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Chronic Pain
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Pain



Related terms
Background
Treatment
Author information
Bibliography
Types of pain

Related Terms
  • Abdominal pain, aches and pains, acute, analgesia, anesthesia, anti-inflammatory, anxiety, arthritis, breakthrough pain, burn pain, cancer pain, cardiopulmonary bypass, CBT, chemotherapy, chronic, chronic pain, cognitive behavioral therapy, complex regional pain syndrome, contrast dye, CRPS, cutaneous, dental analgesia, dental pain, depression, electromyelography, EMG, fatigue, fibromyalgia, herpes zoster, hypochondria, immunomodulator, inflammation, intractable, leg pain, libido, magnetic resonance imaging, metastasis, MRI, multiple sclerosis, musculoskeletal pain, NCS, nerve conduction studies, neuropathic pain, nociceptive pain, nocioreceptor, non-opiate, non-opioid, non-steroidal anti-inflammatory drug, NSAID, opiate, opioid, osteoarthritis, osteoporosis, OTC, over-the-counter, patient-controlled analgesia, PCA, pelvic pain, phantom limb pain, psychogenic pain, rheumatoid arthritis, shingles, shoulder pain, somatic pain, spinal tap, tachycardia, thoracic pain, vascular, viscera, visceral, x-ray.

Background
  • Pain is defined as an unpleasant sensory and emotional experience associated with damage to body tissues, including organs, bones, and muscles.
  • Pain is the most common reason individuals seek medical care. Pain is often classified as acute (immediate, short-term) or chronic (long-term).
  • Approximately 30-40 million Americans annually do not experience symptom relief with use of over-the-counter (OTC) analgesics, such as acetaminophen (Tylenol®), aspirin, and ibuprofen (Advil®). Some researchers estimate that 35% of Americans experience chronic pain.
  • According to the National Institutes of Health (NIH), the annual cost of chronic pain in the United States, including healthcare expenses, lost income, and lost productivity, is estimated to be about $100 billion.
  • The four most common types of pain are lower back pain, severe headache or migraine pain, neck pain, and facial ache or pain. Back pain is the leading cause of disability in Americans under 45 years old.
  • There is no objective measurement of pain for individuals. Pain can only be reported by the individual experiencing it.

