Pain Management

Introduction

What should I know about pain management?

When pain presents itself, one’s first instinct is to find relief from the pain. And while pain is the number one reason why people seek medical advice (1) , it is interesting to note that everyone is an individual in regard to their own personal relationship to pain. Regardless of how one measures pain, it has a tremendous impact on society as a whole and is the reason for millions of lost work hours and, most importantly, a poor quality of life.

Pain is usually divided into two categories - acute and chronic. Acute pain is the type that comes on suddenly when a tissue has been injured. The injury can be the result of anything that is causing damage to body tissue such as trauma, surgery, or cancer. In acute pain, there is usually an increase in heart rate and blood pressure. Also in acute pain, once the stimulus or reason for the pain is removed, the pain is usually reduced. Chronic pain can be, among other things, chronic lower-back pain, chronic headaches, cancer pain, or phantom limb pain. Chronic pain is generally associated with a chronic disease and lacks a clear cause. This is pain that exists past the normal expected healing time.

Pain can present itself as somatic meaning pertaining to the structure of the body; visceral, pertaining to the organs of the body; or neuropathic, pertaining to the nervous system. Somatic pain can be mild to severe and is generally characterized as being a dull, sharp, or aching pain. Visceral is described as being diffuse or gnawing. Both of these types of pain respond well to opioids. Neuropathic pain is a result of a peripheral nerve injury and can be burning, shooting, tingling, and/or numbing. Neuropathic pain usually requires more nontraditional analgesics.

Statistic

Malaysian Medical Association, 1998.

  • Over 3 million Malaysians with chronic pain.

World Health Organization, 2004.

  • One in five people suffer from moderate to severe chronic pain, and that one in three are unable or less able to maintain an independent lifestyle due to their pain.

  • Between one-half and two-thirds of people with chronic pain are less able or unable to exercise, enjoy normal sleep, perform household chores, attend social activities, drive a car, walk or have sexual relations.

  • The effect of pain means that one in four reports that relationships with family and friends are strained or broken.

The National Institute of Neurological Disorders and Stroke of The National Institutes of Health, 1999.

    15 to 20 percent of hypnotizable patients with moderate to severe pain can achieve total relief with hypnosis. 35 percent in any experiment using placebos are able to tap into their brains' endorphin systems.

The American Association of Neurological Surgeons / Congress of Neurological Surgeons, 1998.

    More than 75 million Americans suffer chronic, handicapping pain. Chronic low back pain affects nearly 31 million Americans.

National Institute of Health, 1998.

    Pain costs the U.S. more than $100 billion annually in health care and lost productivity. 40 million visits to health care providers and prolong hospital stays are due to pain.

Signs and Symptoms

[span class=alert]The following list does not insure the presence of this health condition. Please see the text and your healthcare professional for more information.[/span]

Pain is itself an important symptom. It may signal the presence of disease, injury, or other conditions and is the most common symptom for which patients seek medical evaluation. Since the word “pain” can include a variety of complaints, from a small headache, to severe cancer pain, this section will be devoted to the description, or the characteristics of different types of pain. The first classification is to describe pain according to how long it has lasted.

Acute pain is usually associated with an event. It can be described clearly in relation to where the pain is located, when it started, and how severe it is. It may also be accompanied by an increase in heart rate, increase in blood pressure, and profuse sweating. Acute pain usually goes away as the healing process continues. This might include pain associated with having surgery, or pain that happens from an injury. Sub-acute pain is the term used for pain that develops over several days. Episodic pain is the term that describes pain that occurs at regular intervals for specific lengths of time.

Chronic pain is pain that continues for three months or longer. Signs that were present at first, such as increased blood pressure, increased heart rate, and profuse sweating disappear as the patient adapts to the presence of pain. This type of pain often leads to significant changes in personality, lifestyle, the way a person is able to function, and quality of life. Depression occurs frequently in patients with chronic pain. Chronic pain may also be more completely described by understanding the reason the patient has pain. The reasons for chronic pain often fall under one of three categories;

    The presence of disease such as cancers that have spread, sickle cell disease, rheumatoid arthritis, or other pain causing diseases. This type of pain is commonly described as long periods of pain alternating with pain-free intervals, or as a constant pain that gets worse, then becomes less, but never completely goes away. Psychophysiologic disorders causing pain; this means that disease was once present but the initial problem is healed and other factors such as anxiety or fear have caused a change in body processes that produces pain (for example, muscle spasms). Patients suffering from this type of pain generally are physically inactive and commonly think a lot about their pain or talk a lot about their pain. They also suffer more as a result of negative feelings of being chronically ill than from a true physical problem. This often causes them to not get complete pain relief from pain medication alone.Pain without history of disease, injury, or other physical reason; a patient’s explanation of the history of pain is often vague and bizarre. There seems to be no reason or pattern to the location of pain and patients often have severe psychiatric disorders.

Pain can be described in several ways. One of these ways is by describing the severity of the pain. Pain can be described as mild, moderate, severe, or excruciating. Pain may also be described on a 0 to 10 scale with 0 being no pain and 10 being the worst possible pain. Pain severity is a major factor for choosing drug therapy.

Somatic pain is the medical term used to describe pain that is most often localized and easy to describe by the patient. It may be sharp or dull and results from activation of pain sensors in a local area close to the surface of the body. Visceral pain refers to pain in the internal organs of the body such as the heart, liver, and intestines. This term is used to describe deep, aching, and cramping pain. Nerves from deep within have been activated, but we often feel it at a specific site on the surface of the body. Neuropathic pain results from direct injury to nerves, or the central nervous system (which includes the brain and spinal cord). This pain is described as burning, sharp, knifelike, or stabbing.

