Chronic Pain (cont.)
How is pain treated?
Pain management
The goal of pain management is to improve function,
enabling individuals to work, attend school, or participate in other day-to-day
activities. Patients and their physicians have a number of options for the
treatment of pain; some are more effective than others. Sometimes, relaxation
and the use of imagery as a distraction provide relief. These methods can be
powerful and effective, according to those who advocate their use. Whatever the
treatment regime, it is important to remember that pain is treatable. The
following treatments are among the most common.
Acetaminophen is the basic
ingredient found in Tylenol and its many generic equivalents. It is sold over
the counter, in a prescription-strength preparation, and in combination with
codeine (also by prescription).
Acupuncture dates back 2,500
years and involves the application of needles to precise points on the body. It
is part of a general category of healing called traditional Chinese or Oriental
medicine. Acupuncture remains controversial but
is quite popular and may one day prove to be useful for a variety of conditions
as it continues to be explored by practitioners, patients, and investigators.
Analgesic refers to the class
of drugs that includes most painkillers, such as aspirin, acetaminophen, and
ibuprofen. The word analgesic is derived from ancient Greek and means to reduce
or stop pain. Nonprescription or over-the-counter pain relievers are generally
used for mild to moderate pain. Prescription pain relievers, sold through a
pharmacy under the direction of a
physician, are used for more moderate to severe pain.
Anticonvulsants are used for
the treatment of seizure disorders but are also
sometimes prescribed for the treatment of pain. Carbamazepine in particular is
used to treat a number of painful conditions, including trigeminal neuralgia.
Another antiepileptic drug, gabapentin, is being studied for its pain-relieving
properties, especially as a treatment for neuropathic pain.
Antidepressants are sometimes used for the treatment of pain and, along with
neuroleptics and lithium, belong to a category of drugs called psychotropic
drugs. In addition, anti-anxiety drugs called benzodiazepines also act as muscle
relaxants and are sometimes used as pain relievers. Physicians usually try to
treat the condition with analgesics before prescribing these drugs.
Antimigraine drugs include
the triptans- sumatriptan (Imitrex), naratriptan (Amerge), and zolmitriptan
(Zomig)-and are used specifically for migraine headaches. They can have serious
side effects in some people and therefore, as
with all prescription medicines, should be used only under a doctor's care.
Biofeedback is used for the
treatment of many common pain problems, most notably headache and back pain.
Using a special electronic machine, the patient is trained to become aware of,
to follow, and to gain control over certain bodily functions, including muscle
tension, heart rate, and skin temperature. The individual can then learn to
effect a change in his or her responses to pain, for example, by using
relaxation techniques. Biofeedback is often used in combination with other
treatment methods, generally without side effects. Similarly, the use of
relaxation techniques in the treatment of pain can increase the patient's
feeling of well-being.
Capsaicin is a chemical found in chili peppers that is
also a primary ingredient in pain-relieving creams. (see Chili Peppers,
Capsaicin, and Pain in the Appendix).
Chemonucleolysis is a
treatment in which an enzyme, chymopapain, is injected directly into a herniated
lumbar disc in an effort to dissolve material around the disc, thus reducing
pressure and pain. The procedure's use is extremely limited, in part because
some patients may have a life-threatening allergic reaction to chymopapain.
Chiropractic refers to hand
manipulation of the spine, usually for relief of back pain, and is a treatment
option that continues to grow in popularity among many people who simply seek
relief from back disorders. It has never been without controversy, however.
Chiropractic's usefulness as a treatment for back pain is, for the most part,
restricted to a select group of individuals with uncomplicated acute low back
pain who may derive relief from the massage
component of the therapy.
Cognitive-behavioral therapy involves a wide variety of coping skills and
relaxation methods to help prepare for and cope with pain. It is used for
postoperative pain, cancer pain, and the pain of childbirth.
Counseling can give a patient suffering from pain much needed support,
whether it is derived from family, group, or individual counseling. Support
groups can provide an important adjunct to drug or surgical treatment.
Psychological treatment can also help patients learn about the physiological
changes produced by pain.
COX-2 inhibitors
may be effective for individuals with
arthritis. For many years
scientists have wanted to develop a drug that works as well as morphine but
without its negative side effects. Nonsteroidal anti-inflammatory drugs (NSAIDs)
work by blocking two enzymes, cyclooxygenase-1 and
cyclooxygenase-2, both of
which promote production of hormones called prostaglandins, which in turn cause
inflammation, fever, and pain. The newer COX-2 inhibitors primarily block
cyclooxygenase-2 and are less likely to have the gastrointestinal side effects
sometimes produced by NSAIDs.
On 1999, the Food and Drug Administration
approved two COX-2 inhibitors
- rofecoxib (Vioxx) NOTE: On September 30, 2004 the Food and Drug Administration (FDA) acknowledged the voluntary withdrawal from the market of Vioxx (chemical name rofecoxib), manufactured by Merck & Co. FDA also issued a Public Health Advisory to inform patients of this action and to advise them to consult with a physician about alternative medications.
