Manage Your Pain: Practical and Positive Ways of Adapting to Chronic Pain - Michael K. Nicholas, Allan Molloy, Lee Beeston, Lois Tonkin (2012)
Chapter 6. Treatments for Chronic Pain
If pain lasts for more than a few days most people will go to their doctor and seek help. The cause of the pain may be immediately clear to the doctor. Often, however, tests and investigations are needed. At this stage the pain is best thought of as acute pain and usually settles without treatment. People may take medication or use simple methods such as heat, ice or massage during the period of recovery. These approaches rely on the fact that the pain was likely to settle anyway.
If the tests don’t show any problems, your doctor will reassure you that there isn’t a more serious injury present. It also gives the doctor a chance to consider other medical conditions that may be present. If your doctor has a clear idea or diagnosis of what is causing the pain there may be a suitable treatment that will settle the pain.
On the other hand, if the cause of the pain is not easy to diagnose, it is usually not easy to treat. In this case the doctor may suggest trying a particular treatment to see if it will help. If the doctor tells you nothing has been found to explain your pain, this usually also means that there is no evidence of active disease present, such as cancer. If your pain continues your doctor will advise you whether regular checks are needed and how often. The results of the treatment prescribed will also need to be assessed.
At this point there is an important decision to be made. Continuing to seek a cure for your pain risks feeling as though you are on a merry-go-round and being demoralised by repeated treatment failures. The alternative is to look at how to manage the pain most effectively. The ADAPT approach can help you to manage pain, possibly in conjunction with other appropriate treatments. Many people find ways to get on with their lives despite the pain, and without requiring expert help. Others struggle with the idea of managing their pain and continue to seek help or wait until someone comes up with a better treatment.
You might wonder why people wait for someone to fix their pain and reject suggestions that using the ADAPT strategies could help. Often the reason they give is that they are not prepared to live with their pain and are determined to find someone to fix it. Hope is important but by the time the pain has lasted more than a year or so, further treatments are unlikely to cure it. The pain may settle by itself, but we can’t accurately predict when. In short, you will have to face learning to live with it for the foreseeable future. Which means you have some difficult decisions to make.
Understandably, it is often hard to accept that there may be no solution to your pain. But it may help you to come to terms with it if the common treatments tried for chronic pain are explained. In the following pages these treatments are described and brief discussion is given of when and where they can be useful, as well as their shortcomings.
Medications and chronic pain
‘If pain persists see your doctor’ will be a phrase recognised by everyone. Most of the analgesics or pain killers work better with acute pain as they can target the chemical transmitters that are released with tissue damage. Chronic pain is much more complex. Since there is usually no evidence of continuing tissue damage, different types of pain killers need to be considered. While these medications may provide some benefit they are rarely the whole answer. They will not cure chronic pain like an antibiotic will cure an infection. Long-term use of pain killers may lead to unwanted side effects. What’s more, even if they do help, you may overdo activities and stir up your pain anyway.
To help make sensible decisions about tablets for pain problems, this chapter will describe most of the types of medication that people use for chronic pain. Some of the problems of long-term use of medications will also be discussed. It is recommended that medication which is not helping or is ‘just taking the edge off the pain’ should be gradually reduced.
Medication reduction should only be started after discussion with your family doctor or specialist, however, and this process should then be supervised by them.
Advantages of medications
1 Medication can be very effective in reducing pain, particularly acute pain.
2 Medicines are generally safe provided that they are used as directed. All drugs have side effects even if you stick to the recommended dosage, but serious problems are rare with most medications. Always ask your doctor about side effects and find time to read the drug information provided in the box.
3 Stopping a medication will allow the body to clear it from your system, so its effects are usually reversible.
Disadvantages of medications
1 There are no drugs shown to cure chronic pain. A chest infection is usually cured by antibiotics after a standard course. None of the drugs available has been shown to cure persisting pain. If a medication reduces persisting pain then it is usually recommended that it should be taken continuously.
2 All medicines have side effects. Mostly, side effects are mild, such as nausea, light-headedness and constipation. For example, a laxative is usually required with drugs like morphine and codeine as they tend to cause constipation. Severe side effects are uncommon but if they occur, admission to hospital may be necessary.
3 New drugs take a long time to develop. The process required to produce a new medication takes a long time. It can take at least 10 years, be very costly and the drugs are usually licensed only for particular conditions. This usually means that a new drug is expensive and may not be covered by the NHS.
4 Drugs may interfere with your thinking. Many people on medication report that they either cannot think clearly or that they have difficulty remembering things. This can occur with many drugs, especially morphine-like drugs, sedatives and anticonvulsants.
5 An ‘old’ drug may be repackaged and sold under a ‘new’ name. Morphine is available as two preparations—MST Continus and Morcap-SR—which are designed to release morphine slowly into the body. Both preparations are similar, so that if one makes no difference to your pain without side effects, the other is unlikely to benefit you. Thus, if you are offered a new drug by your doctor then it is wise to seek information on whether this really is a new drug and, if so, what the success has been and how common are the side effects.