Treatment
  • Pain treatment or management is generally more effective from a multidisciplinary approach that includes medications (analgesics such as narcotics or non-steroidal anti-inflammatory drugs and pain modifiers such as tricyclic antidepressants or anticonvulsants), non-pharmacologic measures (such as interventional procedures, physical therapy and physical exercise, application of ice and/or heat), and psychological measures (such as biofeedback and cognitive therapy). Analgesics are medications given to reduce pain without resulting in loss of consciousness. Doctors choose an analgesic based on the type and duration of pain and on the likely benefits and risks. Most analgesics are effective for nociceptive pain but are less effective for neuropathic or nerve pain. For some types of pain, especially chronic pain, non-drug treatments are also important, including acupuncture and biofeedback.
  • Pain management practitioners include doctors who specialize in pain management, such as anesthesiologists, neurologists, and psychiatrists. Nurses, nurse practitioners, physician assistants, pharmacists, occupational therapists, and psychologists also are part of a pain management team to ensure that adequate pain control for each individual is achieved.
  • The treatment of pain depends upon the causes of the pain and the individual's tolerance of pain.
  • Medications:
  • Prescription and non-prescription medications are one of the most common methods of treating all types of pain. Doctors may use various combinations and doses of medications. With pain medications used for chronic pain, the most serious considerations are for excessive sedation, severe constipation, and under usage. If the individual is not adequately relieved of the pain, or is relieved for only a part of the day, the treatment is inadequate. Analgesics fall into three categories: opioid (narcotic) analgesics, non-opiate analgesics, and adjuvant analgesics. Adjuvant analgesics are drugs that have weak or nonexistent analgesic action when administered alone but can enhance analgesic actions when given together with known analgesic agents.
  • Non-opioid and opioid analgesics are the main drugs used to treat pain. Opiates are naturally occurring and are derived from the opium poppy (Papaver somniferum). Opioids are synthetic drugs based on the opiate chemical structure and with opiate-like activity. Opioids activate opiate receptors that are widely distributed throughout the brain and body. When the opioid reaches the opiate receptors, it can produce pain relief and also euphoria (a feeling of well-being). The brain itself also produces substances known as endorphins that activate the opiate receptors. Research indicates that endorphins are involved in many things, including respiration, nausea, vomiting, pain modulation, and hormonal regulation. Opiates may be prescribed for the treatment of pain. It is not recommended that opiates be taken beyond the prescribed dosage. Drug abuse leading to addiction and overdose has been reported.
  • Antidepressants, anticonvulsants, and other CNS-active drugs may also be used as adjuvant analgesics in chronic pain or nerve pain.
  • Non-opioids: Non-opioids, such as acetaminophen (Tylenol®), aspirin, and ibuprofen (Motrin®, Advil®), are used to control mild to moderate pain. Some non-opioids can be bought over-the-counter (OTC) without a prescription. Some of these medicines can cause stomach upset, may cause bleeding in the stomach, slow blood clotting, and kidney problems. Acetaminophen does not normally cause these side effects, but high doses or long-term use of it can damage the liver.
  • Prescription non-steroidal anti-inflammatory drugs (NSAIDs), such as flurbiprofen (Ansaid®) and celexocib (Celebrex®) and muscle relaxants, such as cyclobenzaprine (Flexeril®), may also be used for pain control. Side effects of prescription NSAIDs include stomach upset and nausea.
  • Opioids: Opioid medications are used to control moderate to severe pain. Opioids include natural (opiate) and synthetic drugs, such as morphine (MS Contin®, Astromorph®), hydromorphone (Dilaudid®), hydrocodone (Vicodin®), oxycodone (Roxicodone®, OxyContin®), codeine (Tylenol #3®), fentanyl transdermal (Duragesic®), and methadone (Dolophine®). Opioids may cause constipation, drowsiness, sedation, itching, difficulty urinating, nausea, and vomiting. Opioids may also be physically addictive.
  • Opioids may be combined with other medications to increase effectiveness in treating pain. Examples include Percocet®, a combination of oxycodone and acetaminophen, and Percodan®, a combination of oxycodone and aspirin.
  • For chronic pain, sustained relief formulations of opioids are available that provide a longer duration of relief (generally up to 12 hours), such as with morphine (MS Contin®, Avinza®) and oxycodone (OxyContin®). In severe pain, fentanyl patches (Duragesic®) can be placed on the skin (topically) for longer pain control (up to 72 hours). Opioid medications are also available as suppositories for those who cannot take medications by mouth.
  • Patient-Controlled Analgesia (PCA) has become an acceptable and highly effective means of relieving post-operative pain. PCA is a medication-dispensing unit equipped with a pump attached to an intravenous line, which is inserted into a blood vessel in the individual's hand or arm. By means of a simple push button mechanism, the patient is allowed to self-administer doses of opioid medications on an "as needed" basis. There is usually a "lockout" period to prevent the individual from taking too much opiate medication. However, prior to release from the hospital, the individual is weaned from the PCA and given oral medication to control pain. Benefits of PCA include: less apprehension by the individual with pain; narcotic addiction can be avoided because the drug is taken on a short-term controlled basis; pain relief is available around the clock; there is no waiting period for a nurse to deliver pain medication; the individual is assured they are receiving the correct medication and dose prescribed by their physician; doses are smaller and available more frequently, which helps prevent sleepiness and fatigue; and pain is more consistently controlled.
