Is There Hope for People who Experience Chronic Pain?
Velandy Manohar, M.D., F.A.P.A.
Pain is a national public healthcare crisis
- Approximately 50-75 million Americans suffer with persistent (chronic) pain.
- The number of people suffering with chronic pain is higher than and includes, those with breast cancer, AIDS, and nearly all other serious or terminal illnesses
(The Pain Survey, Louis Harris & Associates, 1999)
Connecticut Pain Survey – Impact of Chronic Pain
- Individual who experience pain persistently report that their pain impinges on not only their own quality of life, but the quality of life of their loved ones as well.
- Half of the individuals who experience persistent pain admit that they sometime feel anxious, irritable, or depressed.
- Their pain forces them to lose sleep.
- Their pain prevents them from doing activities they once enjoyed.
(On Target Research, LLC survey to Connecticut adults 2004)
Pain
- Derived from poena meaning penalty
- It is an unpleasant alerting sensory and emotional experience.
- Pain has sensory, motor, emotional, cognitive, autonomic, endocrine and behavioral facets.
Pain Assessment
• Circle the number that best describes your pain at its worst during the last month
– 0 1 2 3 4 5 6 7 8 9 10
(no pain) (worst pain imaginable)
Pain Assessment continued
• Circle the number that best describes your pain at its least during the last month
– 0 1 2 3 4 5 6 7 8 9 10
(no pain) (worst pain imaginable)
Pain Assessment continued
• Circle the number that best describes your pain at its average during the last month
– 0 1 2 3 4 5 6 7 8 9 10
(no pain) (worst pain imaginable)
Pain Assessment continued
• Circle the number that best describes your pain at it is right now
– 0 1 2 3 4 5 6 7 8 9 10
(no pain) (worst pain imaginable)
Pain Assessment continued
Use same scale assessing pain associated with daily functions:
- General activity
- Mood
- Walking Ability
- Normal work routine
- Relations with other people
- Sleep
- Enjoyment of life
- Ability to concentrate appetite
0 1 2 3 4 5 6 7 8 9 10
(Does not interfere) (Completely interferes)
Components of the pain history
- Somatic aspects of pain
- Psychological component of pain
- Social/Adaptive aspects of pain
Somatic aspects of pain
- Onset
- Location
- Quality
- Quantity
- Duration/Chronology
- Setting
- Aggravating/Alleviating factors
- Associated features
Psychological component of pain
- Mood and affect
- Cognitive
- Content
- Process/Styles
- Coping repertoire
- Psychiatric illness
- Lethality assessment
Social/Adaptive aspects of pain
- Impact on relationships
- Capacity for intimacy, sexuality, mutuality
- Activities of daily living
- Vocational/Academic
- Recreational
Pathogenesis of Chronic Non-malignant pain
- Inaccurate diagnosis, delayed, inadequate, ineffective management of acute pain syndrome (primary or secondary)
- Ongoing smoldering injury and inflammation with or without flare-ups.
- Nerve injury and or disease (primary or secondary: IDDM, Toxins, injury) Pathogenesis of
Chronic Non-malignant pain continued
- Traumatized tissues can produce reflex motor activity in the vicinity of the original injury.
- The resulting spasms and inactivity can enhance nociception
- Damage neurons can fire spontaneously or with very light stimulation creating an illusion of acute injury in a vaguely defined area or in a healthy segment which elicits pain behavior.
Categories of chronic non malignant pain
- Nociceptive – somatic
- Nociceptive – visceral
- Neuropathic
- Psychogenic
Nociceptive – Somatic
- Source
- Damage to soft tissue, bone
- Inflammation/Illness
- Localization: very specific
- Characteristic: sharp and aching components
- Onset
- Aggravating/alleviating factors
- Associated features: sleep, appetite, energy level
Nociceptive – Somatic continued
• Effective interventions
- ASA
- NSAIDS
- MU agonists
- COX-2 inhibitors
- Treat the cause
Nociceptive - Visceral
- Source
- Injury or inflammation to wall or organ tissue
- Pressures on neighboring organs/vessels
- Localization
- Examples: gallbladder disease, acute coronary syndrome, bowel infarct, renal colic, appendicitis
- Effective interventions: MU agonists
- Treat the cause.