6 No drug is 100 per cent successful in everyone. Although it may surprise you, a drug that works for one person in three is thought by doctors to be a good treatment. Unfortunately, you may be one of the two out of three for whom it doesn’t work. In reality, many drugs are not as effective as this.
7 Stopping medications can cause a withdrawal syndrome. If you have been taking drugs for a long time, particularly opiates and tranquillisers, it can be very difficult to stop them as they cause various withdrawal effects such as sleep disturbance, abdominal pain, sweating and feelings of anxiety. These complaints are likely to be some of the ones for which the drugs were commenced in the first place. Drugs should not be stopped suddenly unless under medical supervision, since doing so may cause a severe withdrawal commonly known as ‘going cold turkey’.
8 If the pain is bad it may be tempting to take more than the recommended dose of your tablets. Studies have shown that people often take more than the recommended dose of a drug even if the drug is not helping or only ‘takes the edge off the pain’. Taking above the recommended dose is dangerous as it may cause major side effects.
9 Dependency effects. Taking medication can become an habitual way to manage pain instead of learning more helpful ways of coping with pain and the problems that it causes. If you feel you have no other options it is easy to slip into the habit of taking pills every day even if they don’t help very much. As part of changing your approach to managing pain it is recommended that under your doctor’s supervision you gradually reduce medications that are either not helping very much or are not helping at all. Learning and improving your skills at using the more helpful strategies covered in this book will help to reduce your reliance on tablets.
10 Supporting activity which is not sustainable. Relying too much on medication can result in overdoing activities and further aggravating your pain. This is unlikely to be sustainable. It is very easy to overdo things and break through the relief that medication is giving you. This can result in increased pain and more suffering. Once you are using the ADAPT strategies analgesic medication may be a useful aid but it should not be the mainstay of your treatment.
Commonly used medications
There are a large number of different drugs used to manage pain. The list of drugs described here is not intended to be a complete account of all drugs available, but rather a summary of those commonly used for chronic pain. Further information can be obtained from your doctor or pharmacist, and useful reference books can be found at libraries and bookshops.
Suggestions for Using Analgesics with Chronic Pain
1 Take the tablets regularly, at preset times and not simply when the pain gets bad. The pills will be more effective this way and dependency problems will be reduced.
2 Keep a diary of whether the medication is really helping. Record not only your level of comfort, but your level of activity too. Unless you are happy with both, then the medication is not enough by itself.
3 If you decide you would like to stop taking medication for your pain, discuss it with your doctor and draw up a plan with him or her. Cut down gradually, under supervision from your doctor. This reduces the chances of withdrawal effects.
4 Keep a record of your progress and reward yourself when you achieve your goals. You will probably find that your pain is no worse and that you will feel much better in yourself.
Analgesics (pain killers)
There are two main types of analgesic drug: those not like morphine (nonopioids), and those like morphine (opioids), which are often called strong pain killers. Non-opioid drugs (mild pain killers and anti-inflammatory drugs) act to reduce the effect of the pain-producing chemicals released after an injury. They are most effective for mild pain and tend to work quite quickly. Simple analgesics include:
· Paracetamol (eg Panadol)
· Ibuprofen (eg Brufen)
· Indometacin (eg Indometacin)
· Naproxen (eg Naprosyn)
· Sodium diclofenac (eg Voltarol)
· Ketoprofen (eg Orudis).
All simple analgesics can cause irritation of the stomach and for this reason caution is advised in their use over the long term. While this is generally less of a problem with paracetamol, using more than the recommended dose (eight tablets per day) of paracetamol can lead to liver damage. It should be noted that even with the recommended dose there has been a report of liver failure if this dose is taken for some years.
With the opiates (morphine-like drugs), it has been known for many years that very small doses of morphine were effective in relieving pain. Morphine was suspected of mimicking the action of a morphine-like substance in the body. In the 1960s substances called endorphins and enkephalins were shown to be produced in the body and to act in the brain and spinal cord in a similar way to morphine. Recent research has shown that morphine can also act near the site of injury and relieve pain. Unfortunately, morphine-like drugs also have unwanted side-effects such as nausea, drowsiness, constipation, mood change and difficulty in concentrating. A new combined medication has been released that includes a drug (naloxone) to reduce constipation that may occur with oxy-Contin. After the first few months, the body may become used to the drug. This is called tolerance and the dosage may need to be increased. The milder opiates are often mixed with simple analgesics.
Common examples of mixtures of opiates and anti-inflammatory drugs or paracetamol include:
· Dextropropoxyphene and Paracetamol (eg Digesic; Capadex).
· Codeine and Paracetamol (eg Solpadol).
· Codeine and Aspirin (eg Co-codaprin). These can cause stomach problems
· Codeine, Paracetamol and Doxylamine (eg Syndol). Doxylamine is a calmative and, as a result, many people use this medication to help them relax and sleep.