Acute pain

  • Usually associated with an event
  • Related to where the pain is located, when it started and how severe it is
  • May be accompanied by an increase in heart rate, increase in blood pressure, and profuse sweating
  • Goes away as the healing process continues

Chronic pain

  • Continues for three months or longer
  • Signs that were present at first, such as increased blood pressure, increased heart rate, and profuse sweating disappear as the patient adapts to the presence of pain
  • Can lead to changes in personality, lifestyle, and quality of life
  • Depression frequently occurs

Treatment Options

Conventional

Acute/Chronic Pain
The following drugs are commonly used with acute or chronic pain:

Acetaminophen
Aspirin/NSAIDs
Opioids
Anesthetics (lidocaine, bupivicaine)

Muscle Pain

Muscle pain is usually treated with muscle relaxers.

Chronic Neuropathic Pain

This type of pain is often treated by using such things as antidepressants, anticonvulsants, clonidine, or mexelitine.

Nutritional Suplementation


Methyl Sulfonyl Methane (MSM)

MSM is a derivative of DMSO, also known as dimethylsulfoxide. The two compounds reportedly share many of the same therapeutic benefits. Although a number of clinical trials have been conducted with DMSO, very few studies have been conducted with MSM. However, the world’s leading authority on MSM, Stanley Jacob, M.D., has written a book about the benefits of MSM. In the book, Dr.Jacob reports on MSM’s pain-relieving properties in a wide range of conditions based on his clinical observations with patients over a period of twenty years. The conditions in which MSM has reportedly had some level of success in pain reduction includes muscle soreness, fibromyalgia, back pain from herniated discs, tendonitis, bursitis, rheumatoid, and osteoarthritis. (2)


Glucosamine

Glucosamine has been highlighted in many studies for its ability to relieve pain in patients with osteoarthritis. (3) , (4) However, its onset is gradual over a period of several weeks, so it is not effective for acute pain. Also, its use is primarily limited to reducing the pain associated with osteoarthritis.


Chondroitin Sulfate

Chondroitin sulfate is also known for its ability to gradually relieve pain in patients with osteoarthritis. (5) , (6)


Phenylalanine

D-Phenylalanine is an amino acid that helps the body maintain adequate levels of pain relieving compounds over a longer period of time. A study in Japan reported that D-phenylalanine effectively increased the level of analgesia when combined with acupuncture in patients being treated with two conditions, low back pain and tooth extractions. (7)

Other studies have also documented that D-phenylalanine has been used successfully to treat a variety of human chronic pain conditions. (8)

Herbal Suplementation


Ginger

The volatile oils in ginger are thought to act as circulatory stimulants. (9) Gingerol stimulates gastric secretions and peristalsis. (10) Ginger’s structural phenols are similar to aspirin and may have an effect on prostaglandins, PGE2 and PGF2, aiding in decreasing inflammation and pain, as well as decreasing thromboxane, leading to its use as an anticoagulant. (11)


Turmeric

In Ayurvedic medicine (traditional Indian medicine), turmeric rhizome has been used for centuries internally as a tonic for the stomach and liver and as a blood purifier, and externally in the treatment and prevention of skin diseases and in arthritic complaints. (12) The laboratory and clinical research indicates that turmeric and its phenolics have unique antioxidant and anti-inflammatory properties. (13) The anti-inflammatory strength of turmeric is comparable to steroidal drugs such as indomethacin. (14) Turmeric has been reported to be anti-rheumatic, anti-inflammatory, and antioxidant. (15)


Feverfew

Feverfew has gained immense popularity because of its effectiveness in relieving migraine headaches and in other inflammatory conditions. (16) , (17) Feverfew reportedly inhibits the manufacture of inflammatory mediators such as leukotrienes, prostaglandins, and thromboxanes. (18) , (19) Several clinical studies have reported the efficacy of feverfew in the prevention of migrane headaches. (20) , (21) Feverfew exhibits several pharmacological actions that may be implicated in migraine prophylaxis, including inhibition of histamine secretion, (22) inhibition of granular secretion, platelet aggregation and arachidonate mediated responses (23) , (24) , and inhibition of vascular smooth muscle contractility. (25) Also, excess serotonin (5HT) release from platelets has been implicated as one of the primary mechanisms in the pathogenesis of migraines, which may explain some of feverfew’s prophylactic activity in migraine headaches. (26)


Willow

The bark of the white willow tree has been used as a medicinal agent since the ancient Greeks, first reported by Dioscorides in his herbal De Materia Medica written in the first century B.C. (27) During the Middle Ages, willow bark was used therapeutically to reduce fevers and relieve pain, attributed to the salicylates found in the bark. Researchers have discovered over the years that the salicylates have anti-inflammatory and antipyretic activities, and they have been actually synthesized from another plant as a precursor of acetylsalicylic acid, commonly known as aspirin. (28)

References

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  3. View Abstract: McAlindon TE, et al. Glucosamine and chondroitin for treatment of osteoarthritis: a systematic quality assessment and meta-analysis. JAMA. Mar2000;283(11):1469.
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  23. View Abstract: Groenewegen WA, et al. A Comparison of the Effects of an Extract of Feverfew and Parthenolide, a Component of Feverfew, on Human Platelet Activity In-vitro. J Pharm Pharmacol. 1990;42(8):553-57.
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