chronic pain
Chronic Pain

Chronic Pain

Do you or does someone you love suffer from chronic pain?  Then this post is for you!  It’s all about chronic pain and how to manage it.  I received a lecture about it and thought how important this topic is and how so many people are affected by it and wanted to share this valuable information.  I just want to say right off that this article is for how to best try to understand and manage chronic pain.  Chronic pain can be devastating, frustrating, and upsetting for those afflicted and their loved ones.  Often there is no complete cure for chronic pain, and this article will discuss ways to take charge and try to proactively minimize pain using new strategies from different approaches.

As always please discuss any medical treatment plan with your personal physician.  Many thanks to my colleague, Dr Samuel Tiglao, who graciously allowed me to use and edit his presentation for this post.

What is Chronic Pain?

  • Pain comes from the Latin word “poena” meaning a fine, a penalty
  • Localized physical suffering associated with bodily disorder (such as disease or an injury) – Merriam-Webster
  • An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage1
  • A somatic perception containing2:
    • A bodily sensation with qualities like those reported during tissue-damaging stimulation
    • An experienced threat associated with this sensation
    • A feeling of unpleasantness or other negative emotion based on this experienced threat
  • Chronic means long term, usually lasting more that 3-6 months

Chronic Pain Fire

Impact of Chronic Pain

  • Over 100 million Americans3 have chronic pain
    • That’s 3 out of 10 Americans based on current population
    • More than Diabetes (25.8 million), Coronary Heart Disease (16.3 million), Stroke (7 million), and Cancer (11.7 million)
  • 63% seek help from their primary care clinicians5
  • 20% of outpatient visits and 12% of all prescriptions6
  • $100 billion dollars per year in direct (ie health care services) and indirect costs (ie lost productivity)6

Acute Vs Chronic Pain

Chronic Pain Management

  • Opioids (narcotics) are not first line or routine therapy
  • Alternative (non-medication) and non-opioid medications are preferred
  • If opioids are used, should be combined with alternative (non-medication) therapy and non-opioid medications
  • Non-opioid medication therapy is more effective and safer

Why Avoid Opioid Prescriptions for Chronic Pain?

  • Pain relief, function, or quality of life does NOT improve with long-term opioid therapy in randomized controlled clinical trials (<6 weeks)
  • Long-term opioid use for chronic pain is associated with serious health risks:
    • Abuse, dependence and overdose (DEATH)

Chronic pain headache

Effective Treatment for Chronic Pain

  • Non-medication (Alternative) therapies
    • Exercise therapy
    • Cognitive-behavioral therapy (Behavioral Health)
  • Non-opioid medication treatments
    • Acetaminophen (Tylenol)
    • NSAIDs (Non-steroidal Anti-Inflammatory Drugs)
    • Selected anticonvulsants (e.g., pregabalin, gabapentin)
    • Selected antidepressants (tricyclics, SNRIs)
  • Interventional approaches
  • Multimodal and multidisciplinary therapies

Exercise Therapy

  • High-quality evidence for reduced pain and improved function for hip or knee osteoarthritis
    • Improvements sustained for at least 2–6 months
  • Previous guidelines strongly recommended aerobic, aquatic, and/or resistance exercises for patients with hip or knee osteoarthritis
  • Can reduce pain and improve function in low back pain
  • Can improve global well-being, fibromyalgia symptoms, and physical function in fibromyalgia
  • Access and cost for gym membership are listed as barriers to exercise
  • In a randomized controlled trial both groups had the same amount of reduced chronic low back pain intensity, frequency, and disability:
    • Relatively low-cost group aerobics
    • Individual physical therapy sessions
  • Low-cost options to integrate exercise:
    • Lucky we live Hawaii because the beach is always a free option for swimming
    • Brisk walking in public spaces
    • Use public recreation facilities (AKA the park or community center) for group exercise
    • YouTube Exercise Videos
    • Borrow exercise books, Videos, and DVDs for FREE from the library

Runners sports medicine

Cognitive Behavioral Therapy (Behavioral Health)

  • Addresses psychosocial contributors to pain and improves function
  • Trains patients in behavioral techniques
  • Helps patients modify situational factors and cognitive processes that exacerbate pain
  • Positive effects on disability and catastrophic thinking