Common examples of opiates (which vary in strength) include:
· Codeine Phosphate (usually known as codeine)
· Buprenorphine (Butrans Temgesic)
· Oxycodone (eg OxyNorm, OxyContin)
· Morphine Hydrochloride (eg Oramorph)
· Morphine-long acting (MST Continus and Morcap-SR)
· Methadone (Physeptone)
· Tramadol (Tramal)
· Fentanyl (Durogesic)
· Hydromorphone (Palladone)
· Dihydrocodeine (DF-118).
· OxyContin and Naloxone (Targin)
These drugs are usually taken by mouth, apart from Fentanyl which is absorbed through the skin and Buprenorphine which is available as a tablet and a patch applied to the skin. Pethidine is normally given by injection. In certain instances, morphine can be delivered by a needle or by a tube connected to a pump into the epidural or intrathecal space near the spinal cord.
There are two main types of medication used to treat depression, a common accompaniment of chronic pain: tricyclic antidepressants and newer antidepressants. Tricyclic antidepressants are used to lift mood, help with sleep and may reduce pain. In most cases with people who have chronic pain, the typical doses (often 75 mg or less per day) of the tricyclic drugs used are well below the amounts (often more than 200 mg per day) used with people who are profoundly depressed. These drugs can be helpful for sleep and for pain at these lower doses and the higher doses are not necessary.
Common examples include:
· Amitriptyline (eg Lentizol)
· Clomipramine (eg Anafranil)
· Dothiepin (eg Prothiaden)
· Doxepin (eg Sinequan)
· Imipramine (eg Tofranil).
Some people with chronic pain find these tablets to be helpful. Side effects such as weight gain, constipation, blurred vision, dry mouth and drowsiness the following morning can be a problem. Concentration and judgment can also be affected and thinking may be clouded. Difficulty urinating may also occur. These drugs interact with tranquillisers, sleeping pills and alcohol, and can cause drowsiness. It is recommended that they are taken in the evening as they are likely to make people feel drowsy if taken during the daytime.
The newer antidepressants form a mixed group but most people know them by their trade names:
· Fluoxetine (Prozac, Oxactin)
· Sertraline (Lustral)
· Citalopram (Cipramil)
· Venlafaxine (Efexor)
· Nefazodone (Dutonin)
· Moclobemide (Manerix)
· Fluvoxamine (Faverin).
· Desvenlafaxine (Prisiq) / Duloxetine (Cymbalta)
These drugs have been shown to be effective in the treatment of depression and many doctors prefer them to the older, tricyclic antidepressants as they have different side effects. However, this also means they lack the tendency to promote sleep that may be seen as a helpful feature of the tricyclic antidepressants. So if you are taking the newer antidepressant drugs and you have sleep difficulties you will be advised to take them in the mornings. Some of these newer antidepressants have a benefit in reducing neuropathic pain particularly Duloxetine, which has been recommended as a first line treatment for diabetic neuropathy. You should be aware that all antidepressants carry an increased risk of suicide and suicidal thoughts so make sure you discuss this with your doctor and ensure that those close to you are aware and that they know what symptoms and signs to look out for.
It should always be remembered that drugs like the antidepressants may not be enough to fully treat depression. Since they cannot teach you how to deal with stressful events in your life, including managing pain, you may well need to use the sorts of self-help methods outlined in this book. Many depressed people benefit from seeing a specialist in psychological therapies, such as a psychiatrist or clinical psychologist. A description of some of the most useful psychological therapies is provided on pages 72–75.
· Common examples of sedatives include:
· Diazepam (eg Valium)
· Nitrazepam (eg Mogadon)
· Temazepam (eg Normison)
· Lorazepam (eg Ativan)
· Clonazepam (eg Rivotril)
These are often prescribed as a short-term treatment to help improve sleep and to calm you down. But you may feel less alert and more tired during the daytime, and this can result in your feeling more depressed and reduce your sense of control. At night they may be effective in promoting sleep in the short term, but they can disturb the sleeping pattern over the longer period. As your body can become used to them, they are likely to become less effective. This is sometimes treated with an increase in dosage. If you are not careful the same thing will happen again and before long you can be taking a very high dosage without any real benefit. Trying to come off these drugs can then cause a withdrawal syndrome which can be an unpleasant and even a dangerous experience.
Some people report taking these drugs at the same dose for many years and swear they help their sleep or ‘nerves’. However, in these cases it is most likely that their body is so used to them that there is no real chemical effect anymore. Any perceived benefit is likely to be due to the person’s beliefs. However, withdrawal effects can still occur when someone such as this tries to stop taking them. If you would like to stop taking these drugs you should discuss it with your doctor.
These drugs also make it difficult to explore and challenge your feelings and thoughts. If this cannot be done then it is hard to progress to learning more helpful thoughts, which is an essential component of the ADAPT approach to pain management.
