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Pain is now known as a damaging process in its own right instead of just an accompaniment to disease or injury. With its “terrible triad” of suffering, sleeplessness, and sadness, unrelieved pain causes millions of people to miss work, to become depressed, and to neglect their health. The costs associated with prolonged pain total about $100 billion a year. Some 150 million workdays are lost each year to head pain alone.

According to a study of people living with chronic pain, 20 percent have severe pain and 43 percent have mild to moderate pain. But hope is on the horizon. The Joint Commission on Accreditation of Healthcare Organizations and other medical groups have created new standards for assessing and managing pain. Armed with this knowledge, people and their physicians are joining forces to create therapies and pain management plans that work.

Pain management is a comprehensive treatment approach in which people and their physicians treat the complex experience of pain with traditional therapies and balance them with complementary therapies when needed. Traditional medicines, including ibuprofen and aspirin, and complementary therapies, from acupuncture to yoga, help treat the underlying causes of pain, as well as the pain itself.

Understanding Pain

The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage.” Pain includes both the perception of an uncomfortable stimulus and the response to that perception. The following terms describe the specific kinds of pain.

Managing Your Pain

By working closely with your physician, you can learn to develop effective strategies to manage your pain. Your treatment plan—including plenty of communication with your physician—may include symptom management, pain assessment, and treatment goals. Sometimes how you cope with your pain is just as important as managing it.

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Diagnosing Pain

With pain management research and tools at their disposal, more and more physicians view pain as “the fifth vital sign” to check during physical examinations. But because half the people who have pain don’t visit their physician for the problem, doctors also are trying to educate people about the importance of pain management.

Finding the Cause

During an office visit, your physician may ask about your medical history and discuss any other health problems you might have. Because pain can be caused or intensified by stress, depression, and other factors, your physician also may ask about such events as losing a job, parenting stress, or marital problems.

The Mind and Body Connection

Physicians also may look at the mind and body connection to diagnose and treat pain. Recent studies have found that chronic pain is part of a never-ending cycle between mind and body in which agony causes stress and stress intensifies pain. By determining your state of mind, your physician can help you break this cycle. It often takes considerable time and effort to find the right therapy for each person and break this chain of pain, but it’s worth the effort.

Keeping a Pain Diary

A person’s pain diary can be an invaluable tool for helping physicians to diagnose and treat pain. To provide the most benefit, try to keep an accurate diary that includes the following information:

Your physician also may want you to rate the pain’s intensity from 1 to 10. This pain scale can help your physician to better monitor your condition, especially in cases in which medication or symptoms have changed. To help keep your diary accurate, write down the information immediately after you begin to experience pain.

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Current Treatments

Your pain management program may include a variety of medication options, treatments, and complementary therapies. Many pain medications have side effects, and their long-term use usually isn’t advised. Consult your physician before taking pain medications; each person responds differently to pain medications and they may interact with any other medications you may be taking.

Medications

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

NSAIDs block the production of chemicals called prostaglandins, which the body releases when cells are injured. Prostaglandins also contribute to the pain, heat, redness, and swelling that occur following tissue damage. Your physician may prescribe an NSAID and an opiate to relieve the pain in two ways: the NSAID blocks the pain at the injury site, and the opiate signals the brain to alleviate any remaining pain.
Over-the-counter (OTC) NSAIDs include aspirin (Bayer), ibuprofen (Advil), ketoprofen (Orudis KT), and naproxen sodium (Aleve). Prescription NSAIDs, including ibuprofen (Motrin), ketoprofen (Orudis), naproxen sodium (Anaprox), oxaprozin (Daypro), piroxicam (Feldene), indomethacin (Indocin), and nabumetone (Relafen), are usually given at higher doses than OTC medications. Higher dosages are used to relieve pain, inflammation, and swelling.

No one is sure, but acetaminophen (Tylenol) may work by acting on nerve endings to suppress pain. Although acetaminophen is as effective as aspirin in relieving mild to moderate pain and reducing fever, aspirin is more effective in relieving pain from muscle strains and sprains and other soft-tissue injuries or inflammation.

Opiates

Opiates, also known as narcotics, include morphine and codeine and such synthetic narcotics (opioids) as oxycodone (OxyContin), methadone (Dolophine), and meperidine (Demerol).

Opiates relieve pain by mimicking pain-relieving chemicals that the body produces, called endogenous opioid peptides. These peptides activate pain-relieving systems in the brain and spinal cord. Taking aspirin, ibuprofen, or acetaminophen at the same time as a narcotic can enhance this pain-blocking action. Opiates usually are the best choice to relieve moderate to severe pain. Although physicians sometimes use opiates to treat chronic pain, the Food and Drug Administration (FDA) has not yet approved them for this use.
Based on the type of pain and its frequency, your physician may prescribe the opiate to be taken orally, in regular doses by injection, or in smaller doses by patient-controlled intravenous analgesia (PCA), which enables you to control the amount of medication you receive to manage your pain. Although a PCA pump delivers smaller doses, you can feel relief in seconds because the medication goes directly into the bloodstream.