Merck is withdrew Vioxx from the market after the data safety monitoring board overseeing a long-term study of the drug recommended that the study be halted because of an increased risk of serious cardiovascular events, including heart attacks and strokes, among study patients taking Vioxx compared to patients receiving placebo. The study was being done in patients at risk of developing recurrent colon polyps.
and celecoxib (Celebrex). Although the
long-term effects of COX-2 inhibitors are still being evaluated, they appear to
be safe. In addition, patients may be able to take COX-2 inhibitors in larger
doses than aspirin and other drugs that have irritating side effects, earning
them the nickname "superaspirins."
Electrical stimulation,
including transcutaneous electrical stimulation (TENS), implanted electric nerve
stimulation, and deep brain or spinal cord stimulation, is the modern-day
extension of age-old practices in which the nerves of muscles are subjected to a
variety of stimuli, including heat or massage. Electrical stimulation, no matter
what form, involves a major surgical
procedure and is not for everyone, nor is it 100 percent effective. The
following techniques each require specialized equipment and personnel trained in
the specific procedure being used:
- TENS uses tiny electrical
pulses, delivered through the skin to nerve fibers, to cause changes in
muscles, such as numbness or contractions. This in turn produces temporary
pain relief. There is also evidence that TENS can activate subsets of
peripheral nerve fibers that can block pain transmission at the spinal cord
level, in much the same way that shaking your hand can reduce pain.
-
Peripheral nerve stimulation uses electrodes placed surgically on a carefully selected area of the
body. The patient is then able to deliver an electrical current as needed to
the affected area, using an antenna and transmitter.
- Spinal
cord stimulation
uses electrodes surgically inserted within the epidural space of the spinal
cord. The patient is able to deliver a pulse of electricity to the spinal cord
using a small box-like receiver and an antenna taped to the skin.
-
Deep brain or intracerebral stimulation is considered an extreme treatment and
involves surgical stimulation of the brain, usually the thalamus. It is used for
a limited number of conditions, including severe pain, central pain syndrome,
cancer pain, phantom limb pain, and other neuropathic pains.
Exercise has come to be a
prescribed part of some doctors' treatment regimes for patients with pain.
Because there is a known link between many types of chronic pain and tense, weak
muscles, exercise-even light to moderate exercise such as walking or
swimming-can contribute to an overall sense of well-being by improving blood and
oxygen flow to muscles. Just as we know that stress contributes to pain, we also
know that exercise, sleep, and relaxation can all help reduce stress, thereby
helping to alleviate pain. Exercise has been proven to help many people with low
back pain. It is important, however, that patients carefully follow the routine
laid out by their physicians.
Hypnosis, first approved for
medical use by the American Medical Association
in 1958, continues to grow in popularity, especially as an adjunct to pain
medication. In general, hypnosis is used to control physical function or
response, that is, the amount of pain an individual can withstand. How hypnosis
works is not fully understood. Some believe that hypnosis delivers the patient
into a trance-like state, while others feel that the individual is simply better
able to concentrate and relax or is more responsive to suggestion. Hypnosis may
result in relief of pain by acting on chemicals in the nervous system, slowing
impulses. Whether and how hypnosis works involves greater insight-and
research-into the mechanisms underlying human consciousness.
Ibuprofen is a member of
the aspirin family of analgesics, the so-called nonsteroidal anti-inflammatory
drugs (see below). It is sold over the counter and also comes in
prescription-strength preparations.
Low-power lasers have been used occasionally by some physical therapists as a
treatment for pain, but like many other treatments, this method is not without
controversy.
Magnets are increasingly
popular with athletes who swear by their effectiveness for the control of
sports-related pain and other painful conditions. Usually worn as a collar or
wristwatch, the use of magnets as a treatment dates back to the ancient
Egyptians and Greeks. While it is often dismissed as quackery and pseudoscience by skeptics, proponents offer the theory
that magnets may effect changes in cells or body chemistry, thus producing pain
relief.
Narcotics (see Opioids, below).
Nerve blocks employ the use
of drugs, chemical agents, or surgical techniques to interrupt the relay of pain
messages between specific areas of the body and the brain. There are many
different names for the procedure, depending on the technique or agent used.
Types of surgical nerve blocks include neurectomy; spinal dorsal, cranial, and trigeminal rhizotomy; and sympathectomy, also called
sympathetic blockade.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely prescribed and sometimes called non-narcotic or
non-opioid analgesics. They work by reducing inflammatory responses in tissues.
Many of these drugs irritate the stomach and for that reason are usually taken
with food. Although acetaminophen may have some anti-inflammatory effects, it is
generally distinguished from the traditional NSAIDs.
- Ibuprofen is a member of
the aspirin family of analgesics, the so-called nonsteroidal anti-inflammatory
drugs. It is sold over the counter and also comes in prescription-strength
preparations.
