Answer:  Chronic pain is experienced by at least 10% of the population and by many estimates, higher. We have developed many ways to manage it and to make life better for those who suffer it.  But modern medicine has not made much progress on how to cure it.

Here are some points on chronic pain, which I’ll simply list:

Chronic pain is not simply acute pain which has lasted a long time. Acute pain is well-understood and it responds quite well to medication. Once it becomes chronic, it takes on a very different nature.  It affects the whole person, the whole life, and treatments have to be adjusted accordingly.

One specific change is that pain often becomes neurogenic or neuropathic, or what is sometimes referred to as central sensitization. That means that it generates on its own, with no injury or disease to provoke it. The origin is in the nerves which have transmitted the same sensation for so long that they are generating the pain on their own.

Very often, physicians cannot find a physical cause for chronic pain. This does NOT mean the pain is “all in your head”. It is very real, as anyone feeling it will readily tell you. But, while not originating in the brain, it is originating in the nerves, at least partially. To put it another way, neurogenic is not psychogenic.

This is one reason why surgery often has unsuccessful outcomes – the source of the pain often cannot be eliminated, and the surgical trauma compounds the problem.

Pain medicine called opioids (that is, narcotic opiates like morphine and codeine, as well as synthetic opiates like methadone and oxycodone), are good for acute (short-term) pain. They are not so good for chronic pain. A few people are able to stay on a constant, modest dose for many, many years, and others take it occasionally for breakthrough episodes of higher pain. But with regular chronic use, you will develop tolerance, meaning more medicine is needed to achieve the same result.

Tolerance and addiction also mean that more of the negative effects come into play.  Withdrawal, for example.  Also they cause respiratory depression, which causes people die in their sleep.  The effect of respiratory depression lasts longer than the analgesic effect.  And so, patients will often take more medication when it seems to have worn off, and they essentially double down on the risk of fatality.  Add obesity, benzodiazepines, alcohol or other sedatives and and the danger is compounded.

Opioids also reduce mental and physical functioning, so that while pain levels may be marginally lower, so too is quality of life. It is simply not possible to engage as well. But, being anesthetized, the patient may not be as bothered by this as much as everyone else around.

Opioids are sneaky drugs which, as another side-effect, will create a tremendous craving for more.

Finally, they also cause hyperesthesia: lower pain tolerance. Where once a simple knock on the shin may now cause you to curse, later it is so agonizing you can barely catch your breath to cry.

What does this mean for you? In working with your health practitioner, one very important goal is to reduce the pain. But pain-reduction is only one goal, not to be over-emphasized at the expense of others. Note that the word here is reduction, not elimination. Many studies tell us that a 30% reduction is that medication can give. To aim higher is to invite trouble.

It is hard to get used to the idea that a largely pain-free life is out of reach. You will mourn the loss.  But coming to accept the new reality will bring you a new peace.

That was the bad news. Your chronic pain might not be curable, and seeking a cure can make it worse. The good news is that it is treatable, and can always be managed more effectively. Reformulate your goals, your routines and your boundaries, focusing on where you have direct control, and you can reclaim your life.

For example, expand your resources for managing pain. The first on the list of resources is relaxation and stress management. Relaxation is a skill, and it will help to practice and develop your skills in more than one method. Stress and tension mean more pain and lower pain tolerance. Relaxation is the solution.

More on relaxation: I am not talking about run-of-the-mill relaxation, which you undoubtedly practice. I’m talking about powerful relaxation. It’s a discipline which requires a bit of study and daily practice.  The goal is not to become drowsy, but actually to become more alert.

Other resources may include massage, herbs, acupuncture, aromatherapy…in fact, many others – anything and everything to expand on what you have.  Just keep in mind that the goal is not to take away the pain but to improve your management of it.

Ask your prescriber about other medicines. Old-fashioned antidepressants called tricyclics (nortriptyline, desipramine, imipramine, and others), have a good track record with pain management. And you may not need the levels which are needed for depression. They have side-effects but one of them, sedation, is great for sleep, inducing a better quality of sleep (that is, with late-onset REM stage), than other sleep medications (which tend to induce early-onset REM and a less restorative sleep).

Whether with tricyclic medications or not, take care of insomnia. You cannot cope well or heal well without adequate sleep. See relaxation, above.

Expand your activity and areas of involvement. You may not feel like this is helping at first, but it will. The less engagement in life, the more your attention will go to your pain. Meanwhile, life should be meaningful, no matter what our challenges.

Exercise. Yes, I know you get this all the time. It is the overlooked panacea. It helps with energy, with depression and of course with health. And the best way to allow pain to grow and take root is to allow your strength and flexibility to deteriorate. So one more time: Exercise. As long as it is not aggravating an injury, do it every day, no matter how much you hurt. Start with something absurdly modest, but do it daily. When you lapse, as you inevitably will at first, don’t get discouraged. Eventually it will become as automatic a part of your day as brushing your teeth. For more on this, click here.

So to sum up: The way to live with chronic pain is to live with it. Take back the driver’s seat.  Work on all the ways to diminish the pain, and no matter how much it remains, diminish its power by striving to make your life healthy, rich and meaningful.

How can I decide whether to take an antidepressant medication?