  • Tramadol (Ultram®) is a prescription medication that has opiate-like activity but seems to have less addictive and abuse potential than conventional opiates, such as hydrocodone (Vicodin®) and oxycodone (Oxycontin®). Buprenophine (Buprenex®) and butorphanol (Stadol®) are also opiate-like drugs that are used for the treatment of moderate to severe pain.
  • Antidepressants: Antidepressant medications, such as amitriptyline (Elavil®), doxepin (Sinequan®), or trazodone (Desyrel®) may be used to help control tingling or burning pain from damaged nerves. These drugs may also improve sleep. However, these antidepressant medications may cause dry mouth, sleepiness, blurred vision, and constipation.
  • Anti-epileptics: Anti-epileptic (or anticonvulsant) medications, such as gabapentin (Neurontin®) or valproic acid (Depakote® or Depakene®), may help control tingling or burning from nerve injury. These medications may cause drowsiness and may damage the liver and lower the number of red and white cells in the blood. A doctor will order regular blood tests to check for these effects.
  • Corticosteroids: Corticosteroids, or steroids, may help relieve bone pain, pain caused by spinal cord and brain tumors, and pain caused by inflammation. Steroids include prednisone (Deltasone®) and dexamethasone (Decadron®). Steroids may cause fluid to build up in the body and may also cause bleeding, irritation to the stomach, increased blood sugar, muscle weakness, and may decrease immunity. Steroids also increase appetite. Confusion is a problem for some individuals while taking steroids.
  • Others: Pain relievers that are applied directly to the skin (topical analgesics) for localized pain include lidocaine patch (Lidoderm®), commonly used in shingles (nerve pain caused by a herpes virus).
  • Pain clinics: Pain clinics, or pain management centers, are facilities that help individuals deal with chronic pain. A pain clinic may be in a wing of the local hospital or medical center, in a separate medical-professional building, or in a doctor's office. Some pain clinics are affiliated with medical schools and large healthcare centers. Pain clinics have healthcare professionals trained in the field of pain management. The pain centers offer more individual care for chronic pain management, helping the individual receive the most efficient pain control for their unique situation. Pain centers also help the individual with the addictive component of opiate medications in the treatment of pain.
  • Individuals with active addictive disorder or a substance abuse history are at increased risk of receiving inadequate pain management, because of a fear of increasing addiction by using opioid medications, lack of knowledge about addiction, doctor barriers including inadequate training in pain management and addiction medicine, and fear of regulatory sanctions contributing to under-treatment.
  • Other therapies:
  • Psychological treatment: Psychological factors such as mood, beliefs about pain, and coping skills have been found to play an important role in an individual's adjustment to chronic pain. When pain persists for an extended period of time, the individual may avoid doing regular activities for fear of further injury or increased pain, including work, social activities, exercise, or hobbies. As the individual withdraws and becomes less active, their muscles may become weaker, they may begin to gain or lose weight, and their overall physical conditioning may decline. This can contribute to the belief that one is disabled. As pain persists, the person may develop negative beliefs about their experience of pain, such as the feeling of never getting better. These types of thoughts can maintain the pain cycle.
  • Cognitive behavioral therapy (CBT): Cognitive behavioral therapy (CBT) is a psychological treatment that has been found to be highly effective in helping patients to reduce pain, disability, and distress. CBT for chronic pain management involves modifying negative thoughts related to pain, such as feelings or worthlessness or hopelessness. CBT also helps increase the individual's activity level and productive functioning. This approach for pain management has been shown to be highly effective in promoting positive cognitive and behavioral changes in individuals with chronic pain. Treatment can be delivered individually or in a group setting. CBT for pain management is tailored to the individual needs of the patient but may include relaxation training, cognitive restructuring (different ways of thinking about problems and stress), stress and anger management, sleep quality, and activity pacing.
  • Physical therapy and exercise: A physical therapist can apply a variety of treatments, such as heat, ice, ultrasound, electrical stimulation, and muscle release techniques, to areas where pain originates. As pain improves, the physical therapist can teach the individual specific exercises to increase flexibility, strengthen the back and abdominal muscles, and improve posture. Regular use of these techniques may help prevent pain from coming back. Exercise can correct current back problems, help prevent new ones, and relieve back pain, particularly after an injury. Proper exercise strengthens back muscles that support the spine and strengthens the abdomen, arms, and legs, reducing strain on the back. Exercise also strengthens bones and reduces the risk of falls and injuries.

Author information
  • This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography
  1. American Association of Neurological Surgeons. .
  2. American Chiropractic Association. .
  3. American Chronic Pain Association. .
  4. American Pain Foundation. .
  5. Andersen RE, Crespo CJ, Bartlett SJ, et al. Relationship between body weight gain and significant knee, hip, and back pain in older Americans. Obes Res. 2003;11(10):1159-62.
  6. The Movement Disorder Society. .
  7. National Institute of Neurological Disorders and Stroke. .
  8. National Pain Foundation. .
  9. Natural Standard: The Authority on Integrative Medicine. .
  10. Porter SE, Hanley EN Jr. The musculoskeletal effects of smoking. J Am Acad Orthop Surg. 2001;9(1):9-17.
  11. Smith CA, Collins CT, Cyna AM, et al. Complementary and alternative therapies for pain management in labour. Cochrane Database Syst Rev. 2006;(4):CD003521.
  12. Vas J, Perea-Milla E, Mendez C, et al. Efficacy and safety of acupuncture for chronic uncomplicated neck pain: a randomised controlled study. Pain. 2006;126(1-3):245-55.
  13. Wager TD, Scott DJ, Zubieta JK. Placebo effects on human micro-opioid activity during pain. Proc Natl Acad Sci U S A. 2007;104(26):11056-61.
  14. White A, Foster NE, Cummings M, et al. Acupuncture treatment for chronic knee pain: a systematic review. Rheumatology (Oxford). 2007;46(3):384-90.

Types of pain
  • Pain can either be acute (immediate and short-term) or chronic (long-term, lasting more then three months). Various pains are treated differently, based on severity and type. Pain can also be divided into categories that help explain its origin in the body and its effects on the body. The types of pain include nerve or neuropathic, nociceptive, or psychogenic.
  • Acute pain: Acute pain is a normal sensation in the nervous system to alert the individual to possible injury. Acute pain is triggered by a stimulus, such as getting cut by a knife, getting burned, or falling on a rock. Acute pain is frequently associated with anxiety, tachycardia (fast heart rate), increased respiratory rate, increased blood pressure, diaphoresis (sweating), and dilated pupils. Acute pain, for the most part, results from injury to tissues and/or inflammation. Acute pain generally has a sudden onset. For example, after trauma or surgery, acute pain may be accompanied by anxiety or emotional distress.
  • Chronic pain: Chronic pain is resistant to most medical treatments. Chronic pain can, and often does, cause severe problems for the individual. Pain signals keep firing in the nervous system for weeks, months, even years. Initial injuries, such as an infection, sprained back, or sprained muscle, may cause acute pain that may lead to chronic pain. There may be an ongoing cause of pain, such as in back pain, arthritis, diabetes (diabetic neuropathy), or cancer. Some individuals suffer chronic pain in the absence of any past injury or evidence of body damage. Many chronic pain conditions affect older adults.
  • Common chronic pain complaints include headache, lower back pain, cancer pain, arthritis pain, neuropathic pain (pain resulting from damage to the peripheral nerves or to the central nervous system itself), and psychogenic pain (pain not due to past disease or injury or any visible sign of damage inside or outside the nervous system).
  • Chronic pain may be associated with vegetative signs, such as fatigue (extreme tiredness), loss of libido (sexual drive), loss of appetite, and depressed mood. Individuals vary considerably in their tolerance for pain. Chronic pain is widely believed to represent disease itself. It can be made much worse by environmental and psychological factors.
  • Nerve pain: Nerve pain, or neuropathic pain, is caused by pressure or damage to nerves or the spinal cord. Nerve pain can be caused by: tumors; injury, such as during surgery or falls; chemical damage, such as with mercury, lead, chemotherapy, and radiation; or viruses, such as herpes zoster (shingles or chicken pox).
  • Nerve pain is severe and usually described as burning or tingling. Nerve pain usually occurs in one particular place on the body or along the path of a nerve. Nerve pain can occur in entire limbs, such as the legs or arms. Nerve pain has very different medication treatment options from other types of pain. For example, opioids (such as morphine) and non-steroidal anti-inflammatory drugs, or NSAIDs (such as ibuprofen, COX-2 inhibitors), are usually ineffective in relieving nerve pain.
  • Phantom pain is a type of nerve pain felt where an amputated limb used to be. The individual feels the presence of a missing limb through pain and sensation. Some secondary sources report that 60-70% of people who have had an arm or leg removed feel phantom limb pain. The pain may resemble squeezing, burning, or crushing sensations, but it often differs from any sensation previously experienced. For some people, phantom limb pain occurs less frequently as time passes, but for others, it persists. Massage can sometimes help, but drug therapy is sometimes necessary.
  • Nociceptive pain: Most pain is nociceptive pain. This type of pain is typically aching, sharp, or throbbing. Pain receptors for tissue injury (nocioreceptors) are located mostly in the skin or in the internal organs. These nocioreceptors are nerve fibers in the body that only send signals to the brain when they receive strong stimulation, such as with pain. Damage to these nocioreceptor neurons alters the way that they can respond to neurochemicals and makes them more sensitive after injury, which may be the cause of some types of chronic pain. Damage also causes the cells to release chemical mediators of pain and inflammation, including potassium ions, bradykinin, prostaglandins, serotonin, histamine, and substance P. Nociceptive pain is caused by an injury to body tissues. The injury may be a cut, bruise, bone fracture, crush injury, tumor invasion, burn, or anything that damages tissues. The pain experienced after surgery is almost always nociceptive pain. The pain may be constant or intermittent, often worsening when an individual moves, coughs, laughs, or breathes deeply or when the dressings over the surgical wound are changed. Nociceptive pain can be further divided into somatic pain and visceral pain.
  • Somatic pain is pain caused by activation of pain receptors in cutaneous (body surface) or deep tissues, such as muscle and bone. Common causes of somatic pain include minor problems such as paper cuts, burns, or scrapes. Severe somatic pain can occur with metastasis (spreading) of cancer into the bone, and post-surgical pain from a surgical incision, such as after cardiopulmonary bypass. Somatic pain is generally localized in one area of the body and is intense, sharp, and easily identifiable as compared to throbbing visceral pain.
  • The viscera refers to the internal areas of the body that are enclosed within a cavity. Visceral pain is caused by activation of pain receptors in the thoracic (chest), abdominal, or pelvic viscera. Common causes of visceral pain include pancreatic cancer, kidney disease, and metastases in the abdomen. Visceral pain is not well localized and is usually described as pressure-like, deep squeezing.
  • Psychogenic pain: Psychogenic pain is pain of psychological origin. Psychogenic pain is entirely or mostly related to a psychological disorder, such as hypochondria (health anxiety phobia). Psychogenic pain does cause physical pain. When individuals have persistent pain with evidence of psychological disturbances and without evidence of a disorder that could cause the pain, the pain may be described as psychogenic. Pain that is purely psychogenic is rare. Pain complicated by psychological factors still requires treatment, often by a team that includes a psychologist or psychiatrist. For most individuals who have chronic psychogenic pain, the goals of treatment are to improve comfort and physical and psychological function. Medications, including antidepressants, and psychological counseling are often used.

Copyright © 2011 Natural Standard (www.naturalstandard.com)


The information in this monograph is intended for informational purposes only, and is meant to help users better understand health concerns. Information is based on review of scientific research data, historical practice patterns, and clinical experience. This information should not be interpreted as specific medical advice. Users should consult with a qualified healthcare provider for specific questions regarding therapies, diagnosis and/or health conditions, prior to making therapeutic decisions.



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