Coping with the burden of chronic pain
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.
Chronic pain that is left for months or years becomes a deeply complex issue.
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
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.