Managing Chronic Pain

Helen Dearman, 52, of Houston, had a broken back for more than a decade and didn't know it. After falling from a ski lift in Mt. Hood, Ore., when she was 23, Dearman was diagnosed with a broken left arm and thought that was her only injury. Her arm healed. But she developed excruciating back pain that made it hard to sleep and move around. "I worked as a teacher, so some doctors suggested that the problem was from standing on my feet all day," Dearman says. "Others told me it was all in my head. For years, I left doctors' offices feeling desperate for help."

The pain grew worse during her 30s. One morning, Dearman woke up with stabbing pains in her back and could barely walk. This time, her husband took her to an orthopedic surgeon who specialized in back problems. The doctor ordered X-rays that revealed three old fractures in Dearman's spine.

"When the doctor showed me the X-rays, I cried," Dearman says. "Someone had finally given me the words and understanding for all the pain I had been suffering from for so long."

Pain That Persists

WBy definition, acute pain after surgery or trauma comes on suddenly and lasts for a limited time, whereas chronic pain persists. "Acute pain is a direct response to disease or injury to tissue, and presumably it will subside when you treat the disease or injury," says Sharon Hertz, M.D., deputy director in the Food and Drug Administration's Division of Anti-Inflammatory, Analgesic, and Ophthalmologic Drug Products. "Chronic pain goes on and on--for months or even years."

Common types of chronic pain include back pain, headaches, arthritis, cancer pain, and neuropathic pain, which results from injury to nerves. In Dearman's case, her untreated back injury caused her spine to twist out of place, not only resulting in severe back pain, but also putting intense pressure on the nerves in her legs. "I often felt pain shooting down my legs," she says, "like a jolt of electricity."

Experts say the first step in treating chronic pain is to identify the source of the pain, if possible. Many people with chronic pain try to tough it out, according to research from the American Academy of Pain Medicine. But persistent pain should never be ignored because it could signal disease or injury that will worsen if left untreated. Sometimes, it turns out that the cause of pain is unknown. Fibromyalgia, for example, is characterized by fatigue and widespread pain in muscles and joints. While scientists have theorized that the condition may be connected to injury, changes in muscle metabolism, or viruses, the exact cause is unclear.

Regardless of the type of chronic pain, the physical and emotional effects can be devastating. Dearman says, "My teaching career suffered, my children were confused about why I always felt bad, and our finances were ruined." Sometimes, she says, she even considered suicide.

Finding Relief

Dearman believes the first two surgeries she had to repair the fractures in her back and realign her spine were necessary. But she questions the four surgeries that followed. "I talked myself into the operating room more than once because I was desperate to feel better," Dearman says. "Even when doctors told me there was only a small chance another surgery would help, I wanted to take the chance." But after several surgeries, Dearman's pain only seemed to be getting worse.

The turning point occurred in 1995 when a physical therapist referred Dearman to a pain management specialist, a professional who takes a multidisciplinary approach to managing pain. She was treated by a team of pain experts. Doctors and nurses worked with her to manage pain medications. Psychologists addressed her depression and anger, and physical therapists helped improve her strength and mobility.

Dearman finally found effective drug treatment with a pump implanted into her abdomen that delivers morphine through a catheter into the fluid surrounding her spine. The pump, called an intrathecal drug infusion pump, is used for severe pain only after other oral and intravenous drug therapies have failed. The pump is programmed to deliver a controlled amount of medication continuously. Risks include surgical complications, such as infection, and complications with the catheter or pump. "It doesn't take away all the pain, but it's a drastic improvement and allows me to be in control of the pain," says Dearman, who also takes other pain medication as needed.

Seddon Savage, M.D., a pain specialist on the faculty of Dartmouth Medical School in Hanover, N.H., says there are times when it's impossible to eliminate pain. "The goal of pain management is to provide as much pain relief as possible and improve functioning," Savage says.

Because pain varies from person to person, treatment is individualized. Someone with arthritis may do well with occasional use of an over-the-counter pain reliever, whereas someone else with arthritis may need a prescription pain reliever and regular aerobic exercise to feel good.

"Treatment for chronic pain is about much more than medication," Savage says. It can also involve stress relief and relaxation, physical therapy, improved sleep and nutrition habits, and exercise. Dearman says that through a multidisciplinary approach to pain management, she also learned to pace her activities so that she is realistic about how much she can do in a certain time period.

