port from your net­work, re­main­ing in­volved in ac­tiv­i­ties, and ac­cept­ing that doc­tors won’t have all the an­swers. Keep­ing a pos­i­tive at­ti­tude can be re­ally hard, but it will help.

❚ Trial med­i­ca­tions when sug­gested, and take them as rec­om­mended. There are nu­mer­ous op­tions – from sim­ple anal­gesics (such as parac­eta­mol), to anti-in­flam­ma­to­ries (such as di­clofenac or ibupro­fen), and pain-mod­u­la­tors (in­clud­ing some an­tide­pres­sants and epilepsy drugs). I would ad­vo­cate tri­alling things one at a time if you can, so you know which has been ben­e­fi­cial, and give them all sev­eral weeks to take ef­fect – many won’t work overnight, and you may be stop­ping an ef­fec­tive treat­ment too early. I of­fer cau­tion to my pa­tients about start­ing an ‘‘opi­oid’’ or mor­phine-based treat­ment, though it is, at times, the only op­tion that will work. Opi­oids tend to lead to side-ef­fects, and are ad­dic­tive, so can quite rapidly lead to more prob­lems than you had in the first place – that said, if you have tried all other op­tions un­suc­cess­fully, don’t rule it out.

❚ Look af­ter your men­tal health – although it is thought to be a pre­dic­tive fac­tor for de­vel­op­ing chronic pain in the first place, it is also a nat­u­ral con­se­quence of liv­ing in pain and be­ing un­able to do all the things you love. Most pa­tients with chronic pain will also have stress, anx­i­ety or de­pres­sion at some point. Talk to those around you as well as health pro­fes­sion­als. CBT (a ther­apy of­fered by psy­chol­o­gists) can be re­ally use­ful in com­ing to terms with a change in life­style that chronic pain may have caused. An­tide­pres­sants can help with the pain and lift your mood, help­ing you cope.

❚ Lastly, think broadly – the best out­come for chronic pain is when dif­fer­ent ap­proaches are tried, and dif­fer­ent peo­ple are in­volved. That may in­clude a GP, coun­sel­lor, physio or acupunc­tur­ist – it may also in­clude some­one who can give you advice about what ca­reer may be more suit­able if chronic pain is im­pact­ing on your abil­ity to work, or talk­ing to other suf­fer­ers about what they have found help­ful.

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Prob­a­bly around 20 per cent of us will have a de­gree of chronic pain at some time in our lives.

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