Your physician may also choose to administer opiates via epidural therapy. Used to relieve pain during childbirth and other types of intense pain, epidural therapy doesn’t cause the harmful side effects of regular narcotics because medications injected into the epidural space don’t travel to the brain.

For years, physicians have weighed the benefits of narcotics against the possibility of addiction. In years past, physicians who were afraid of prescribing too much of a narcotic sometimes were undermedicating people. Now, people and physicians are working together to ease their pain with correct doses of narcotics. Addiction is still a possibility, but a rare one, especially in cases in which people have severe pain and no history of drug dependency. Physicians have learned that people in severe pain may need a higher dose of a medication to maintain the same level of pain relief because their bodies no longer respond as well to the narcotic’s current dose.

Adjuvant Analgesics

Adjuvant analgesics, a diverse group of medications that were developed to treat other conditions, have been found to relieve pain in some people. The following medications used to treat other disorders may be used to relieve pain:

Electrical Nerve Stimulation

If you have back pain, your physician may recommend electrical nerve stimulation. Two methods are used.

.Brain stimulation involves surgically implanting electrodes in the brain to deaden pain. This method is often used to control the severe pain of advanced cancer.

Biofeedback

Biofeedback has been found to help people manage pain more effectively by gaining voluntary control over certain body activities that are usually considered involuntary. For example, to help control tense muscles that produce pain, a person can use monitoring devices that emit a sound when muscle contractions occur. The person then tries to mimic the conditions that prevent the device from going off (in this case, relaxed muscles). There have been mixed results concerning biofeedback’s ability to reduce pain.

Behavior Modification

Behavior modification is a multifaceted approach to pain management in which people learn to alter their lifestyles to better live with chronic pain. The approach stresses coping skills and problem solving.
For example, in cases in which pain has made working difficult, an occupational therapist can help find alternative ways to do tasks at home and at work. A family therapist can help people and their families develop day-to-day living solutions and new ways to handle everyday tasks.

A psychologist can offer ideas about how to cope with the pain. A psychologist also may use cognitive refocusing, also known as distraction, to help take a person’s mind off the pain. Cognitive refocusing directs attention and concentration from the pain away to another stimuli, including a phone call, a hobby, or humor.

Physical Therapy

A physical therapist can guide people through exercises that improve overall muscle strength, as well as specific exercises that reduce pain, including range-of-motion movements, strengthening techniques, and aerobic conditioning.

In some cases, a physical therapist may use complementary therapies. The Alexander technique, for example, is a complementary therapy that stresses proper body alignment and positioning to treat chronic pain. Other techniques include craniosacral manipulation, osteopathic manipulation, and myofascial release.

Relaxation

Relaxation techniques, including meditation and yoga, help relieve pain by helping people focus on something else. By reducing muscle tension, relaxation techniques also help people to manage stress, which has been proven to worsen pain.

Yoga focuses on altering the state of a person's mind to generate healing within the body. By assuming a series of asanas (positions) and concentrating on breathing, people keep their spines loose and systematically exercise all of the body's primary muscle groups. This, in turn, strengthens the organs by promoting respiration and blood flow. Yoga improves flexibility, eases pain, reduces fatigue and muscle stiffness, and increases mental alertness.

Complementary Therapies

Other forms of complementary therapies also have been found to help patients relieve pain.

Diet

Some common foods contain salicylates, the pain-relieving substances found in aspirin. Foods that are naturally high in salicylates have anti-inflammatory and painkilling properties. These foods include blueberries, cherries, dried currants, curry powder, dried dates, gherkins (small pickles), licorice, paprika, prunes, and raspberries.

Surgery

Many consider surgery the method of last resort for pain relief. Although cutting the nerve endings can bring about dramatic pain relief, it also can destroy other sensations or create a source of new pain. Additionally, surgery doesn’t provide permanent pain relief; the pain can return between 6 months and a year after surgery.

Cordotomy, during which a surgeon cuts the nerve fibers on one or both sides of the spinal cord with express routes to the brain, is the most common type of pain surgery. After the procedure, a person’s sense of pain and temperature are reduced.

Another surgical option is to sever connections at primary pain pathway junctions or to destroy parts of important relay stations in the brain, such as the thalamus, an egg-shaped cluster of nerve cells close to the center of the brain. Surgeons also can relieve pain by destroying nerve fibers or their parent cell bodies outside the brain or spinal cord.

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Research

The National Institute of Neurological Disorders and Stroke is investigating ways to reduce sensitivity to some types of pain by disabling certain nerve cells that send pain signals to the brain. Researchers are experimenting with a neurotransmitter, known as substance P, that stimulates pain receptors. By using saprin, a protein that deactivates substance P, researchers are trying to prevent pain signals from reaching the brain. Research has focused on animals up to this point, and further studies are planned.

Scientists also have discovered certain chemical receptors in the brain that respond only to specific types of pain. Molecular biologists are working to target the unique molecules that comprise the pain system, after which they hope to create pain medications without any side effects.

In addition, researchers are working to unravel the links between pain, gender, and genetics. Just as everyone experiences pain differently, some people are more sensitive to pain than others. Research indicates that men and women not only respond differently to pain, but also develop pain for different reasons. One study found that the brains of male mice include a set of pain receptors that don’t exist in female mice. Researchers also hope to uncover the genes responsible for differences in pain perception and tolerance.

Other research may lead experts to develop more effective pain management therapies based on the distraction theory. Researchers have found that the area of the brain that processes pain shows less activity when someone is distracted during the introduction of painful stimuli. For example, children are urged to hold a teddy bear while a doctor gives them a shot.

Researchers also have found a new piece of the complex puzzle of chronic pain. People with chronic pain produce proteins in their brains that others don’t. Scientists hope to develop new medications that stop the manufacture of these proteins.

Scientists are investigating whether diet can affect a person’s pain perception. If diet is clinically proven to affect pain perception, it could help researchers understand the physiology of pain and find new ways to treat it. A recent study found that laboratory rats fed diets rich in soy meal experienced far less pain after nerve injury than rats that were fed soy-free diets. Other research has shown that cloves, garlic, ginger, licorice, onion, and peppermint may have painkilling abilities.

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Clinical Trials You Can Join
Interested in participating in a clinical trial to test new medicines or therapies? We can help. Visit our Treatment Options and Clinical Trials from Veritas Medicine, which offers comprehensive information on clinical trials and treatment options for more than 40 serious, chronic medical conditions.

Toward the Future

With increased funding and heightened interest in studying both the origins of pain and how people perceive and cope with it, researchers hope to unravel the causes of pain and create better ways to treat it. Studies will continue to investigate ways to manage pain to achieve a higher quality of life. Researchers are investigating whether complementary therapies can help reduce pain.

Neuroscientists will continue to study how the brain and nervous system perceive pain. This research is expected to lead to more condition-specific treatments with fewer side effects. Researchers also will continue to investigate the roles of gender and genetics in the hope of developing better pain management treatments.

Scientists will continue to educate people regarding pain management, and physicians increasingly will include pain assessment and management in routine office visits.

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References

1. “Pain: Hope Through Research,” National Institute of Neurological Disorders and Stroke, Nov. 7, 2001.

2. “IASP Pain Terminology,” International Association for the Study of Pain, Nov. 7, 2002.

3. “Joint Commission Focuses on Pain Management,” Joint Committee on Accreditation of Healthcare Organizations, Aug. 3, 1999.

4. “The Management of Pain,” American Society of Anesthesiologists, 2003.

5. “Challenges in Pain Management at the End of Life,” American Family Physician, American Academy of Family Physicians, Oct. 1, 2001.

6. “Keeping a Pain Diary,” American Pain Foundation, 2003.

7. “Yoga and Pain—Finding Peace of Mind,” American Pain Foundation, 2003.

8. “Chronic Pain,” American Pain Foundation, 2003.

9. “Managing Your Pain,” National Institutes of Health, April 1998.

10. “Acupuncture,” National Center for Complementary and Alternative Medicine, March 2002.

11. “Chronic Pain Medicines,” American Academy of Family Physicians, 2001.

12. Stein, C. “Opioid Treatment of Chronic Noncancer Pain: Point-Counterpoint,” APS Bulletin, American Pain Society, March/April 1996.

13. “Psychosocial Factors Provide Clues to Pain,” American Psychological Association, 1997.

14. “Complementary Therapies,” National Pain Foundation, 2003.

15. Kiefer, S. “Alexander Technique,” BackCare, 2002.

Writer: Christine Norris
Clinical Reviewer: Patt Panzer, MD, MPH
Editors: Andrea King, Joanne Poeggel
Source of Material: Rockhill Communications, 14 Rock Hill Road Bala, Cynwyd, PA 19004, (610) 667-2040, http://www.rockhillcommunications.com
Date Written: 3/13/01
Date Revised: 5/2/03