The Heavy Burden of Chronic Pain
Because chronic pain has been conceptualized as a normal experience, it has led many people to dismiss and even hide their pain. The notion that chronic pain must be proven through injury, disability, or impairment makes diagnosing chronic pain subjective because a doctor may or may not say a patient has chronic pain if he or she is lacking any visual signs of impairment, injury, or disability. To make things worse, forms of chronic pain, like persistent back pain, can often be seen as something that should just be tolerated and that is all in the sufferers’ head. These are just a few of the many burdens people suffering from chronic pain face daily, so can these types of people ever find total relief from their pain? According to The Mayo Clinic Health System and many other health organizations, there are no cures; with that being said, there are things that can either help or hinder improvements in chronic pain patients’ pain management as well as quality of life.
What Hinders Relief
Errors such as faulty interventions, diagnosis and poor environment can lead to worsened productivity and inability to attend to work or school. These errors create a negative feedback loop and amplify someone’s pain. In addition to these issues, several interventions such as seeing a chiropractor are costly; low income, the area a person suffering from chronic pain may live in, inadequate health insurance and limited travel options could prevent the patient from receiving those kinds of aids.
Another factor that interferes with pain relief is mindset. In today’s culture, there is no real emphasis for the patient to adopt the right mindset and motivation when initiating recovery. If a person suffering with chronic pain wallows in self-doubt and pity, nobody will be able to help them. Patients can only receive care for their pain and dysfunctions once they care and believe in themselves first. There needs to be a willingness to change the factors that elicit pain like poor mental and physical health.
In an interview with the Chief Medical Officer of Aviva Health, Dr. Jay Richards, he suggested that patients with financial difficulties should apply to the Oregon Health Plan: “Well, I think first and foremost would be to see if they qualify for the OHP. We have at Aviva an Oregon health plan which assists patients getting on to insurance and if they don’t qualify for OHP they can give them other recommendations. If they are on OHP, and they feel like they’d benefit from seeing a pain specialist there can be transportation coverage for Oregon Health Plan.”
Roles of Various Coping Mechanisms and What Could Relieve Pain
With a mixture of non-pharmacological interventions such as physical therapy, exercise, massage therapy, acupuncture, and behavioral therapies and pharmacologic interventions such as non-opioid analgesics, opioid analgesics, antidepressants, benzodiazepines, and anticonvulsants, people suffering from chronic pain can experience some pain relief, better functioning, or both in some cases.
Most interventions that provide social support can greatly reduce pain because emotions and beliefs greatly affect someone’s chronic pain. Prolonged forms of support from physical therapists, pain specialists, clinical psychologists, nurses, and other healthcare professionals can help with stress management, strength, mobility, flexibility, pain perception, and overall health.
If a person with chronic pain does not know much about their situation, that person’s pain can be much worse due to the stress and hopelessness. Healthcare professionals educate their patients on their condition to help them understand their disease, and that information helps the patient function better and gain the confidence to perform tasks. This can go a long way in managing the anger, fear and hopelessness someone suffering with chronic pain deals with. They do not just have to reach out to a healthcare worker to find out information about their condition either. There are many books such as “Rehab Science” by Dr. Tom Walters that are made to educate people on chronic pain in a way that’s understandable to both doctors and patients.
It may seem contradictory to move while in pain, but exercise and mobility greatly help with improving the quality of life for a person suffering with chronic pain. Physical therapy, for example, is a great intervention for people suffering from chronic pain who want to find relief through movement and non-pharmacological means. Dr. Garrett Stroup, Owner and Founder of OrMobility Physical Therapy & Performance helps patients with chronic pain. First, he will assess the frequency and intensity of the pain as well as the timing and type of pain the patient is in (the frequency, intensity, timing, and type of pain is known as the FITT principle). Afterwards, the patient will try out therapeutic exercises, manual therapy, functional training, and learn proper body mechanics during the session catered towards what the physical therapist learned about them. When the patient comes back, the physical therapist will answer any questions the patient has about the exercises, discuss how the patient felt during the time after the session, help the patient understand the predicament they are in and then go through treatment.
Stroup believes “the physical therapist’s role is to ensure that we provide the best possible care that we can to the patient while also explaining the limitations that we hold. This is important because if a patient does not respond well to their therapist, the patient might benefit from a different therapist. Also, if physical therapy is not beneficial, the patient should at least still believe that maybe a different provider from another profession could help. The patient should not believe that since they didn’t benefit from you that they will never experience improvement.”
It’s perfectly okay to be skeptical about non-pharmacological interventions, but being able to move and function healthily is vital to improving quality of life; being deconditioned while having chronic pain will make performing daily tasks a nightmare. “The vast majority of people who can improve their chronic pain elect these passive services too quickly, thus not believing that they could control their pain with movement. So many of these people lack confidence to believe that they can do something for themself on a day to day basis,” Stroup contends. A person suffering with chronic pain should try very easy mobilizations and exercises; With time, a person with chronic pain could start weight training or lifting. Weak muscles are known to cause chronic back pain after all, so strengthening and stretching core and back muscles along with testing pain tolerance safely can greatly improve long-lasting pain.
The Consequences of Opioids
Opioid medications are met with a lot of controversy because of adverse side effects like physical dependence, yet the lack of clarity that other non-opioid interventions bring entices many patients to use opioids to relieve their pain. This is not just patients either; doctors may rely on opioids too. Richards explains why doctors may do this.
“You have providers that may have their own practice and don’t have great access to behavioral health providers or community health workers to help their patients, so some providers feel like the only thing they can provide is medications… It’s a very complicated situation and system, but I think over time things have been improving quite a bit from when I was practicing ten years ago.”