Common examples of anticonvulsants include:
· Carbamazepine (eg Tegretol)
· Sodium Valproate (eg Epilim)
· Gabapentin (Neurontin).
· Pregabalin (Lyrica)
These drugs are called anticonvulsants because they were initially developed to manage epilepsy. It was then discovered that they had other beneficial effects, including reduction of some types of pain. These drugs are taken by mouth and are thought to act on the spinal cord and brain to block messages that occur with nerve injury or neuropathic pain. They also have a helpful effect on mood in some people but are also associated with an increased risk of suicide and suicidal thoughts. Unfortunately, they do not work in all types of pain nor in everyone with neuropathic pain.
Steroids may be given in different ways but the usual way is by mouth. They are frequently used in chronic conditions such as rheumatoid arthritis to reduce inflammation. In chronic pain they are sometimes given into joints or into the epidural space. Longterm or frequent administration can cause problems, particularly with osteoporosis.
Common examples of local anaesthetics are:
• Lignocaine (eg Xylocaine)
• Bupivacaine (eg Marcain).
• Ropivacaine (Naropin)
These drugs act on nerves and the spinal cord to block the transmission of the pain messages. They cannot be taken by mouth. Lignocaine may be given either by injection near a nerve, into a vein or under the skin. These drugs can relieve many types of pain but do leave a numb area and may cause weakness. They are usually not appropriate for long-term use (except in cancer).
People have surgery for different reasons. One of the most common reasons is to try to reduce pain. In the past a general surgeon could perform most operations, but now they have become highly specialised. For example, there are now surgeons who operate only on shoulders and others who are expert in problems around the ankle. New research and ideas have grown out of this and today there are more and more options for dealing with pain in a certain part of the body. A note of caution. New operations are like new medications. You have to be careful of ‘miracle cures’ until a treatment has been fully assessed by eminent doctors and scientists in carefully controlled studies in more than one hospital or clinic.
Advantages of surgery
Surgery can cure pain but its success depends on having a clear idea of what is causing the pain. For certain conditions, such as appendicitis and a meniscal tear in the knee, surgery has an excellent success rate at curing pain and improving function. I recall as a junior doctor talking to a lady after her hip replacement. She had been in pain for many years and was particularly disturbed by it at night. The morning after surgery she was ‘over the moon’ because she had slept through the night without pain as a result of her new hip. Surgical success depends on having a clear idea of what is causing the pain.
Disadvantages of surgery
1 Surgery can make the pain worse. Many patients attending pain clinics report that their pain is worse after the operation. There is a saying: ‘there is no pain that cannot be made worse by an operation.’ There is a strong element of truth in this. Some of the reasons for this are discussed in Chapter 3. If your pain is no better or worse after surgery then discuss this with your surgeon. Consider your options with the surgeon and your family doctor. This book should provide some helpful approaches.
2 Surgery is rarely 100 per cent successful. Minor operations can be very successful, but the ‘bigger’ and more difficult the operation the more chance there is of problems.
3 There are many common and rare complications that can occur during surgery and while you are recovering. Improved anaesthetic techniques and surgical skills are helping to make these less common, but they do still happen.
4 You may still need medications after surgery. Some pain may remain and you may feel that you still need to take medication.
Main types of surgery
It is not possible to cover all the operations that are performed for pain. Since back pain and back operations are the most common types of surgery, they are covered in some detail here.
Many patients with back pain are referred to a spinal surgeon—either an orthopaedic surgeon or a neurosurgeon. The role of surgery in this area is often controversial, however. For example, a number of studies have found marked variations in the frequency of back surgery between countries and even from one part of a state to another. Back surgery in the United States is far more common than it is in Australia or the United Kingdom, yet the same problems are seen in each country. Sometimes, patients with persistent back pain are so desperate for help that the surgeon may feel pressured to operate although there is no clear indication for surgery. There is no doubt that certain types of back pain can be helped by surgery but it is not certain who is going to do well. In general, back operations are only successful where there is a clear cut cause for the pain. This must be based on an assessment by a specialist doctor and complemented by tests such as a myelogram, CT scan or MRI scan.
There are two main types of spinal surgery: a laminectomy, the discectomy, and a fusion. During a laminectomy the surgeon removes the lamina (a part of the vertebra) to allow access to the prolapsed disc material. People often refer to a ‘slipped disc’. This term gives the wrong impression of a hard disc moving and pressing on a nerve. What in fact happens is that the central jelly-like substance in the disc bursts through the strong fibrous layer that surrounds it. In turn, this may press on the spinal cord or nerves, causing numbness, weakness and pain in the area associated with that part of the spinal cord or nerve. Fortunately, most disc protrusions settle down without surgery, but if a bulging disc continues to press on a nerve, the bulging disc may need to be removed. If the surgeon is absolutely sure there is a bulging disc, and it has been shown on a scan to be pressing on the nerve, then this operation is usually successful (in 70 to 80 per cent of cases for buttock and leg pain). Success rates for back pain are much lower, however. A laminectomy is usually not successful when it is done for just a suspicion that there may be some pressure on the nerve.
