Chronic Pain Management
What is pain?
The International Association for the Study of Pain (IASP) defines pain as:
"An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage."
1. Introduction
Pain is a complex sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. It is a subjective experience that varies greatly among individuals. This definition emphasizes several important aspects of pain:
Subjectivity: Pain is a personal experience that is influenced by biological, psychological, and social factors. It cannot be objectively measured but is reported by the individual experiencing it.
Sensory and Emotional Components: Pain has both physical and emotional dimensions. The physical aspect relates to the actual or potential tissue damage, while the emotional aspect relates to the distress or discomfort caused by the pain.
Potential Damage: Pain can be a warning sign of potential harm to the body, not just actual harm. It can occur even in the absence of tissue damage.
Variability: The perception and tolerance of pain vary widely among individuals and even within the same individual over time, influenced by factors such as culture, previous pain experiences, mood, and overall health.
This comprehensive definition recognizes that pain is not just a simple sensation resulting from physical injury but a complex experience influenced by a variety of factors.
2. The Purpose of Pain
The purpose of pain is fundamentally protective. It serves as a complex and vital warning system, essential for survival. Here are the key roles pain plays in the human body:
Alerts to Danger: Pain acts as an alarm, alerting an individual to potential or actual harm. For example, the pain from touching something hot alerts you to withdraw your hand, preventing burns.
Promotes Healing: Pain often leads to behaviors that promote healing. For instance, if you have a painful ankle sprain, the pain discourages you from using the injured ankle, thereby giving it time to heal.
Indicates Health Issues: Chronic or acute pain can be a symptom of underlying health problems. It prompts seeking medical attention, leading to the diagnosis and treatment of conditions that might otherwise go unnoticed.
Learning and Adaptation: Painful experiences can lead to learning and avoiding harmful behaviors or environments in the future. It forms part of the body's learning and adaptation mechanism.
Regulatory Function: In some cases, pain can be part of the body's regulatory processes. For example, the pain associated with hunger or certain physiological functions can prompt necessary biological responses.
However, it's important to note that while acute pain (short-term pain that arises suddenly in response to a specific injury or illness) generally serves these protective and adaptive functions, chronic pain (long-term pain that continues beyond the usual course of an acute illness or healing of an injury) may not serve a clear protective or adaptive role. Chronic pain can be a disease in itself, where the pain no longer signals actual or impending tissue damage but becomes a persistent condition that can significantly impact quality of life.
It's a common misconception that pain is solely a biological process, unrelated to our thoughts, perceptions, or emotions. This view stems from the traditional Western medical perspective that often separates the mind ("mental") and the body ("physical"). However, this dichotomy is particularly unhelpful and inaccurate when understanding pain. Research, including Edwards et al. (2016), shows that pain is influenced by a myriad of factors: thoughts, beliefs, perceptions, emotions, past experiences, context, and bodily sensations. These elements continuously and consistently shape our experience of pain. To illustrate this concept, consider the illustrative narrative: "A Tale of Two Nails."
3. A Tale of two Nails
Case 1
In a 1995 case reported by the British Medical Journal, a 29-year-old construction worker experienced severe pain after a 7-inch nail seemingly pierced through his boot. Rushed to the ER and sedated, it was later discovered that the nail had miraculously missed his foot entirely, causing no physical harm. This incident highlights a crucial aspect of pain perception.
Despite no physical injury, the worker's pain was real. His sensory receptors signaled a potential threat after the accident, leading his brain to assess the situation using various inputs: the sight of the nail, his hazardous work environment, the reactions of his co-workers, and other contextual clues. This information, combined with his emotions such as panic and fear, triggered a series of biological and neurochemical responses. His brain, interpreting these signals, produced pain as a protective mechanism, despite the absence of any tissue damage. This case exemplifies how pain can be a complex and subjective experience, not always directly tied to physical injury
Case 2
Conversely, in a 2007 incident described by Dimsdale and Dantzer, a construction worker had a contrasting experience with pain. While using a nail gun, it accidentally fired, hitting him in the face. Initially, he only noticed a mild toothache and a bruise under his jaw, assuming he was largely unharmed. It wasn't until six days later, during which he continued his normal activities, that a visit to the dentist uncovered a shocking discovery: a 4-inch nail lodged in his head, having penetrated his cerebral cortex, posing a serious risk to his health.