Money was another big factor that drove doctors to prescribe such interventions. An analysis from Harvard T.H. Chan School of Public Health, Harvard Medical School, and CNN revealed that thousands of doctors were paid 25,000 dollars or more during 2014 to 2015 by opioid manufacturers.
Doctors may only use the lowest dosage of opioids if the benefits of using it outweigh the risks as stated by The Centers for Disease Control and Prevention’s guidelines.
Pharmaceutical interventions have their place too. With a mixture of non-pharmacological and pharmacological interventions, some people with chronic pain could have better outcomes. Non-opioid medications are another coping mechanism for chronic pain patients. Antidepressants, anticonvulsants and anti-inflammatory medication are used to relieve muscular pain as well as neuropathic pain.
Clinician Beliefs & Challenges
Since chronic pain is very complex, there is no definitive cure for that condition. There is no quick way to diagnose it either. Chronic pain is known to mimic other injuries and diseases such as hyperthyroidism and lyme disease which only further confuses healthcare workers and delays a proper diagnosis. Doctors use a variety of interventions in hopes of confronting these issues. Despite this, since pain is subjective and complex, interventions can vary greatly from doctor to doctor. This confuses the patient because advice is not consistent, and can cause him or her to distrust the healthcare provider.
According to Richards, there is no gold standard treatment for chronic pain.
“It’s not like you have gallbladder disease, and I can do an ultrasound, and I can see that it’s infected, send you to a surgeon then the gallbladder is removed and the pain is gone. It doesn’t work like that for a lot of chronic pain patients. You do have some providers who are more up to date on some of the newer guidelines that are coming, then you have other providers that are…treating patients based on older guidelines.”
In addition to Dr. Richard’s observation, Dr. William H. Bayer, founder of Jefferson Family Medicine, expands on the problems within primary care saying, “I think the science of chronic pain has advanced considerably but still has a long way to go. There are a lot of pain centers, but not many take a holistic approach to pain. Most are focused on money-making procedures like injections which have not generally been proven to be helpful. I think the best approach might be a support group with backup from a holistic pain specialist.”
Patient-doctor relationships can also be a great challenge; the relationship established could either worsen or improve the severity of one’s pain. For example, if the doctor informs them of only negative possible outcomes, those words can cause a nocebo effect and worsen the pain because of self-catastrophization. On the flipside, if the healthcare provider informs the patient on how to deal with their illness and provide positive reinforcement, then it could help him or her with the abnormal pain.
Primary care’s role and how the way pain is assessed, diagnosed, and treated has evolved over the years.
Primary care is a place good for finding a plan or general direction patients should take in hopes to ease their frequent pain. Today, doctors are integrating a more individualized and patient-centered approach to improving chronic pain. Whereas back then, doctors relied on quick and easy interventions like opioids; they treated opioids like a cure for chronic pain. Bayer claims that “for a number of years we doctors were kind of brainwashed by the pharmaceutical companies into prescribing large amounts of opioid drugs which, in their place, can be effective, but obviously have ignited the opioid epidemic.”
How Pain & Chronic Pain Works
Modern science suggests that pain comes from nociception and the brain’s interpretation of afferent input. Nociception is when receptors in the peripheral nervous system (not including nerve tissue) pick up on dangerous stimuli. Then, pain is caused when the brain receives the dangerous stimuli picked up by nociception and different emotional, cognitive, or sensory inputs (ie., heat and pressure). After that, the brain takes those inputs and stimuli into account and decides if those warrant a pain response such as a feeling or motor action. However, the brain doesn’t need dangerous stimuli to create pain either; non-painful stimuli can be confused as pain from the brain. The brain can also interpret the pain as being good; For instance, someone experiencing discomfort during a muscle pump from working out.
Chronic pain occurs when the body confuses various non-nociceptive stimuli as harmful, thus eliciting a painful interpretation; or the neural network in the brain that surrounds the interpretation of these stimuli becomes more refined. This causes the body to be hypersensitized to certain sensations. At this point, the brain has created pathways in the nervous system that tell the body the pain is very severe. There are also biological, psychological, and social factors that contribute to the chronic pain experience (i.e., a person’s memories, beliefs about pain, expectations of pain, and emotional support.)
Chronic pain is very similar to a phobia in a way because the person’s memories and fears put their body into a constant state of protection. Pain is classified as chronic when pain does not reflect what is going on in the tissue and typically has been occurring for over six months; however, time should not be a true indicator of whether or not pain is chronic because it could just be that somebody keeps reinjuring themself.
Chronic pain does not just originate from a tissue injury and nociception either it could be from chronic health conditions like fibromyalgia and autoimmune disorders; pain can be neuropathic (nerve pain) or inflammatory. inflammation can chemically sensitize nerves. This sensitization will cause the nerves that provide information to the brain to more quickly sense pain.
All in all, pain is a very complex and subjective experience, and is not always a signal that something is wrong with your body; it is not always a sign of potential or actual damage either.
The Big Takeaway
In short, even though chronic pain cannot be cured most of the time, there are ways to improve pain management and quality of life. It is crucial to not lose sight of the main goal, which is becoming functional, when looking at the vast sea of emotional and physical problems to deal with. In order to ease symptoms of chronic pain, learning how chronic pain works is vital. Patience as well as having a good grasp of the causes of chronic pain can reduce fear and make someone realize that it’s alright despite the pain signaling otherwise. Treatment is not a “one size fits all thing”; Trying out various interventions, having faith and open mindedness can go a long way in improving pain management.