A fusion is a major operation where two or more vertebrae are fixed together, either with bone or with metal rods and screws. This operation obviously stops much of the movement in the back, which after all, has a purpose. Fusion is successful in a small number of cases, but once again, it is not generally worthwhile when there is no clear cut cause for the pain or when more than two vertebrae would need to be fused.
As with laminectomies, the use of fusion operations for back pain is controversial. It is useful in some cases of cancer, congenital spine disorders and trauma to the spine, but it is less successful with so-called ‘degenerative’ conditions, from which most adults suffer as they age. Take this case:
Ruth had managed her back pain for years. So much so that at the age of 65 she had travelled around Europe on a bus. She had a lot of ‘wear and tear’ in her back and the spine had become bent. As she was getting older and she was concerned about the pain, she had a fusion where the spine was straightened up and fixed ‘to look like new’. Unfortunately, after surgery she was unable to get out of bed because of her pain and the restriction in mobility that the surgery had caused.
In general, if a clear cause for back pain is found, the first back operation is the most likely to be successful, but second or third operations are usually much less successful and the pain could be worse. This means that if an individual has been unlucky enough to have an unsuccessful operation, further operations are unlikely to solve the problem. If a fusion is unsuccessful, however, a further operation may be recommended to take out the metal used for the fusion. This means another major operation. There are also many complications that can follow multiple back operations, including arachnoiditis where scarring occurs around the nerve roots. Unfortunately, very little can be done about arachnoiditis, which can be very painful. In some patients a spinal drug pump (see page 69) can ease the pain and should be considered but it is certainly not the answer for everyone. We have also found that even when these devices are helpful the patients function better if they use the types of strategies described in this book.
Before the high quality imaging available today, many people with persistent pain had what was commonly called an exploratory operation in an attempt to see what was going on in their backs. Remember, you cannot see pain when you do an operation, just as you cannot see anger or happiness by looking into someone’s brain. For this reason it is often illogical to do exploratory operations for pain problems. If there is no defect shown on X-rays or other tests, there is little to be gained by an exploratory operation. Most of these operations are unsuccessful and are not to be recommended.
Surgery to cut nerves
A number of surgical procedures involving cutting nerves are used to try to relieve pain. They include operations on the spinal cord, such as cordotomy, spinal nerves (rhizotomy), and on smaller nerves outside the spine. It can be tempting to think that if pain is due to a compressed or damaged nerve, then cutting or destroying the nerve might stop the pain. Unfortunately, it is not as simple as that. For example, you would not expect to fix a faulty computer by cutting a few of its wires. Equally, it is unrealistic to expect to solve chronic pain by damaging the system further. In fact, most procedures where nerves are cut are not helpful for chronic pain. Operations where nerves are cut are usually recommended only for severe cancer pain in terminally ill patients, once all other options have been excluded. For example, cordotomy can be very effective for a small proportion of patients with certain types of cancer pain.
This type of nerve surgery is one of the exceptions to the rule. The small nerves to the facet joints in the back can be interrupted by placing a needle beside the nerve which heats and selectively destroys it. Once the nerve is cut, the ‘pain signals’ cannot get through to the brain and pain relief may occur. Unfortunately, the nerve grows back. For this reason the patient may experience the return of their back pain after a period of three months to one year. While the procedure can be repeated, it is not known at present how many times this can be done safely. It should also be emphasised that this procedure has only been shown to be helpful in a small group of patients with spinal pain who meet stringent selection criteria after undergoing a series of nerve blocks in the spine.
It can also be successful in some types of facial pain (eg ‘tic douloureux’ or trigeminal neuralgia) where the application of this technique to the trigeminal nerve can ease the pain in the majority of cases for up to several years. However, it should be stressed that this treatment is only effective in a specific type of facial pain and it is not recommended for all persisting facial pain problems.
There are three types of injections used to treat chronic pain:
1 Local anaesthetic injection. These types of injections are also known as ‘nerve blocks’. For someone with persistent pain, it can be useful to see the effect of injecting a local anaesthetic on a selected nerve. The effect can tell the doctor which nerves are involved in the pain. Sometimes local anaesthetic injections are also helpful in relieving persistent pain. In particular, blocks such as epidurals or facet joint injections can sometimes help back pain. Many people with chronic back pain get no benefit from these injections, however. In general, the longer the person has had the pain, the less successful the treatment will be. Although the risk of damage from the injection is very low, some people do report being worse off afterwards.
2 Steroid injections. Steroids are anti-inflammatory drugs which are often added to injections in an attempt to cure the problem. They are not a ‘miracle cure’, and they certainly don’t work for everyone. While steroid injections may be helpful, they cannot be repeated very often.