Answer:

It’s good to be ambivalent. Careful thought is better than little thought. Usually, I will support the decision a patient makes. Occasionally, I’ll lean on someone to take something or to delay taking it. Here are guidelines I’ll often bring up in a discussion about the decision:

You may want to gather information, but you may also want to limit your research. The more you cruise the information sources, the more you may find that there are few established facts that aren’t contradicted by someone. I myself hold with the dominant view that most people who take an antidepressant are helped, and that the benefit outweighs the consequences. As with all health information, consider the source. Treat carefully any testimonials, no matter how impassioned or who they are from. Take the same care with information that comes from the pharmaceutical companies as well as that which comes from the rabid zealots in any camp.

If you are inclined against taking medication, you should ask yourself how much energy you are prepared to put into the alternatives. A passive sit-and-wait strategy may or may not be a good one, whereas a reasonable plan of action should give you more confidence. You should also ask, if I’m not doing badly enough to take a medication now, how much worse would it have to get to change my mind? How will I know when I’m there, and can get past my hesitation if I get there?

If you are inclined to take it, can you make a good commitment to doing it right? This means taking it daily as prescribed, keeping in touch with the one who prescribes it, tolerating the manageable side effects, and staying on it for a long-enough period of time. As a general rule, eight months is the shortest period of time anyone should be on the medication, and longer is often better, depending on your specifics. While on it, would you enjoy the benefit with complacency, or could you use the opportunity to learn what got you down and what can keep you up, so that you’ll be equipped to stay off it once finished?

My doctor has advised me start taking an antidepressant. She tells me they are not addictive but I don’t understand how they can’t be. If you rely on a drug to be happy, isn’t that a form of dependence?

Answer:

You may choose to go without a medication for any number of reasons, but this should not be one of them. I hope that some points here can lay the concern to rest.

A minority of those who take an antidepressant do take it indefinitely, but this is always a free choice, usually for one who has had recurrent or chronic depression. For most others, it is taken for roughly eight to twelve months. This way, the chances of remaining depression-free are better. I advise people that they can use this window of time while on medication to improve the odds even further. By learning a bit about your own risk factors and in putting some self-care habits in place, you can assure yourself that you are coming out with a higher level of emotional resilience and a smaller chance you will need medication ever again.

Now we’ll get a little technical. The drugs that are addictive have several characteristics that set them fully apart from the antidepressants:

1.  The tolerance effect. This is when you must gradually take more of the same drug to experience the same results. As addiction becomes severe, say with narcotics or alcohol, it is no longer taken for pleasure, but simply to avoid pain.
2.  Craving. I myself crave coffee in the morning. As much as anyone might appreciate the effect of an antidepressant, “craving” is not a word used to describe the motivation in taking it.
3.  Loss of control. Most of us are familiar with how an addict might take a desired substance in spite of efforts not to. Getting off the wagon is as easy as falling. Those on antidepressants are able to stop when they choose, and do not continue if it goes against their better judgment.
4.  Addictive chemicals (at times behaviors too, such as gambling) induce a euphoric effect of some kind. Antidepressants on the other hand do not. They have no street value.
5.  Several other features might be included depending on who you ask, such as denial, secrecy, accelerating use despite mounting consequences and reorganizing one’s life to facilitate continued access to the drug.

Here is where confusion comes in: It is true that most of the antidepressants have one thing in common with addictive drugs – the withdrawal effect. If you stop “cold turkey” you are likely to experience unpleasant physical consequences. With some of the other substances, occasionally with alcohol for instance, this can be lethal. Among the antidepressants, Paxil (paroxetine) and Effexor (venlafaxine) are noted for the potential withdrawal effects. These occur in part because the chemical is eliminated from the body quickly, while the other drugs take longer, making for a sort of a natural tapering effect. The withdrawal can be highly uncomfortable – nausea, dizziness, agitation and many other unpleasant symptoms. Another consequence of going off any of the antidepressants too quickly is that you are at higher risk for relapsing into depression.

All of this is avoidable however if you follow this advice: If you choose to take an antidepressant, it should be in your system for a long-enough period of time, and you must taper off the medication gradually, in a planned way. Your prescriber should give you the uncomplicated specifics. The process simply needs due attention, not undue fear.

I’ve just been told I have bipolar affective disorder. Just what does this mean?
 

Answer:

I’ll very briefly summarize some important points about bipolar disorder, years ago called manic-depressive illness. First, it is important to differentiate it from unipolar depression for one primary reason: the treatments are different. For example, the mood-stabilizing medications (one being lithium) are the first-choice option much more often than are the antidepressants.  If you have something of an “under the radar” form of bipolar and go on an antidepressant, it can at times bring about a full-blown manic episode. Another difference is that there is more of a congenital predisposition to bipolar disorder. That is, to a large degree it is something you are born with, whereas other forms of depression a less predetermined. Features of mania may include symptoms such as rapid, pressured speech, racing thoughts, grandiosity or inflated self-esteem, poor judgment, reckless behavior, high distractibility, agitation, a general spike in eccentric behavior and, at times, psychotic features such as delusions or hallucinations. These and other symptoms would be prominent enough to cause notable consequences.

There are various types of bipolar, such cyclothymia, kind of a low-grade version. There is a mixed state, where elements of mania and depression occur together, and bipolar II, where depression seems to be the primary problem and the up-swings are “hypo-manic”, shorter-lasting and less extreme.

Unlike with “basic” depression (if only there was such a thing), those with bipolar need to keep a wary eye on early warning signs for upward as well as downward swings. You may need to be extra careful to keep your life routine and filled with other stabilizing influences such as good social connections and solid self-care practices. Medications may well be a necessity for a long time, whether you like it or not, and the prescriber may need to be a psychiatrist or otherwise have specialized knowledge.

For more information, a good place to start is http://dbsallianc.org/.