Savage recommends that people seek professional help for chronic pain when they feel that pain is interfering with their quality of life. "Start with your primary care physician, who may refer you to other specialists," she says. "Consider asking your doctor about a pain management specialist if you feel that your pain is just not getting better over time." Another reason to seek advice from a specialist is if you are experiencing intolerable side effects from medications.

Concerns About Drug Abuse

One of Dearman's biggest fears was of becoming addicted to pain medications. "It's a common concern for both patients and health providers," says Savage, who specializes in addiction.

"Most forms of chronic pain respond to non-opioid drug treatments," she says. Examples of non-opioid pain relievers, which don't have addiction potential, include aspirin, acetaminophen, ibuprofen, naproxen, and other non-steroidal anti-inflammatory drugs. A combination of different types of analgesic medications at lower doses is often more effective than a single high-dose medication.

"But if opioids are prescribed for your pain, you are not abusing drugs if you are taking the medication as prescribed," Savage says. "Taking doses of drugs to relieve pain is not the same as taking drugs to get high."

Opioids are controlled substances that are potentially addictive. Pain medications containing opioids include Vicodin (hydrocodone), OxyContin and Percocet (oxycodone), MS-Contin (morphine), Tylenol #2, #3 and #4 (codeine), and the Duragesic Patch and Actiq (fentanyl).

June Dahl, Ph.D., director of the American Alliance of Cancer Pain Initiatives and professor of pharmacology at the University of Wisconsin-Madison Medical School, says she recently took a call from a man with cancer who said he stopped taking an opioid pain medication on his own for fear that he was becoming addicted. "But what he described were not signs of addiction, but signs of physical dependence," Dahl says.

Addiction is characterized by craving and compulsive use of drugs. Physical dependence occurs when a person's body adapts to the drug. If someone has become physically dependent on a drug and suddenly stops taking it, withdrawal may occur. These symptoms can include muscle aches, watery nose and eyes, irritability, sweating, and diarrhea. Physical dependence is a normal response to repeated use of opioids and is distinct from psychological addiction.

Savage says that in prescribing potentially addictive medications, doctors should consider patients' personal and family histories of addiction, as well as psychological and social stressors that may affect medication use. Also, some people who begin taking opioid medications for pain as prescribed may later discover that they are using the medication for its psychic brain effects. Physicians need to be aware of this potential adverse effect, and should educate patients and their families about appropriate use of addictive drugs.

To better guide physicians, the Federation of State Medical Boards adopted guidelines for the use of controlled substances for pain treatment in 1998. The guidelines advise physicians on patient evaluations, treatment plans, and medical records.

The use of opioids in pain treatment remains controversial for several reasons. The rate of addiction in the properly treated pain population is unknown. The media has highlighted problems of addiction to pain medicine among celebrities. And there has been considerable drug abuse involving OxyContin, which the FDA approved for moderate-to-severe pain in 1995. The FDA strengthened warnings for oxycodone in 2001, while continuing to recommend appropriate pain control for people living with severe pain.

But experts say that finding a balance between cracking down on drug abusers and protecting people in pain is an ongoing struggle. "Some doctors fear regulatory scrutiny for over-prescribing these drugs," Dahl says. "And concerns about the small segment of people who abuse drugs ends up interfering with effective pain management for others."

Sheryl Kaufman, 40, of Boston, who uses oxycodone and a fentanyl patch for severe pain associated with breast cancer, says she recently filed a grievance with a pharmacy over her struggles to get prescriptions filled. "They made me feel like a criminal," she says. "Sometimes I've had to go without pain medication for two to three days because of delays in filling prescriptions."

The Value of Support

Dearman's experiences with chronic pain led her to establish the National Chronic Pain Society in 2002. The organization provides peer support for people with chronic pain and their families.

"We give people support for dealing with all of the issues that can go along with chronic pain-not having your pain taken seriously, frustration over not finding relief, how to communicate your pain to your doctor, and how to maintain relations with your family," Dearman says.

Penney Cowan, executive director of the American Chronic Pain Association, another peer support organization in Rocklin, Calif., says support systems are important because they give people with pain the coping skills needed to take an active role in their recovery. "Sometimes doctors tell people they'll have to learn to live with the pain," Cowan says. "But too often they stop short of telling them how to accomplish that."

Dearman says finding effective treatment and gaining the skills to live with her pain made all the difference. "It's about being a person first and not letting pain define who you are," she says. "Our motto is: Pain may be unavoidable, but suffering is optional."

By Michelle Meadows, staff writer
FDA Consumer Magazine
March-April 2004

Reviewed by athealth on February 5, 2014.