3 Phenol injections. Phenol is a drug that damages nerve tissue. It is used to try to destroy the nerve in the hope that it will relieve the pain. There are two problems with this. First, phenol doesn’t always totally destroy the nerve, so you can be left with a partially damaged nerve. If the pain is due to damaged nerves anyway, it is not surprising that this sometimes makes matters worse. Second, as mentioned earlier, destroying a nerve may not relieve the pain. There are a few occasions when a phenol nerve block can be of value, however, especially when the pain is due to cancer.
Spinal drug pumps
Specialised pumps can be placed under the skin to deliver small quantities of a drug, usually morphine (and sometimes a non-morphine drug like Clonidine), into the fluid around the spinal cord. At least two hundred times more morphine would need to be given by mouth to try to achieve the same effect. This approach can avoid many of the side effects by limiting the dose of morphine. The drug is then carried to the spinal cord to block specific pain receptors, which can have a very powerful effect on pain in certain circumstances. Surprisingly, the reduction in pain is not always associated with increases in function and mood. It can be particularly useful for some types of cancer pain and in a small proportion of patients with pain due to nerve injury, including spinal cord injury. The main risks are infection, loss of menstruation in females and impotence in males. This technique is not suitable for everyone and is normally only done in carefully selected cases. Frequently, as with drugs taken by mouth, the patient with a morphine pump will still benefit greatly from using the types of strategies outlined in this book.
A number of techniques are used by physiotherapists for pain problems. Passive techniques involve the physiotherapist doing something to the patient. Examples of these techniques include manipulation, massage, diathermy, interferential, ultrasound, and hot and cold packs. While these techniques can be helpful for acute pain problems, they are not effective for chronic pain. Any help they may provide is usually short-lived. There is a possibility that you can become more disabled as you wait for the treatment to fix you. Passive treatments risk keeping your attention on the pain and its relief rather than working on things that you can do for yourself. In the long run, as you can’t take your physiotherapist home with you, it is what you do that matters.
Active physiotherapy is quite different from passive techniques. It involves trying to get the body moving again and also deals with building up strength and fitness. As you will already know, getting stiff and weak is a common problem with chronic pain. Active physiotherapy helps the patient to get the body going again, to get the joints moving, and to build up the muscles. If the patient is in poor physical condition, the exercises involved need to be built up slowly and thoroughly. While it may not cure the pain, active physiotherapy plays a vital part in helping chronic pain patients get back to normal life again. Active physiotherapy has also been shown to be helpful in preventing people with acute back pain from slipping into disabled lifestyles.
The use of small needles inserted into the surface of the skin has long been used to obtain pain relief. In recent years the use of acupuncture in western countries has steadily increased. It can be a helpful treatment for many non-specific painful conditions, such as stiff shoulders and tennis elbow. Acupuncture does not cure chronic pain, however. Some patients do find that they get pain relief for short periods, but they have to keep going for treatment regularly. A typical course of treatment is weekly visits for six to ten weeks. Follow-up sessions, however, are often needed. Unfortunately, like so many treatments, acupuncture is not the total answer for chronic pain.
TENS (Transcutaneous Electrical Nerve Stimulation)
As you will recall from the discussion in Chapter 3 on the ‘gate’ mechanism in the spinal cord (see page 33), the ‘gate’ can be closed by stimulation of the nerves that carry touch sensations. Closing the gate mechanism in the spinal cord can relieve pain to some extent. This is why rubbing your knee or skin after you bump it can ease the pain. TENS works along the same lines.
Powered by battery, the TENS machine delivers small electrical impulses to the skin by electrodes that are attached to the skin. The electrical impulses stimulate the nerves and it is thought that this closes the gate in the spinal cord and so reduces the pain. TENS does not work with all pain problems but it is worth giving it a good try. You should be shown how to use it by a trained person. Most patients with chronic pain find that if it does help to begin with, it gets less effective as time goes on. Remember, it is not a cure. For best results with TENS you should combine it with the exercises and techniques in this book, in particular, pacing.
Dorsal Column Stimulation (spinal cord stimulation)
This is a type of TENS unit which can be implanted under the skin and is connected to a number of small electrical terminals near the spinal cord. It works along similar lines to TENS and is also powered by battery. This treatment is most useful when the pain is in one or both legs and is a result of nerve injury. It is less effective for back pain. More recently it has been used for pains in other parts of the body such as arm pain and the pain that occurs if not enough blood gets to the heart or the legs (ischaemic pain). Like TENS, however, it doesn’t work for everyone. Even when it does reduce the pain to begin with, it may lose some of its effectiveness after three to four months. Patients who have had the unit put in may also suffer complications, such as wires breaking or infections. As a result, the units may have to be adjusted, replaced or even removed, which takes another operation to fix. Overall, dorsal column stimulators are not recommended for most pain syndromes but can be useful in carefully selected cases.
As with all treatments that can ease pain, you should not rely on these devices or drugs alone for the best results. The ADAPT methods described in this book should be the mainstay of your pain management plan. Drugs, devices or implants should be seen as aids to the things that you do yourself to manage the pain.
Peripheral Field Stimulation
In selected cases the electrodes used in Dorsal Column Stimulation can be inserted under the skin near the painful area and still be successful. This has been used for many painful conditions such as back pain, pain after hernia surgery and headaches. This avoids the risk of nerve injury when the electrodes are placed near the spinal cord.
Most of these treatments are provided as part of a ‘pain management package’; that is, they can be combined with interventions like medication and exercises. Often your physiotherapist or doctor will use these methods as part of their treatment too, so it is not always necessary to see a psychologist for psychological treatments.
Hypnosis is like relaxation except that it is usually performed by a therapist who speaks to you in ways that can help you to become calmer and more relaxed than you can achieve by yourself. You remain awake and aware of what is going on around you in the room, but noises such as the telephone ringing may not bother you as much as usual.
Once you are relaxed, the therapist or hypnotist will also make various suggestions that can help you to take your mind off the pain or even to change the way it feels. For example, under hypnosis the painful area can be made to feel numb or just a pleasant warm feeling, like you might feel after a day in the sun.
While hypnosis can be pleasant, it is not a cure. Like many other treatments, it only works for a short time (an hour or two at most) and so is not very useful for chronic pain. It also requires a therapist, which can make it expensive. You can be taught to hypnotise yourself, but that doesn’t offer any advantages over simply learning how to relax yourself.
Relaxation is very similar to hypnosis (and meditation). You can use a relaxation exercise to calm yourself, to help you cope with pain, and to help you sleep. You can be taught to do it by a trained therapist or by using a tape recording. But in the end, whether or not you become good at relaxation depends on how much you practise it. Relaxation is really just a skill, like playing tennis or singing. Like all skills, practice makes perfect.
Relaxation is most helpful if you learn to do it anywhere. If you become reasonably good at it, you should be able to take the edge off the pain whenever it starts getting stirred up. In the long run, relaxation will help you more than tranquillisers. Of course, you won’t stop the pain with relaxation, but relaxation can help you to cope better and to feel more in control.
Cognitive therapy is aimed at helping you to work out ways of coping better with pain (and other problems, such as depression and stress by changing unhelpful responses). We all react to pain in different ways. Sometimes, the ways we react can become part of the problem and can make the pain harder to deal with it. For example, if you often find yourself getting upset and grumpy with the pain, you not only have pain to deal with but you also have to deal with being upset and grumpy.
It could be that your distress is more the result of the way you are thinking than simply the pain alone. Thoughts like ‘This pain is terrible. How can I be expected to do everything in this much pain? I’ll never be able to do anything. Nothing works’ may be understandable but they are also self-defeating and risk promoting a sense of helplessness and, ultimately, depression. The good news, however, is that they can be changed.
If you are getting really upset about your pain it is likely you are thinking about it in unhelpful ways. If you could stop and reconsider these unhelpful reactions, you might work out more helpful ways to deal with the pain. As a result, you could minimise your distress and improve your quality of life.
Cognitive therapy can help you to sort out problems such as these. It involves examining the ways you think and how your thoughts affect your feelings. If your current ways of thinking are not really helpful, cognitive therapy can help you to work out other, alternative ways of looking at your problems. Becoming proficient at doing this on a daily basis does, of course, take time. But with practice, this more helpful way of dealing with a problem can become a habit.
Because we are all different, this type of therapy works best if you are prepared to look as honestly as possible at your reactions to pain. Doing so will help to make the therapy more useful to you. Typically, clinical psychologists are the best trained professionals to provide the cognitive therapy, but some psychiatrists and other health care providers also use this approach. Cognitive therapy forms a major part of this book and a fuller account can be found in Chapter 11.
Behavioural therapy is concerned with helping you to change the ways you do things—your behaviour—which, in turn, can help your mood and alter the ways you think. Behavioural therapy can also help you to learn new skills and new ways of doing things. Many people say that all this requires is willpower, but it is not as simple as that. We are all full of good intentions that we fail to carry out. By using what we call a behavioural approach you can work out ways of making it easier for you to carry out those good intentions.
Without going into too much detail, behavioural therapy is basically:
· getting you to specify what you want to achieve (in terms of what activity you want to do),
· working out a realistic way of achieving your goal,
· working out what might get in the way of this and how to overcome it,
· putting your plan into action and rewarding or reinforcing your attempts each time you try.
Behavioural therapy doesn’t tell you what goals to work for but it helps you to work out how to achieve your goals. Naturally, it is not as easy as it looks. Behavioural therapy techniques will help you to learn all the skills and exercises taught on the ADAPT program. In fact, without the behavioural therapy part of the program, you would probably have trouble achieving your goals. You would certainly have more trouble keeping up your exercises and other skills.
