WHAT IS CHRONIC PAIN? John D. Loeser, M.D. December 11, 2015 Bend, OR ADVICE THAT WILL HELP MOST PATIENTS AND REDUCE THE NUMBER OF RETURN VISITS: GOOD PAIN MANAGEMENT Eat a live toad and nothing worse will happen to you that day. WHERE ARE WE TODAY? TOO MANY OF US ARE FIXATED ON THE BROKEN PART HYPOTHESIS CHRONIC PAIN REQUIRES A NEW WAY OF THINKING
TYPES OF PAIN TYPES OF PAIN Transient Pain Acute Pain Chronic Pain TRANSIENT PAIN Elicited by the activation of nociceptors in the absence of tissue damage. It is ubiquitous in everyday life and rarely a reason to seek health care. Relevant only to procedural pain, this is not a major issue in clinical medicine. It has, however, been the subject of most experimental pain paradigms in man and animals until very recently. ACUTE PAIN Elicited by injury to the body and activation of nociceptive transducers at site of damage. Local injury alters the response characteristics of nociceptors, their central connections, and the autonomic nervous system in the region. Healing of damaged tissue occurs with restoration of normal nociceptor function. Common medical problem: health care blocks pain and facilitates healing.
CHRONIC PAIN Triggered by injury or disease Perpetuated by factors other than those that started the pain Body unable to heal because of nerve injury or loss of body part Stress, affective, and environmental factors likely to play a large role. CHRONIC PAIN Not well managed by Cartesian concepts. Requires a bio psycho social model. May be induced by CNS changes in response to injury that are not reversible even though healing occurs. Modulation can be detrimental or beneficial, hence role for psychological therapies. Relentless search for broken part not productive, nor are therapies for this. CHRONIC PAIN WHY? 1. CNS changes persist after injury. 2. Injuries to nervous system generate pain. 3. Genetic differences may determine who gets pain and who does not. 4. Affective responses may differ. 5. Cognitive responses may differ. 6. Some chronic pains may be peripherally driven. PERIPHERALLY DRIVEN CHRONIC PAIN Chronic degenerative hip or knee with pain Fails conservative management Joint replacement: most patients wake up with severe incisional pain and report that the chronic joint pain is gone. Joint pain almost never recurs. Where is the central sensitization that everyone talks about?
CENTRAL PAIN GENERATION Interstitial cystitis or chronic prostatitis pains are usually not relieved by cystectomy or prostatectomy. Of course, neither diagnosis is associated with any itis. CHRONIC PAIN WHY? Afferent input that would not normally signify tissue damage now triggers responses in dorsal horn and other central neurons that looks like the responses to noxious input. Clinically, this is called allodynia. ACUTE PAIN AND CHROIC PAIN SHARE ONLY THE FOUR LETTER WORD PAIN. ACUTE PAIN IS DUE TO TISSUE DAMAGE; CHRONIC PAIN IS USUALLY A MANIFESTATION OF CENTRAL NERVOUS SYSTEM DYSFUNCTION. MUNCH THE SCREAM
SYMPTOM RELIEF AND FUNCTIONAL IMPROVEMENT SHOULD BE THE GOALS OF THE TREATMENT OF A CHRONIC PAIN PATIENT. Ask not only where do you hurt?, but also what does your pain prevent you from doing? And, what would you do if you did not have this pain? SUCCESSFUL THERAPIES FOR CHRONIC PAIN PATIENTS REQURE ACTIVE PATIENT PARTICIPATION. ISSUES IN OFFICE MANAGEMENT OF CHRONIC PAIN PATIENTS Time Treatment planning Engaging the patient Whose pain problem is it? Follow up and recidivism
COMPONENTS OF OFFICE MANAGEMENT Drugs Physical activity Sleep hygiene Cognitive/behavioral Goal setting Work status Contract? PHYSICAL ACTIVITY Required for the well being of every organ General conditioning Specific exercise for injured part of body Role of PT is to educate patient, most do not need extensive physical therapy Passive modalities are of little value SLEEP HYGIENE SLEEP A good night s sleep makes everything better Physical and mental activities during the day hasten sleep at night Use behavioral and cognitive strategies to enhance sleep Tricyclic antidepressants are often helpful All sedative/hypnotics are short duration drugs
MEDICATIONS CAN BE USEFUL AS A COMPONENT OF CHRONIC PAIN MANAGEMENT Antidepressants Anticonvulsants Anti inflammatories Analgesics Opioids INAPPROPRIATE MEDICATION USE IS COMMON IN CHRONIC PAIN PATIENTS If drug is not successful in reducing pain and increasing function, consider tapering and discontinuing it. It is relatively easy to get patients off of opioids; benzodiazepines are more difficult. Muscle relaxants are sedatives and have no effect on muscle tone. In general, they are bad for patients. MANAGEMENT OF INAPPROPRIATE MEDICATION USAGE IS A MAJOR COMPONENT OF THE TREATMENT OF THE CHRONIC PAIN PATIENT. PHYSICAL ACTIVITY IS A COMPONENT OF EFFECTIVE CHRONIC PAIN MANAGEMENT. Strength Flexibility Endurance Utilize an incremental program that rewards performance, not the complaint of pain.
BE CERTAIN THAT THE PATIENT UNDERSTANDS THAT HURT AND HARM ARE NOT SYNONYMS. COGNITIVE AND BEHAVIORAL STRATEGIES Have a psychologist trained in pain management available for consultation and treatment when necessary People who have something better to do do not hurt as much Look for small steps toward ultimate goal Rewards for progress WHOSE PAIN IS IT? Do not let the patient give you the responsibility for his pain The patient must decide if the pain will run his life or if he will contain the pain Health care providers can provide treatment resources and support; the patient must do the work GOAL SETTING Realistic measures of success Build in achievable goals Expect fluctuations Have contingency plans Schedule return visits Involve family
ADDRESSING THE COMORBIDITIES SHOULD BE A CORNERSTONE OF PATIENT MANAGEMENT. CO MORBIDITIES OF CHRONIC PAIN PATIENTS Depression De activation Drug mis use Disability Inappropriate beliefs about the body Catastrophizing Misinformation from docs and peers RELIEF OF PAIN IS ONLY ONE ASPECT OF THE TREATMENT OF A CHRONIC PAIN PATIENT. Alleviating the co morbidities is also essential for a good outcome. PAIN MANAGEMENT MUST BECOME PART OF GENERAL MEDICAL PRACTICE; THERE ARE NOT ENOUGH SPECIALISTS TO HANDLE THE NUMBER OF PATIENTS WHO SUFFER.
PHYSICIANS DO MORE THAN APPLY TECHNOLOGY. SINCE THE DAWN OF HISTORY THEY HAVE OFFERED INFORMATION. CONSOLATION, SYMPATHY, AND TRUST. THEY ALSO DETERMINE THE RELATIONSHIP BETWEEN THE PATIENT AND SOCIETY BY APPLYING A DIAGNOSIS. THANK YOU