What is Chronic Pain Syndrome?
Pain is considered a symptom, not a medical condition. Most common type of pain, called acute pain, is a symptom any normal person would experience with no risk factors or underlying medical conditions. When we use a medication for acute pain it is resolved and never experienced again. Examples include, pain experienced from minor bruising, bike injury, cuts on skin etc. This kind of pain would last somewhere from few days to up to 4 weeks.
But, any recurrent or persistent pain associated with or without medical condition lasting more than 12 weeks is categorized as chronic pain. Chronic pain is not limited to specific body part or tissue. It can be related to anything- an injury, nerve damage or some chronic disease.
Chronic pain needs immediate medical attention even though the severity of pain is low.
Examples of chronic pain are: pain in sciatica, pain in fibromyalgia, pain in lupus, lower back pain, chronic neck pain, arthritic pain, neuropathic pain, diabetic neuropathy, persistent back spasms, pain in shingles etc.
Now let us identify what symptoms signal that you need to see your doctor ASAP.
Signs of chronic pain – when to see doctor
- Pain of any severity (mild/moderate/severe) not resolved after enough doses of over the counter pain medications such as acetaminophen (tylenol), ibuprofen, naproxen (NSAIDs)
- Unexpected sharp and burning-sensation kind of pain anywhere in the body without any actual injury in the past (yes chronic pain can also happen without any actual cause)
- If you have pain of any type described above and you also have any of these conditions : sleeping problems, depression, anxiety, panic disorder, diabetes, high blood pressure, cancer, shingles, IBD, arthritis, lupus syndrome, fibromyalgia, sciatica etc.
- If pain is causing unusual emotional disturbances- for example, feeling tired, not wanting to socialize, avoid eating etc.
- Having trouble doing normal daily activities and running errands
Diagnosis of Chronic Pain
At the time of consultation your doctor will do any of these investigation tests and exams to determine if your pain is chronic and refer the patient to an appropriate specialist such as osteopath, Rheumatologist, neurologist etc.
- CT-Scan or MRI test to find out the affected tissue
- Clinical history- most importantly measuring pain threshold and determining the severity of pain on a scale of of 1-10
- Neurological exam to study your nervous system responses
- Electromyogram test – a test of your muscle cells activity
- Psychological history – questionnaire or interviews to find out any underlying mental health problem disguised under pain
- After the diagnosis of chronic pain, it is time to create a realistic care plan. Patient is quite clearly explained that chronic pain is not something treatable completely, rather the most important thing is to maintain a normal life as functional as possible. Let us look at the goals of therapy:
Goals of therapy in Chronic pain
- To minimise pain just enough so that the patient is able to perform daily activities- achieve pain control to quickly send patient back to normal routine
- To prevent any absence at work
- To monitor psychological health and social complications that may arise out of chronic pain
- To improve overall quality of life
- Resume healthy diet and exercise regimen
Chronic Pain Management – Alternative therapies
Here are some expert reviews on using non-drug therapy pproaches:
- Acupuncture – the mechanism of how it works is not yet known, but this therapy is quite popular among alternative therapy enthusiasts. An acupuncturist uses tiny needles to prick on various skin parts to induce pain control – insufficient evidence of this practice
- Behavioral or cognitive therapy – licensed mental health counselors work with patients to help them identify the barriers in therapy and provide support to attain a normal and healthy routine – no evidence of effectiveness
- Yoga and meditation – yoga and meditation helps you to understand your body and mind and the way they are both linked. A deep state of calmness and relaxation is achieved after enough practice and it can help patients in coping with chronic pain especially the emotional side of pain. Consult a yoga instructor to discover the best yoga poses suitable to your pain. It is better to practice yoga when supervised by a professional – safe to practise, mixed reviews on evidence.
- Exercise – muscle strength is achieved with exercises of hip, back, knees and neck. At this point, it is safe to say that no matter how your progress in pain management, exercises are always prescribed to everyone since they also help to train body to get back up to performing normal daily tasks such as moving, lifting, walking etc. – safe to use, helps to restore functional life
- Biofeedback – training to understand and become conscious of certain functions of body using biofeedback sensors attached to body. This sensor sends signals on the computer and it records detailed activity of how your body reacts to external stimuli – conflicting evidence
- Walking – Prescribed walking programs (30 minute brisk walks) and keeping a walk diary – evidence to improve quality of life in lower back pain patients
Alternative pain therapy (Non-drug measures) summary:
Chronic pain management program (a multi-discliplinary approach) can help patient restore their normal daily life
It is even better to combine multiple approaches when treating chronic pain without medications, for example recommending yoga + meditation + relaxation or exercise + yoga + biofeedback , patient education and psycho-social counselling programs can boost their confidence and help coping with chronic pain easily
Keep track of progress and identify any barriers that might slow it down
Non-drug therapies listed above are not always as successful as medications. They should be used as an additional help when living with chronic pain and not by instead ignoring the use of medications. Also, it is advised for patients to not spend too much money on non-drug measures because there is no evidence that these interventions will work as good as medications.
Chronic pain management guidelines using Medications
Strategy for pain management & when to follow up with doctor:
Patient needs to be clearly explained that restoring normal daily function is the only realistic milestone to achieve when managing chronic pain disorder. It is never possible to treat chronic pain.
After all tests and investigation your doctor will design a personalized plan to manage chronic pain symptoms.
Let us break it down into 3 steps and go in more detail:
Step 1 – Over-the-counter (OTC) pain medications
If doctor’s investigation suggest that pain experienced by patient is mild and has no risk factors that could worsen pain then they will recommend over-the-counter treatment as first line approach.
Acetaminophen (Tylenol), NSAIDs (Ibuprofen, naproxen, topical diclofenac gel) and muscle relaxants (short-term use only) are tried and if they provide desired pain control then it is safe to continue taking these medications.
Always mointor if pain gets worse despite following instructions of doctors on how to take over the counter pain medications.
If for some reason the pain gets worse, it is time to step up the therapy to step 2
Step 2 – Using a mild opioid analgesic or drugs with antidepressant actions
It is now time to introduce a mild opioid analgesic to reduce pain symptoms. If patient responds well then they are maintained on it as therapy guidelines suggest.
Examples of weak opioid analgesic – tramadol, tylenol with codeine
For patients presenting chronic pain symptoms as well as psychological symptoms like depression or anxiety, antidepressants are favored. It is not quite clear how they work but it is suggested that they tend to improve the emotional well being in depressed patients dealing with chronic pain. Examples are Duloxetine (brand name – cymbalta) and tricyclic antidepressants (amitriptyline).
Anti-seizure medications like gabapentin and pregabalin are also for select patients if necessary due to their neurological actions. Experts say there is not enough clinical evidence around their use.
Step 3 – Strong Pain relief by strong opioid analgesics
Some patients may rarely progress to higher severity of pain and again, the goal of therapy here is to select a strong opioid which will make the pain bearable by minimising it.
“Pain management is recognized as a fundamental human right”
Now your doctor might have to prescribe a strong opioid analgesic like Fentanyl (Duragesic), Oxycodone, Morphine SR (Kadian SR) etc.
Patients are advised to strictly follow dosing directions of opioids medications since taking them more than instructed can build tolerance over time and makes therapy ineffective. Also, abuse potential is the highest among these medications and so doctors should always monitor patients for this kind of behavior.
How to ask help from your pharmacist
Your pharmacist can be a great help at any stage of chronic pain management. They will help you select the best suitable over-the-counter medications for chronic pain management and also follow up with your doctor on your behalf if any barriers to pain control are noticed. Patients are often unaware that pharmacists can also help them navigate through different support groups or programs that are tailored for dealing with chronic pain.
Pharmacists will collect your complete medical history and prepare a personalized treatment plan for you.
It includes : Drugs to avoid due to allergies, maximum daily dose of pain medication, indicators of when to see doctors, drug interactions with herbal or natural products taken by patient for treating pain, screening patient’s choice of drug for their safety of long term use.
