PAIN MANAGEMENT

PAIN...IT'S A WARNING!

Pain tolerance varies from person to person, but you should never ignore pain. Pain is a message that there's a problem. If you can't figure out why you're in pain, or if the pain persists when the injury or infection has healed, or if your usual over-the-counter "painkiller" doesn't relieve the pain, see a doctor.

Pain management is a medical specialty. You have the right to get an opinion from a specialist in pain management if your own physician is not providing adequate control and relief of your pain.

Almost everyone knows pain. Excepting the few individuals born with congenital analgesia, a rare disorder which leaves them unable to feel pain, we are all familiar with pain. That's a good thing. Pain is often a signal that we should change our behavior. A person with congenital analgesia has no immediate way of knowing if he or she is sitting on a tack, touching a hot stove, or suffering an ulcer.

Pain is a warning signal that can mean the difference between life and death.

Pain is classified into two types: acute pain and chronic pain. Both types can span the full range of sensation, from barely noticeable to agonizing. There are many words to describe the various sensations of pain, for example: tingling, jolting, burning, dull, sharp, throbbing, searing, nagging, stabbing, pounding, gnawing, piercing, blinding, radiating, aching.

The pain of touching a hot stove causes an almost instant reflex in the muscles near the source of the pain. Your hand jerks away. You don't even think about it. The spinal cord triggers the reflex before the pain signal even gets to your brain.
That's the simplest sort of acute pain...the result of an obvious insult to surface tissue. Ouch!

Acute pain:
• Begins suddenly.
• Usually has an obvious source - a wound or a bruise - and cause - a cut, a stubbed toe, too-tight shoes. There's a subset of acute pain which includes headaches, sinus pressure, muscle cramps, gastrointestinal bloating, toothache and so on. The circumstance causing the pain ends (the shoes come off, you rehydrate and lose the hangover headache, the weather changes and your sinuses clear) or the tissue damage heals within a predictable time, and the pain ends.
• Acute pain can increase heartrate, elevate blood pressure and cause rapid breathing. It can trigger a dangerous state of shock.

Chronic pain:
• Lasts longer, often many weeks, months, sometimes years.
• Can come and go or remain constant.
• Can disrupt sleep, decrease appetite, and bring about clinical depression.
• Often has no secondary symptoms like increased heartrate or blood pressure.You may not know the reason for chronic pain. The original injury has apparently healed, yet the pain remains — and may be even more intense.

Chronic pain can also occur without any apparent injury. In the past, patients who complained of pain for which the doctor could find no cause were thought to be imagining the misery or seeking attention. The medical profession now knows that chronic pain is real.

Often, the cause of a patient's chronic pain is a mystery. There may be no evidence of disease or tissue damage that your physician can identify as the source.

Sometimes, chronic pain is due to a chronic condition, such as arthritis, which produces painful inflammation in your joints, or fibromyalgia, which causes aching in your muscles. Lower back pain may result from degeneration of the spinal column...or from the strain of counterbalancing a big belly or huge breasts.

Sometimes an accident, infection or surgery will damage a nerve, causing it to send pain signals to the brain continuously or intermittently for months or years. Nerve pain that continues after the original injury heals is called neuropathic, meaning the damaged nerve, not the original injury, is causing the pain. Damaged nerves can result from diseases such as diabetes or alcoholism, not just bacterial or viral infections.

Diagnosis

Pain is a symptom. Diagnosis of a cause for chronic pain can be challenging. No lab test can absolutely prove the existence of pain. Determining the level of pain is almost as difficult. No two patients are exactly alike. No single stimulus will cause the exact same pain experience in two different people. Once the specific cause of pain is diagnosed, it may be possible to prevent pain from recurring by promoting healing or preventing a particular stress. For instance, once a patient is diagnosed with an ulcer, certain dietary changes and/or an antibiotic might help prevent pain.

Treatment

As with many medical conditions, treatment of the symptom (pain) will usually start immediately, while the doctor tries to find a cause and decide on a further treatment. There are a many drugs and alternative treatments which help block, mask or moderate pain but again, no two patients are the same.

Analgesics are the most common remedies. Analgesics can be narcotic or non-narcotic. Plain acetaminophen (such as Tylenol) is a non-narcotic that interferes with pain messages. Other non-narcotic analgesics, such as aspirin and ibuprofen (such as Motrin ), work in two ways: by interfering with pain messages; and by reducing inflammation and swelling that can irritate the painful nerves.

Narcotic analgesics, such as codeine and morphine, are the most powerful pain treatments. Narcotic analgesics may cause constipation, drowsiness and other more serious side effects. Discuss them with Marjori if you have concerns.

Other drug classes such as anesthetics, antidepressants, anticonvulsants and corticosteroids may be effective in the case of specific pain syndromes in some patients.

Non-drug treatments for pain include:
• Acupuncture
• Counterirritation (eg: heat rubs)
• Massage
• Chiropractic
• Relaxation
• Psychotherapy
• Transcutaneous (through the skin) electrical nerve stimulation (also known as TENS), which uses electrical impulses to stimulate the nerve endings at or near the site of pain

Non-drug treatments may be especially useful for chronic pain. Some treatments stimulate the body's production of endorphins, natural painkillers in the body. Some treatments act directly on nerves, interfering with pain messages. Some things seem to work for some patients, but nobody knows why. Pain is not yet well understood.

Prognosis
For patients with acute pain, the prognosis is usually good. Many drugs are effective in relieving pain. When its cause is healed or removed, acute pain ends.
Chronic pain sufferers may have a more difficult time. The causes of their pain can be hard to determine and to treat, and with associated nerve damage, pain may continue even after the original cause is treated.

The chronic pain patient may need to learn to cope with pain for a long time. Lifestyle changes may be essential and non-drug treatments may have to become routine.

Feel free to talk to Marjori about your pain management challenge.
It's one of several areas of particular interest and expertise for your friendly neighbourhood pharmacist!