Chronic Pain

Question:  How can I live with my constant low back pain when my doctor won’t give me the medications I need?

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.

2 Responses to “Chronic Pain”

  1. Kathleen Says:

    I am a person who has lived with severe chronic pain for 15 years. I have taken opiates for almost as long. I am also very intelligent, high functioning, and a former nurse. Therefore, I feel justified in taking you to task on this cavalier, oversimplified and very debatable answer. In fact, my gut response to you is a simple “How dare you!”
    Chronic pain is multifacted; each person with chronic pain has any number of factors contributing to his or her pain-physical,psychological, social, behavioral and interpersonal factors all play a role in how a person experiences pain, as do many environmental factors, too many to enumerate here. Most people with severe chronic pain need a multidisciplinary approach to their pain problem to achieve optimal results. And one of those disciplines-an extremely important one- is pharmacologic intervention-that is, medication.

    Your response regarding opiates is categorically inaccurate and, in my opinion, designed to frighten and control the person asking for your help rather than inform him. Tolerance, for example, while a sometimes unavoidable effect of opioid use, is not a prescription for “dying in your sleep.” and does not always require an increase in the dose of opioids a person receives. Many times the addition of an adjunctive medication, such as an antidepressantr or NSAID, is more effective than just increasing the narcotic medication. In fact, using different classes of medications is a common treatment strategy used by most pain management specialists. Furthermore, most practitioners of pain medicine take the “start low and go slow” approach to opiates, and many times a patient will need several dose adjustments before his pain is satisfactorily controlled. If done properly, this will not lead to any serious negative side effects. Finally, respiratory depression does not always result in death, and it is certainly not the only reason people die in their sleep.

    Virtually all of your statements about opioids are as fraught with inaccuracy and innuendo as this example. For instance, the statement you made about opioids decreasing a persons level of functioning is -as a rule-patently incorrect. In fact, the exact opposite is almost always true. Pain causes people to be fatigued, irritable, unable to concentrate, and depressed-to name just a few of the common “side effects” of chronic pain. When a person’s pain is decreased to a tolerable level, he or she will virtually always experience improved functioning. He will be more awake, more interested in social engagement, more active and -usually within 72 hours-able to resume many or his normal activities such as driving, caring for children, and going to work. (with the approval of his physician, of course.)

    And as to your veiled reference to the fact that chronic opioid use causes addiction- “Opioids are sneaky drugs which, as another common side-effect, can create a tremendous craving for more.”-it too, is simply not supported by any factual data. Just the opposite, in fact. Even in young people, whose desire for new experiences often overshadows good sense, the incidence of prescription opioid use causing narcotic addiction is minimal… as is-by the way-evidence that opioids in general cause hyperesthesia. It is true that this phenomenon has been observed in some individuals. However, in now way is “obervation” or experiential data a substitute for valid scientific research, which at this time simply does not exist in sufficient quantity to support your sweeping generalization.

    While much of the rest of your suggestions are quite valid, they are sadly overshadowed by the inaccuracy of your overtly prejudiced and prejudicial statements about opioid use. Might I suggest that before you write again about a subject as important as this one you get your facts straight first.

  2. Tom Linde Says:

    Kathleen, thanks for the thoughtful response!
    We agree on many things. Chronic pain certainly is “multifactorial”, influenced by so many variables and each person’s case is distinct from others. A multidisciplinary treatment approach is the gold standard. Pain itself certainly can be debilitating, and good control of the pain will improve functioning and quality of life. Chronic opioid treatment (COT) does indeed work for many people and I erred in not emphasising this fact.
    This said, I stand by my statements overall. They come from my reading of the literature, from multiple expert opinions in national conferences and from professional colleagues.
    My piece has been reviewed by two general family physicians and one chronic pain specialist.
    I’ll reiterate several points. There is an ample body of research showing that the best level of relief to be expected from COT is 30%.
    The development of tolerance to opioids, while not at all inevitable, is far, far too common, it is dangerous and it is tragic.
    Respiratory depression is not always fatal…nor are car accidents. Very, very often it is fatal – most often, when opioids are combined with a sedative of any kind.
    I should have used the more specific word hyperalgesia (heightened sensitivity to pain), rather than hyperesthesia (heightened sensitivity to sensory stimulation in general). Google opioid-induced hyperalgesia and then decide if there isn’t some valid scientific research.
    Prescription opioids are creating absolute havoc in adolescents and young adults. Overdose poisoning is now the second-highest cause of accidental death nationally and the highest in many states, including mine, Washington. The vast majority of these poisonings are from opioids and the rate from prescription painkillers has skyrocketed in the last decade.
    I don’t want to get into citing the specific scientific literature to support all of my statements here because it is not what this website is about. But I’ll suggest two links for you:
    http://healthpolicyandreform.nejm.org/?p=13085
    jama.ama-assn.org/content/303/1/21.full
    Finally, this is not that I want to get into jousting with anyone here. But I appreciate the “First, do no harm” credo of physicians, and I fear that iatrogenic (caused by treatment) death, disease and distress is more common than we generally realize. Finally, I want those who suffer to have the broadest set of resources possibly available.

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Tom Linde M.S.W.
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