Helpful tips – How to make dealing with chronic pain easier
- Always follow healthy eating habits and maintain balanced diet
- Exercise at least 2 times per week can help maintain muscle strength to perform daily activities
- Stop smoking – this one cannot be stressed enough. Ask your pharmacist how to start a smoking cessation program. You might be eligible for a free drug coverage under provincial programs of Quit Smoking
- Avoid alcohol – drinking alcohol can make you dehydrated and tired, often hangover due to alcohol can make you lazy to go out during the day
- Mental health support – a counselor can help you identify barriers in pain management and motivate you to build healthy lifestyle
- Relax and reduce stress with yoga and meditation
- Pick up something of your interest and turn it into a hobby
- Pain diary to keep track of progress to share with your doctor
LIFE HACKS TO HELP COPE WITH CHRONIC PAIN
Social media groups and communities are the best place to go look for help and interact with people people living with chronic pain. Sharing your challenges and helping each other cope up with pain can positively affect your attitude towards chronic pain.
Here are some life hacks we found from one community of chronic pain.
“ Do things you love to do and you won’t realize how time passed by”
“ using popsicles to numb stomach pain”
“ put rice in slipper socks and freeze them to use as ice packs”
“Setting alarm an hour early to wake up with medications already kicked in”
“ have a bar stool in kitchen to avoid standing long time to cook”
“Using good cushions to rest your back in car seat”
“Keep drawers by bed full of snack bars and water bottles to avoid going in the kitchen when pain is bad”
Check out the community of chronic pain here and discover what people are talking about social community
Your pharmacist – always a message away
Chronic pain patients are often taking multiple medications to manage pain. In this article we have not gone into details about medications used to treat chronic pain. We invite all patients suffering from chronic pain to Ask our online pharmacist if you have any questions on how to take pain medications and what medications to avoid.
You will receive instant personalized answers on how to initiate over the counter treatment of chronic pain and stay informed about any other prescription medication you take. A registered online pharmacist is available to answer medication questions anytime on Ask questions to online pharmacist
Statistics & Facts about chronic pain in Canada
- Around 30% of patients who reported to have depression due to pain are suicidal
- 72.1% patients complain that pain interferes with their daily routines
- 40-50% Canadians experiencing pain after surgery from top hospitals have no access to proper pain management
- Pain is one of the biggest number of emergency visits reason
- Around 20% of adults suffer from chronic pain in Canada
- The quality of life with chronic pain is just as bad as with chronic heart and lung diseases
- Chronic pain increases the chances of patient becoming suicidal
Quick Recap: Questions & Answers about Chronic pain management
Why is it important to monitor for symptoms resulting into depression and anxiety during chronic pain management?
If you are experiencing difficulty sleeping, focusing or eating properly then it might be associated with depression or anxiety. Loss of appetite and loss of interest in social life are frequently related to chronic pain which point towards underlying mental health problem. Once identified, your doctor will make necessary changes to your prescription medication and other alternative therapies.
2. Why joining support groups on social media is useful?
This is a great opportunity to discover more about experiences of people living with chronic pain and use their thoughts to help your situation.
3. Can I take herbal products like capsicum, devil’s claw, or white willow bark to help with my pain?
Yes you can. You just need to be cautious of products that can interact with your prescription medication. Ask your online pharmacist anytime to find out.
4. What does my doctor mean by “realistic” pain control?
It means that the goal of chronic pain management is to bring down the pain to a level where it is tolerable by patient and maintain that level of control as long as possible. Often, doctor will also advise patients to keep up with healthy eating and exercise to achieve maximum benefit from their chosen strategy.
5. Is it safe to take NSAIDs everyday for chronic pain?
Non-steroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen, naproxen, diclofenac etc are reported to achieve adequate pain control in most patients. For otherwise healthy patients with no risk factors or diseases NSAIDs are used long term if the doctor intends to do so. However, Pharmacists and doctors need to be careful about their safety of long term use in patients with cardiac diseases and those with underlying liver/kidney/stomach problems
Canadian Pain society fact sheet about pain
Compendium of Therapeutics (CTC) – Low Back pain, Neuropathic pain
Mighty social networking group – chronic pain
Compendium of therapeutics – Minor ailments – Back pain