Sometimes people with chronic pain are sent to see a psychiatrist because they are very depressed or because no physical cause for the pain has been found and no physical treatment is considered suitable. In the view of some doctors, when no physical cause for pain is found it means that the pain could be ‘in the mind’. In other words, the person is thought to be imagining the pain or exaggerating it, or even saying they’ve got pain when the real problem is depression or some other emotional upset. However, not all doctors (including many psychiatrists) share these views. Nevertheless, many pain sufferers think that being referred on to see the psychiatrist is tantamount to being told that their pain is not real.
Being referred to a psychiatrist is sometimes a cause of concern and uncertainty for the pain sufferer and his or her family. Therefore, it is important to clarify what psychiatry has to offer someone with chronic pain, as well as its limitations.
First, it is important to realise that, like all types of doctors, different psychiatrists hold different views about chronic pain. In large part this depends on their experience and area of specialisation. Some psychiatrists will try to assess whether or not a pain sufferer has a particular mental illness. If the psychiatrist doesn’t think the patient has a mental illness, he or she will probably say that they can find nothing really wrong and will then send the patient back to the referring doctor. Of course, if the psychiatrist does think the pain sufferer has a mental illness—which may or may not be related to the pain problem—then they will offer some form of treatment. On the other hand, other psychiatrists (especially ones with a lot of experience with pain sufferers) will try to assess the way the patient is being affected by the pain and will try to help them come to terms with it. This type of psychiatrist could offer to work with the patient using the types of methods outlined in this book. Their aim is to help the patient to cope better with their pain.
And second, there are some specific psychiatric treatments that have been given to pain sufferers. These include:
· ECT (electro convulsive therapy) involves passing an electric current through the brain. It can be useful in some depressive illnesses but it is not helpful in chronic pain. In the absence of major mental illness, patients should not have ECT for chronic pain.
· Psychiatrists often use drugs to treat depression and other mental illnesses. Many of these drugs may cause unpleasant side effects which patients with chronic pain find difficult to put up with. Although some chronic pain patients find low doses of these drugs to be helpful, high doses are seldom of benefit.
· Psychotherapy is any form of psychological therapy that involves talking things over with a trained therapist, who may be a psychiatrist, clinical psychologist, counsellor or social worker. It should not be confused with simply getting advice from someone. Rather, psychotherapy usually involves a therapist helping a patient to make sense of particular problems or even life-long difficulties. This can help the patient to work out possible ways of dealing with these problems. Psychotherapy can be helpful to someone with chronic pain, but it may not be enough. Therapies that emphasise not just understanding but also changing unhelpful behaviour and thought patterns are more helpful in the long run. Nevertheless, psychotherapy can be a useful addition to the more action-oriented approaches recommended in this book.
Alternative approaches (or complementary medicine)
There are a number of different types of treatment for pain which are offered by practitioners who are usually not medical doctors. These approaches may be called ‘alternative treatments’ by some and ‘complementary medicine’ by others. They include osteopathy, chiropractic, homoeopathy, reflexology, faith healing and aromatherapy. While many pain sufferers report having tried these types of treatment, it has been difficult to work out how helpful they really are. For example, if they were helpful was it because the therapist listened, spent more time, and seemed to understand more than a standard consultation with a medical doctor allows? Are these treatments better for some problems and not others? Do they risk causing harm? How long do the effects last?
The trouble is that this sort of information is often not available for many alternative treatments. In part, the difficulty in testing these alternative treatments is due to the fact that they tend to be offered on a private practice basis and can’t be easily studied, compared to treatments offered in a public hospital. Many medical doctors are also concerned that the people providing these types of treatment may overlook serious medical problems in pain patients because of their lack of medical training. Thus, they run the risk of not only mistreating the pain patient but actually making things worse.
All this is not to say that you shouldn’t try these treatments. Rather, you should keep your wits about you and make sure that you understand what treatment is being offered, what it is expected to do, what are the risks, how likely is it to help and how long should it last. Of course, you should also take the same approach to any treatment offered by a medical doctor or other health care professional.
One problem can be the cost. If you have to keep going back week after week for these treatments they can become very expensive. So make sure you can afford the treatment before you start. Alternatively, budget for a certain number of treatments and then stop and think if it is really helping on a long-term basis. Keep in mind that because of your pain you may feel desperate and be willing to try almost anything. If you are in this state you are at risk of making unwise decisions, so don’t rush in. Take your time over your decision and discuss it with someone you trust.
The best approach
Unfortunately, for most chronic pain conditions there is no magic cure. Of course, there are treatments available which provide temporary relief, and they may be worth trying. Even so, the short-term effects achieved by some treatments do not return the patient to the same condition they were in before the pain started. People with chronic pain have to come to terms with this. In this chapter we have looked at advantages and disadvantages of different kinds of treatment. This will help people with chronic pain to make up their own minds about what to do next. At the same time, however, we are trying to help each person learn how they can help themselves. In the end, it is how the person with the pain thinks and behaves that will determine how much the pain affects his or her life.