Remarkably, his pain response was minimal. The lack of immediate severe pain and alarming contextual clues led his brain not to trigger a significant pain response, despite the serious nature of the injury. This case underscores the complex relationship between physical injury, contextual factors, and the perception of pain, demonstrating how actual bodily harm can sometimes result in surprisingly subdued pain experiences.
4. What this teaches us about pain
These "Tales of Nails" offer insightful lessons for both those experiencing pain and healthcare providers. Firstly, they illustrate that pain is not a reliable measure of tissue damage. One can endure severe pain without any physical injury, as seen in the case of the nail in the boot, but not in the foot. Conversely, significant bodily harm, like a nail penetrating the face, may result in minimal pain. This demonstrates that pain does not always correlate with the extent of physical harm; "hurt" is not synonymous with "harm."
The second key point is the role of mental and emotional factors in the experience of pain. Thoughts, perceptions, emotions, and the surrounding context, along with sensory input from the body, significantly influence how pain is perceived. These elements can both intensify and diminish the experience of pain, underscoring its complex and subjective nature.
Ultimately there is no absolute correlation between pain and tissue damage. This is where chronic pain comes in. Acute pain has a protective feature, modifying your behaviour and allowing your body to recover. In chronic pain (pain of more than 3 months), there is often no tissue damage – therefore if you introduce the same adaptations (reduction in movement) this is unhelpful. As stopping you from moving ultimately only worsens your overall health, and strength and in most cases worsens the pain over time. Ultimately patients with chronic pain enter a viscous cycle where the pain makes them do less, and because they do less, they’re getting weaker and stiffer – which in turn makes the pain worse.
Patients with chronic pain often worry about what the pain is, and the damage they may be doing when the pain occurs, or if they move through the pain.
5. Introduction to the Consultation
Acknowledging Time Constraints: It is essential to recognize that a thorough history and patient engagement require significant time, a challenge within the typical 12-minute consultation frame. For complex chronic pain patients, consider arranging follow-up sessions or scheduling extended appointments for a comprehensive evaluation.
Understanding the Pain's Effects: In your assessment, it's crucial to explore the extensive impact of the pain on the patient's physical and emotional health, as well as its influence on social interactions and relationships. Additionally, it is of utmost importance to discern the patient's specific objectives for the consultation. Inquire about activities they aspire to resume and understand what is significant to them that is currently hindered by their pain.
Consultation Goals: The primary intention of consulting with patients suffering from chronic pain is to aid in enhancing their functional abilities, thereby improving their overall quality of life. This improvement may be achieved through various modalities including medications, interventions, physiotherapy, and psychological therapy. Consider adopting the three-step model as proposed by Dave Moen in his book "Permission to Move," which includes:
Ensuring the patient is safe to engage in movement - You need to establish that there is no serious underlying pathology that would prohibit the patient from moving
Effectively communicating this assurance to the patient.
Implementing strategies to facilitate the patient's initiation of movement.
6. Ensuring the patient is safe to move
Evaluate for red flags and perform a physical examination to ascertain if the pain is indicative of a serious underlying condition. The goal is to provide a constructive diagnosis that emphasizes the safety of movement for the patient. We are trying to make a diagnosis that “it is safe for them to move”. We need to move away from what is wrong, to more “what can we do to make things better”.
7. Effectively communicating this assurance to the patient.
It is critical to communicate with the patient that it is safe to move. How this message is conveyed significantly impacts the success of the consultation. Patients require a new perspective on understanding pain to feel confident and secure in moving.
Initially, you should Explore the patient's thoughts and worries regarding their pain to establish their current health beliefs about the pain. If the patient thinks that moving is going to cause harm due to the pain, then the brain will activate its self-defence mechanism, and it will prioritise the pain messages and draw attention to them. Thereby exacerbating the vicious pain cycle
Use questions such as:
"What do you think is going on?"
"How do you think we can help?"
"What have others told you about what the pain means?"
Once we establish their health beliefs, we can then set about trying to reassure the patient with phrases like,
"After listening to your history and examining you, I'm confident that the pain isn't due to anything dangerous. It isn't always possible to identify the cause of the pain, but I can tell it is intrusive and affecting your quality of life, but it is not dangerous."
“When you move and it hurts, it doesn’t mean you're harming yourself.”
8. Explain what’s going on
You also need to offer an explanation as to what is going on. You don't need to spend hours explaining pain physiology – but you should give a brief overview of what pain is and how it works. Offer analogies to explain pain, such as comparing it to a fire alarm that sometimes malfunctions, to illustrate how the pain mechanism can become faulty. Similarly, the pain mechanism should only fire up when the body is in danger, but sometimes it becomes faulty.