- Aspirin may be the most widely used pain-relief agent and has been sold over
the counter since 1905 as a treatment for fever, headache, and muscle soreness.
Opioids are derived from the
poppy plant and are among the oldest drugs known to humankind. They include
codeine and perhaps the most well-known narcotic of all, morphine. Morphine can
be administered in a variety of forms, including a pump for patient
self-administration. Opioids have a narcotic effect, that is, they induce
sedation as well as pain relief, and some patients may become physically
dependent upon them. For these reasons, patients given opioids should be
monitored carefully; in some cases stimulants may be prescribed to counteract
the sedative side effects. In addition to drowsiness, other common side effects
include constipation,
nausea, and
vomiting.
Physical therapy and
rehabilitation date back to the ancient practice of
using physical techniques and methods, such as heat, cold, exercise, massage,
and manipulation, in the treatment of certain conditions. These may be applied
to increase function, control pain, and speed the patient toward full recovery.
Placebos offer some
individuals pain relief although whether and how they have an effect is
mysterious and somewhat controversial. Placebos are inactive substances, such as
sugar pills, or harmless procedures, such as saline injections or sham
surgeries, generally used in clinical studies as control factors to help
determine the efficacy of active treatments. Although placebos have no direct
effect on the underlying causes of pain, evidence from clinical studies suggests
that many pain conditions such as migraine headache, back pain, post-surgical
pain, rheumatoid arthritis, angina, and depression sometimes respond well to
them. This positive response is known as the placebo effect,
which is defined as the observable or measurable change that can occur in
patients after administration of a placebo. Some experts believe the effect is
psychological and that placebos work because the patients believe or expect them
to work. Others say placebos relieve pain by stimulating the brain's own
analgesics and setting the body's self-healing forces in motion. A third theory
suggests that the act of taking placebos relieves stress and anxiety-which are
known to aggravate some painful conditions-and, thus, cause the patients to feel
better. Still, placebos are considered controversial because by definition they
are inactive and have no actual curative value.
R.I.C.E. - Rest, Ice, Compression, and Elevation-are four components prescribed
by many orthopedists, coaches, trainers, nurses, and other professionals for
temporary muscle or joint conditions, such as sprains or strains. While many
common orthopedic problems can be controlled with these four simple steps,
especially when combined with over-the-counter pain relievers, more serious
conditions may require surgery or physical therapy, including exercise, joint
movement or manipulation, and stimulation of muscles.
Surgery, although not always an option, may be required to relieve pain,
especially pain caused by back problems or serious musculoskeletal injuries.
Surgery may take the form of a nerve block (see Nerve Blocks in the Appendix) or
it may involve an operation to relieve pain from a ruptured disc.
Surgical
procedures for back problems include:
- discectomy or, when microsurgical
techniques are used, microdiscectomy, in which the entire disc is removed;
- laminectomy, a procedure in which a surgeon removes only a disc
fragment, gaining access by entering through the arched portion of a
vertebra; and spinal fusion, a procedure where the entire disc is removed
and replaced with a bone graft.
- In a spinal
fusion, the two vertebrae are then fused together. Although the operation
can cause the spine to stiffen, resulting in lost flexibility, the procedure
serves one critical purpose: protection of the spinal cord.
Other
operations for pain include:
- rhizotomy, in which a
nerve close to the spinal cord is cut,
- cordotomy, where bundles
of nerves within the spinal cord are severed. Cordotomy is generally used only
for the pain of terminal cancer that does not respond to other therapies, and
- dorsal
root entry zone operation, or DREZ, in which spinal neurons corresponding to the
patient's pain are destroyed surgically.
Because surgery can result in scar tissue formation that may cause additional
problems, patients are well advised to seek a second opinion before proceeding.
Occasionally, surgery is carried out with electrodes that selectively damage
neurons in a targeted area of the brain. These procedures rarely result in
long-term pain relief, but both physician and patient may decide that the
surgical procedure will be effective enough that it justifies the expense and
risk. In some cases, the results of an operation are remarkable. For example,
many individuals suffering from trigeminal neuralgia who are not responsive to
drug treatment have had great success with a procedure called microvascular
decompression, in which tiny blood vessels are surgically separated from
surrounding nerves.
Next: What is the role of age and gender in pain? »
- tramadol, Ultram - Read about tramadol (Ultram), a drug prescribed for chronic pain, and moderate to severe pain. Side effects, dosage, and drug interaction information included.
- Cortisone Injection - Read about cortisone injection treatment for inflammation, allergic reaction, sciatica and arthritis. Learn about side effects and complications of a cortisone shot.
- Rheumatoid Arthritis - Learn more about rheumatoid arthritis, an autoimmune disease that causes chronic joint inflammation, which has symptoms that include stiffness, fever, muscle and joint aches, loss of appetite, and fatigue. Treatment of rheumatoid arthritis incorporates the use of first-line drugs (aspirin and corticosteroids for pain and inflammation) and second-line drugs (methotrexate and hydroxychloroquine to prevent joint destruction and promote remission).
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