Neuropathic
- Source: damage to neural tissue, PNS and ANS
- Localization: wide segmental distribution
- Features: paresthesias, numbness, burning, pins and needles
- Examples: Post herpetic neuralgia, trigeminal neuralgia
- Effective interventions:
- anti-convulsants
- Antidepressants
- Lidoderm
- surgical
Psychogenic
- Source:
- Psychological distress
- No clear etiology
- No detectable current, recent or distant somatic, visceral, neuropathic tissue damage, inflammation or disorder
- Localization:Generally poorly localized
- Features: vague, broad, and sweeping. May be somewhat localized
- Examples: somatization disorder, dyspareunia
- Effective interventions:
- Psychotropic medications
- Psychotherapy
Chronic Pain “Patient-Hood”
• It is a psychological-social state of mind and being with:
- A characteristic ever tightening descending spiral over time of distress and disability marked by
- Fear, self-doubt, distrust
- Loss of capacity for and enjoyment of intimacy or social interaction
- Isolation and impairment
- Helplessness, hopelessness and worthlessness
Simple Chronic Pain Syndrome
- Features clearly defined
- Treatment alliance: Patient engages collaboratively.
- Social support systems: usually present and stable
- Co-Morbid disorders: relatively mild and tractable
- Response to treatment: collaborates successfully with plan to improve function and reduce suffering
Simple Chronic Pain Syndrome continued
- Generally attempts to pursue interest and do more than is recommended or even prudent. Axis V GAF can be respectable.
- Litigation and secondary financial gain: not central to treatment effort and does not hamstring goal setting and attainment.
Complex Chronic Pain Syndrome
- Features: multiple complaints and foci of concern
- Treatment alliance: hot and cold, up and down, hostile dependent, saint and savior or persecutor and quack. Attempts to write own plan including medication recommendations, disability certification and get it endorsed by treater
Complex Chronic Pain Syndrome continued
- Social support system: highly stressed with burned bridges and burned out helpers. Major Axis II and Axis IV factors.
- Co-morbid disorders: usually mixture of severely disabling AXIS I and II and occasionally Axis III disorders.
Complex Chronic Pain Syndrome continued
- Response to treatment: poor to fair, inconsistent, contradictory reports of effects/side-effects. Functional capacity and suffering usually unchanged at end of course of treatment.
- Treatment strategy: multi-disciplinary, targeted and closely monitored with a rehabilitative approach to reduction of suffering, capacity to habituate to pain experience and gradually increasing personal responsibility for improving autonomy.
Complex Chronic Pain Syndrome continued
- Litigation, secondary financial gain: these issues interfere with building trust relationships and hamstrings goal setting and attainment.
- Complicating factors
- Deconditioning
- Reinjury
- Obesity
- Medial co-morbidity
- Drug-drug interaction ass to disability and increasing frustration, anger and acting out behaviors
Chronic Pain Syndrome clinical presentation
- Pain Specific behavior • Interactional matrix
- Affective presentation
Pain Specific Behavior
- Physical display of disability maximized
- Suffering emphasized verbally
- Suffering dramatized non-verbally
- Disability prolonged by non-compliance and avoidance
Interactional Matrix
- Nothing has helped and what you suggest won’t help either
- Repeated efforts to convince listener about authenticity of complaints
- High stress and anxiety expressed but not internalized in organized manner to offer insight
- Magical thinking about getting cured by present treated or some one out there who has a cure.
Affective features
- Angry, irritable, dysphonric, resentful and envious of others
- Sarcastic and bitter alternating with sweet endearing, denying and resistive
- Demanding and critical or passive and dependent wanting to be cured without personal; effort.
- Presents as weak and needy and the opposite hostile and help rejecting.
Multi-axial categorization of Pain Complaint
(International association for study of pain, subcommittee on taxonomy 1986)
- Axis I: Location and distribution of pain source
- Axis II: Specify source and type of mal-function that is the cause of the altered nocioception.
- Axis III: Temporal and experimental characteristics
- Axis IV: Obtain patient approximation of pain severity
- Axis V: Identify bio-medical, affective/motivational, cognitive evaluation components that may exacerbate or ameliorate the pain syndrome, and in turn may help or hinder treatment.
Co-morbid psychiatric disorders
(chronic non-malignant pain)
- Delirium and cognitive impairment secondary to medications or co-morbid disorders e.g.. Head trauma, substance use, medical, surgical disorders.
- Anxiety disorders
- Depression and demoralization
- Sleep disorders
- Appetitive disorders, food, sexual, pursuit of once enjoyed activities
- Substance use disorders, pseudo-addiction
Co-morbid psychiatric disorders continued (chronic non-malignant pain)
- Somatoform disorders
- Conversion disorder
- Hypochondriasis
- Pain disorder
- Somatization disorder
Factors that influence pain
Cognitive patterns associated with chronic pain
- Catastrophizing tendency to view and expect the worst e.g. “I am never going to get rid of this pain. I will be miserable for the rest of my life”
- Helplessness: “Nothing that one does will make an iota of difference” this includes any test or treatment option the physician may offer to alleviate pain.
Factors that influence pain
Cognitive patterns associated with chronic pain continued
- Help rejecting behavior: attempts to help and assist patient to cope with pain and alleviate distress are rejected as a means of expressing anger and frustration. It may be a means of manipulating others for personal benefit.
Factors that influence pain
Cognitive patterns associated with chronic pain continued
- Labeling: attaching a demeaning label to caregivers who prescribed a medication that offered no relief or produced side effects
Factors that influence pain
Cognitive patterns associated with chronic pain continued
- Magnification: the exaggeration of the significance of specific unpleasant event. :My pain got worse when I went for a walk. I better not do that again ever. Something is really wrong with me.
Factors that influence pain
Cognitive patterns associated with chronic pain continued
- Over-generalization: over interpreting the negative significance of a setback on a given day and anticipating the worst in all areas of life.
- Personalization: the tendency to interpret that an mal-occurrence or series of them indicates that there is something gravely wrong with oneself.
Factors that influence pain
Cognitive patterns associated with chronic pain continued
- Selective abstraction: the vulnerability to attend to and recall negative occurrences and misfortunes while turning a blind eye to many satisfying aspects of ones life.
Factors that influence pain
Cognitive patterns associated with chronic pain continued
- Self-fulfilling prophecies: effectively precluding choices that can lead over time to the attainment of positive and hope for goals by concluding at the very outset of treatment intervention that both or wither the treater or the treatment cannot help the pain.
Elements of a comprehensive plan
- Education about chronic non-malignant pain
- Intractable non-malignant pain is not indicative of a threat to life or overall health except through inactivity and cognitive impairment.
- Sensation of pain is real, but the response to the pain and level of suffering can be modified.
Education about chronic non-malignant pain continued
- Patients are taught that they can gain control of their pain problems and may be able to modify their work, social, and play activities to reduce suffering and enhance functional capacity.
- Emotional, social, family, vocational evaluations followed by appropriate interventions to prepare patients to attempt to restore functional role capacity.
Education about chronic non-malignant pain continued
- Adjustment of the dose, schedule and type of drug as well as focused use of analgesic medications can alleviate suffering and increase functional capacity gradually over time.
Education about chronic non-malignant pain continued
- Pain experience cannot be ameliorated by avoidance of activity or isolation from others.
- This kind of pain experience cannot ordinarily be cured by copious use of opiates, sedatives, hypnotics or alcohol.
- The pain experience does not represent a moral failing or a punishment for specific choices and actions.
Education about chronic non-malignant pain continued
- It is not necessary to first find out the answers to all the whys of the disorder to gain better control of the pain and suffering and improve function.
- Intractable non-,malignant pain does not have to totally ruin your day or predetermine a worthless, hopeless and useless life in the future.
Pain Treatment Ladder
Neuroablation (chemical or surgical) |
Implantable therapy Intraspinal Morphine Infusion |
Implantable therapy Spinal cord Stimulation |
Long-term oral narcotics |
Corrective surgery |
Behavioral Programs |
Nerve Blocks |
Physical Therapy/Manipulations/TENS/ Muscle relaxants |
NSAIDS/Over-the-counter drugs |
Setting Treatment goals
- Pain Diary
- Pain Management Agreement (contract)
Effective Care of Patients with Chronic Pain
- Individualized care
- Multidisciplinary, multi-modal, multi-tiered, multi-staged • Effectively communicated
- Effectively documented
- Regular follow-up with coaching, guidance and support
Alternative treatments for Pain
- Nonpharmacologic
- Cognitive-behavioral therapy'?"
- Exercise therapy
- Complementary medicine'!" (e.g., yoga, meditation, acupuncture)
- Nonopioid analgesics
- Anticonvulsants (gabapentin or pregabalin)']
- Antidepressants
Alternate treatments for Pain
- Interventional and neural-stimulation therapies
- Epidural injection; may provide short-term improvement for certain pain associated conditions
(e.g., Lumbar Radiculopathy)
- Brain, spinal cord, and nerve stimulation, including transcranial magnetic stimulation, transcranial direct current stimulation, electrical deep-brain stimulation, and stimulation devices for peripheral nerves or tissues.
Alternate treatments for Pain
- Biofeedback
- Electromyography to help patients learn to control muscle tension and electroencephalography
- to help patients learn to influence brain electrical signals
- in order to modulate pain; may be beneficial in treatment of headaches,
- some forms of chronic back pain, and other pain disorders!"
- Neurofeedback with the use of functional magnetic resonance imaging as a
- supplemental approach for chronic pain management'?
10 Promising Practices to De-Stress
- Science of Integrative Medicine- Brent Bauer, MD Mayo Clinic
- Acupuncture,
- Guided Imagery,
- Hypnotherapy,
- Massage,
- Meditation [Both Stationary and Movement based -Tai Chi, Dance, Medicine Ball],
- Music Therapy- Listening to chanting,
- Spinal Manipulation,
- Spirituality,
- Tai Chi.
- Yoga- Stationary and Movement based.