You then need to apply the explanation to their condition: the following is an example used if presenting with chronic back pain
“the nervous system is sending signals causing your back muscles to spasm, this is because your brain is thinking it needs to protect the spine, even when there is no underlying damage.”
“Whilst it can't make the pain go away, but if you can start moving, it will start strengthening those muscles, meaning that you can do more, despite your pain.”
“ When you start using the muscles, you’ll also find that they start relaxing, which should help reduce the spasming, and in turn, reduce pain. “
9. Implementing strategies
Patients require engagement and time to process the information shared. They need to acknowledge the chronic nature of their pain and understand that while it may not completely dissipate, steps can be taken to improve their life quality. Convey messages like,
"Yes, it is chronic, it is not going to go away, but we can help you move forward from here. We can’t help with pain intensity, but we can help with the knock-on effect of the pain like how it’s limiting your life or affecting your mood.”
“We are looking at pain management, not pain reduction."
It's essential to identify and address any barriers preventing the patient from engaging, such as unhelpful beliefs about the pain: such as overreliance on manual manipulation, perceptions that work or exercise is causing or contributing to the problem or contextual factors like over solicitous families or ongoing litigous claims etc...
If they are willing to engage, then you can start by encouraging paced exercise. Pacing is important as doing too much or too little can worsen the symptoms. If they start undertaking activities, then they need to start gently. Stop any activities before the pain becomes unbearable. Patients need to be reassured that
“just because you push yourself, doesn't mean you are causing tissue damage”
“even if the pain flares up, it’s not due to underlying damage, just the fact that the nervous system has become over sensitised”
10. Alternative Treatment Options
The patient could be referred to a pain clinic with an MDT input, or a physiotherapist who specialises in pain management. If you do refer, it is important that you set expectations that neither referral will reduce pain intensity, and that referral is there to help improve activity levels and thereby improve quality of life.
If patients aren't willing to engage with exercises or referral due to any of the afore mentioned barriers, then you can at least ensure they are not coming into any further harm by reducing the medications they are on. We will discuss this further below:
11. Rethinking Medication Efficacy
Recognise that medications, especially Opiates and Gabapentinoids, are often less effective in primary chronic pain (pain where there is no known physiological or anatomical cause – the vast majority of chronic pain falls into this group) cases and should not be routinely used, as supported by NICE guidelines.
Applying this to a case of someone who presents with ongoing pain despite being on strong opiates and gabapentinoids, it is sensible to conclude that the painkillers are not working, as they are still in pain. As a side note, It is also important to be aware of the Medicines Alert that was issued about the increased risk of respiratory suppression and death when opiates and gabapentinoids are used together.
How to approach this in a consultation:
“the medications are clearly not working, as you are still in pain.”
Followed by an explanation of why that might be:
“this is because your body has become used to the pain killers, therefore the best way forward is to start a wean down approach to allow your body to recover so that you can respond again in the future if you need pain killers – such as after surgery”
Tolerance develops quickly; within a month or two patients will become dependant / tolerant of a particular opiate dose. It is therefore far better to use analgesics on a PRN basis to help improve function (such as going on a long walk that might flare up pain) as this reduces the issue of tolerance and improves efficacy when used.
12. Counter arguments by patients
I’m sure we’ve all been faced with resistance when trying to reduce a patient’s pain medication. Here are some of the most common counterarguments you might hear from a patient.
“well I'm in pain all the time, so I need the pain killers!”
“I once missed a dose and the pain was really really bad, therefore surely it is doing something?”
“It’s not that it’s not helping – it's helping a little bit, so I still need them, but I need something more”
To address the above you need to target the perception that the opiates are actually working:
“the medications aren't doing anything for you, you just feel that they are working, because if you miss a dose, then the pain becomes worse. This is actually a withdrawal reaction, and not actually a representation of how they are working.”
“If we reduce the pain killers slowly, then initially you will get a little worse, but then this will settle down in a day or two as your body gets used to the lower dose”
It may take months for patients to be succesfully weaned off regular, high dose analgesics. However in the long run, it has been shown that the pain ususally settles down to the same baseline whether they were on the medication or not. It is therefore far safer for the patient not to be on these medications long term.
Putting theory into practice
Now that you have read the above, and are expertly versed in the art of breaking bad news - this is your time to put theory into practise, and hone your skills on one of our many breaking bad news cases: