Ask anyone what is the worst pain they have experienced and you are likely to get one of the following answers: childbirth, a kidney stone, toothache or earache. We have all experienced these last two, and in terms of acute pain, they reach a level of severity far greater than their medical seriousness would suggest they should.
Short-duration pains such as these are felt by the body in a completely different way to more chronic, longer-lasting pain. Whereas paracetemol and codeine will go a long way to alleviating acute pain, a different approach to pain management is required for the chronic variety.
From a medical point of view, chronic pain is defined in terms of its chronicity rather than its cause. Anyone with pain lasting longer than three months comes into this category. The reason for this is that pain which continues for this length of time does not serve any useful function. This is in contrast to acute pain, which is a warning to us that something is wrong. Whereas acute pain travels in a straight line along the nerves of the body, chronic pain is less predictable. It is relatively poorly understood and is the subject of much ongoing medical research. Evidence is emerging to suggest that changes take place in the area of the spinal cord in patients who develop chronic pain. A modulation of the usual pain pathways takes place at "gates" in the spinal cord. These changes make the nerves more sensitive and reactive, and so unpredictable or chronic pain results.
The other important element in chronic pain is our perception of it at the level of our consciousness. This takes place within the brain itself and includes emotional, psychological and even social factors which affect how we "feel" pain. Chronic pain affects about five per cent of the population at some period in their lives. Common sites for this kind of pain include the back and neck. Arthritis, nerve pain after shingles, and chronic pelvic pain are other typical examples.
The treatment of chronic pain usually requires a multi-layered approach. Indeed it is a very good example of the value of a holistic approach to medical problems. Many people find relief from a variety of complementary sources. For people with chronic pain the key to rehabilitation is a pain management programme. The aim of such a programme is that you are taught to manage your pain and to live your life as fully as possible. Medical, psychological, physical therapy and complementary medical techniques are used in combination.
Medical techniques: There is an ever-increasing range of conventional medical treatments available for chronic pain. Some drug approaches include the use of anti-depressant and anti-convulsant medications as pain relievers. This came about following the discovery that an anti-depressant called amitryptalline was effective in the burning pain that affects some people after a dose of shingles. It is used in a much smaller dosage than for depression, so the drug is not acting on the emotions when used in this way.
Anti-convulsants are helpful in the treatment of a "shooting or stabbing" pain. The classical example of this is the pain of trigeminal neuralgia, in which a severe, shooting pain travels up the side of the face along the area served by the trigeminal nerve.
Another drug which is showing great promise is Tramadol. This is a relatively new opiate which, so far, does not appear to carry the addictive risk of its morphine cousins. Your doctor will be able to tell you if you are a suitable candidate for this new agent.
Medical pain specialists are usually anaesthetists by training and can offer a range of treatments. Nerve blocks, in which the anaesthetist injects the nerve with a permanent blocking agent, are helpful in some forms of back pain. The latest technique involves the implantation of spinal cord stimulators. These act by cutting off the painful messages at a spinal level. They are expensive to insert and maintain, but are showing promise in people who have not responded to other types of treatment. Transcutaneous electric nerve stimulation (TENS) machines are very useful in the management of chronic pain. They stimulate the affected nerves in a way that reduces the nerves' ability to transmit pain. TENS machines are readily available for purchase or hire and also from physiotherapists.
Psychological techniques: The area of cognitive behaviour therapy (CBT), a "talking therapy", has brought enormous benefits to people with chronic pain. By addressing the emotional, behavioural and cognitive dimension of the pain experience, it gives people a sense of control over a potentially chaotic situation. The principles are best learnt from a trained cognitive therapist but, increasingly, doctors and other health professionals are becoming aware of the principles of CBT. Through a combination of relaxation therapy, pacing and goal setting, people with chronic pain learn to take an active role in their own recovery.
Physical and complementary therapies: Physical therapy is useful in certain types of chronic pain and is available from trained physiotherapists. Complementary medicine has a definite role to pay also, through techniques such as hypnosis, acupuncture, homeopathy and medical herbalism. Different complementary therapies work for different people. Chronic pain can take over your life and interfere with a number of pleasurable activities which most of us take for granted. It is important to realise that there is a lot more to treating it than simply prescribing drugs; the best outcome will be achieved through a combined approach to pain management.
I hope to return to cognitive behavioural therapy in a future column. In the meantime you may find the following book helpful: Dealing with Chronic Pain - The Pain Management Approach, by Barett et al, published by Onstream Publications (tel: 021-385798).
Dr Muiris Houston can be contacted at mhouston@irish-times.ie