Help You Can Provide For Chronic Pain

  • Encourage patient to take an active role
  • Teach relaxation techniques see link Observing Your Breath Exercises Handout
  • Support engaging in beneficial but potentially anxiety-provoking activities, such as exercise
  • Support patient coping strategies
  • Ask physician about support, self-help, and educational community-based programs
  • Suggest formal therapy with Behavioral Health (Psychologist or Psychiatrist) for people with more entrenched anxiety or fear related to pain, or other significant psychological distress

Acetaminophen (Tylenol)

  • Yes, good old Tylenol is very effective and safe for chronic pain as seen in multiple research trials when people didn’t know it was just Tylenol they were taking
  • Multiple guidelines state acetaminophen is first-line for:
    • Osteoarthritis
    • Low back pain
  • Follow prescribing directions because it can hurt the liver  at > 3-4 grams/day
  • Do not use without discussing with a physician in people with a history of chronic alcohol use or liver disease/failure

chronic pain massage

Non-steroidal Anti-inflammatory Drugs (NSAIDs)

  • Common examples are: Ibuprofen, Aleve, Naproxen, Motrin, Advil, Celebrex, and Mobic
  • NSAIDs first-line treatment for:
    • Osteoarthritis
    • Low back pain
  • NSAIDs risks:
    • Stomach Upset
    • High and prolonged dosages can cause ulcers
    • Bleeding risks because it affects your platelets
      • which is why it is used to help prevent heart attacks
    • Topical NSAIDs have less systemic risk than oral NSAIDs

Anticonvulsants

  • Selected anticonvulsants (e.g., pregabalin, gabapentin) are effective and recommended in multiple guidelines for
    • Neuropathic pain (e.g., diabetic neuropathy, post-herpetic neuralgia)
    • Fibromyalgia symptoms
  • Start pregabalin or gabapentin at low dose and increase gradually given dose-dependent dizziness and sedation
  • Check baseline and periodic CBC and LFTs with carbamazepine

Antidepressants

  • Tricyclic Antidepressants (TCAs, like amitriptyline) and Serotonin & Norepinephrine Reuptake Inhibitors (SNRIs, like duloxetine) are effective and recommended in multiple guidelines for
    • Neuropathic pain (e.g., diabetic neuropathy, post-herpetic neuralgia)
    • Fibromyalgia symptoms
  • TCAs are contraindicated in severe heart disease, especially conduction problems
  • TCAs are started at low dosages, wean up as needed and tolerated
    • Often effective at lower doses than for depression
    • Common side effects include sedation–use at bedtime, and dry mouth

medication and needles

Interventional Approaches

  • Injections can improve short-term pain and function
    • Steroid injections in rheumatoid arthritis, osteoarthritis, and rotator cuff disease
  • Epidural (spinal) injection for lumbar radiculopathy
  • Potential risks
    • Cartilage changes (in osteoarthritis)
    • Infection
    • Rare but serious adverse events associated with epidural (spinal) injection: loss of vision, stroke, paralysis, death

Multidisciplinary Approaches

  • Can reduce long-term pain and disability more effectively than single modalities
  • Involve coordination of medical, psychological, and social aspects of care
  • Are not always available or reimbursed by insurance
  • Can be time-consuming and costly for patients
  • Should be considered for patients not responding to single-modality therapy, or who have severe functional deficits
  • Combinations should be tailored depending on patient needs, cost, and convenience

Alternative Therapies Proven to Work for Chronic Pain

  • Yoga
  • Music Therapy
  • Pet Therapy
  • Adequate Sleep
  • Supplements
    • Omega-3 Fatty Acids (Fish Oil)
    • Vitamin D
      • Low levels associated with fibromyalgia
  • Anti-inflammatory diet click link for examples Bachlet your AI diet-PDF
  • Acupuncture/Acupressure

https://youtu.be/RWMKucuejIs

There’s a App for That!

Here is a listing of FREE Android, iPhone, and iPad Apps for Chronic Pain Management.  To install apps, go to your app store and search for the Red BoldedTerms

Pain Tracking/Pain Journal App:

Pain Care: Electronic pain journal.  Report pain episodes, triggers, and medications. Then get insight into causes of pain and what medication / therapy is effective.  You can share data with physicians.
https://market.android.com/details?id=com.stanislav.android
http://itunes.apple.com/us/app/pain-care/id347787779?mt=8&ls=1

Movement Therapies/ Pain Management for Android:

Daily Yoga for Back: A series of Yoga exercises.  Back muscles and fit figure building routine based on 19 yoga asanas, with an average 10-minute training duration. Demonstration animation to guide you through the whole sequence.
https://market.android.com/details?id=androidcap.dailyyoga.back

Qi Gong Meditation Relaxation: Gentle movement combined with breathing. Qi Gong is a basic form of Tai Chi where you can experience the health benefits of Tai Chi without the years of training.
https://market.android.com/details?id=com.excelatlife.motivation

Perfect Posture Exercises: Back pain is a horrible feeling that affects your entire body. If you do experience back pain, chances are the pain is from your Posture… and the good news is that Posture is something that you can learn to FIX!
https://market.android.com/details?id=com.appbuilder.u42008p85327&feature=search_result#?t=W251bGwsMSwxLDEsImNvbS5hcHBidWlsZGVyLnU0MjAwOHA4NTMyNyJd

Stop Panic & Anxiety: Use Panic Assistance audio to coach you when you experience a panic attack
and to help you learn to tolerate and control anxiety symptoms. Also, can be used to assist with
exposure therapy for Agoraphobia (fear of open spaces).
https://market.android.com/details?id=com.excelatlife.panic

Fix Emotion And Body Pain Hypnosis App: Pain management hypnosis audio by Elizabeth Harford, certified hypnotherapist.  For physical and emotional pain.  Chronic pain feeds itself, creating a self-reinforcing cycle that must be broken and then reversed to bring relief.
https://play.google.com/store/apps/details?id=com.successtrace.fixpainapp&feature=search_result#?t=W10.

Stretching Routines:Stretching keeps muscles flexible and prepares them for movement. This app provides different sets of stretches (or stretching routines) for before and after physical and muscle exercises and sports.
https://play.google.com/store/apps/details?id=com.u440.estiramientos&feature=related_apps#?t=W10.

Movement Therapies For Apple iOS

Daily Yoga: Free Daily Yoga is your own personal yoga instructor. The app contains a 20, 40 and 60
minute yoga routine that steps you through each pose. Each pose is demonstrated by a certified personal trainer, so simply choose your workout length and follow along in the comfort of your own home!
http://itunes.apple.com/us/app/daily-yoga- free/id413817051?mt=8&amp;ls=1

Tai Chi: Fundamentals Tai Chi – a simple but effective Step-by-Step program of exercise and stress reduction. A carefully structured sequence of movements to build up the body’s internal strength,
suppleness, and stamina.
http://itunes.apple.com/us/app/tai-chi- fundamentals-for- ipad/id476232694?mt=8&ls=1

Qi-Gong Lite This is a try and buy version.  Learn how to develop your life power and serenity by working on your Qi. Benefit from both mental and body relaxation.
http://itunes.apple.com/us/app/qi-gong- lite/id419287393?mt=8&amp;ls=1

Universal Breathing – Pranayama.  Balance your life and experience a relaxed meditative state to relieve your daily stresses and tensions.
http://itunes.apple.com/us/app/universal-breathing- pranayama/id435871685?mt=8&amp;ls=1

Anxiety Free Anxiety, tension and stress are common in everyday modern life, and as well as a source
of unhappiness. This App can be used to learn self-hypnosis for tackling many other problems.
http://itunes.apple.com/us/app/anxiety-free/id410805846?mt=8&ls=1

References:

  1. Merskey H, et al Classification of Chronic Pain, 2nd ed, IASP Press, Seattle 1994
  2. Price DD., Psychological Mechanisms of Pain and Analgesia in Progress in Pain Research and Management, IASP Press, Seattle 1999 Vol 15
  3. Dzau VJ, Pizzo PA. Relieving pain in America: insights from an institute of Medicine Committee Current population: 324,600,000
  4. cdc.gov: Division of Nutrition, Physical activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion
  5. National Centers for Health Statistics. Chartbook on trends in the Health of Americans 2006. http://www.cdc.gov/nchs/data/hus/hus06.pdf (Accessed on April 12, 2010).
  6. TIUpdate in pain medicine.AUAlford DP, Liebschutz J, Chen IA, Nicolaidis C, Panda M, Berg KM, Gibson J, Picchioni M, Bair MJ SOJ Gen Intern Med. 2008;23(6):841. Epub 2008 Mar 11. ADBoston University School of Medicine, Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Boston Medical Center, Boston, MA 02118, USA. dan.alford@bmc.org
  7. CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016. JAMA. 2016;315(15):1624-1645
  8. NIH Pain Consortium

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