Old Views/New Views

Managing Chronic Pain

Tackling Pain from Many Angles

Keeping a Pain Diary

Integrative Pain Management Program

Conclusion

Reprinted with permission from Dr. Andrew Weil's Self Healing newsletter, February and March, 2001. Subscriptions from 800.523.3296. © 2001 Thorne Communications, Inc.

Many  doctors  dread  patients  with  chronic  pain. These patients take up a lot of time, their cases are rarely clear-cut, and conventional treatment with surgery or drugs rarely provides improvement. Rather than look deeper at the reasons for these difficulties, doctors often blame the patients, labeling them as "whiners" or "malingerers." This attitude is becoming less common, however, as researchers toss out old ideas about chronic pain and piece together a new pain paradigm. Below I’ll describe five changes in thinking about pain and the development of chronic pain and then discuss the management of chronic pain.

Old View: Chronic pain is acute pain that lasts a long time.

New View: Chronic pain is different from acute pain.

There are two types of pain, acute and chronic. Acute pain is familiar to most of us: You feel it when you cut yourself, twist an ankle, or suffer a burn. This kind of pain is a biologically useful symptom that warns of actual or potential physical damage so you can seek treatment or avoid further harm. ("Acute" in medical terms means only that it has a rapid onset and doesn’t last long.) Acute pain has an identifiable cause and a limited duration. On the other hand, the chronic pain felt with problems such as low back pain or fibromyalgia persists continuously or intermittently for months or years—long past the time when it might be biologically useful—and it doesn’t subside with time or rest.

Old View: Similar injuries cause the same amounts of pain.

New View: People vary tremendously in their perception of pain.

It’s now accepted that pain is a subjective experience influenced by memory, expectation, stress, fatigue, environment, and genetic programming. This explains why the intensity of a person’s pain may have no relationship to the severity of the injury—because it’s not just the injury itself that causes pain, but also the emotional and learned response to it. There may even be genetic and gender-based differences in pain sensitivity and response to pain medications that are hard-wired into us. These observations have taught us that pain management programs must be customized for the patient.

Old View: Pain should go away in the absence of a clear cause.

New View: Some pain may be here to stay.

Sometimes chronic pain has no obvious physical cause. The original wound may have healed, or there may never have been an injury as severe as the pain would suggest. Also, the brain can feel pain even without any input from the body. For example, an amputee may feel pain in a missing limb. The sensation of physical injury clearly cannot come from a body part that is not there, so it must originate in the brain. It appears that the brain can even cause pain by sending signals that tell nerve endings to release inflammatory
chemicals.

Chronic pain syndromes can actually change the way the body’s pain sensing mechanisms and its natural pain relieving systems operate, so the nervous system becomes more sensitive to pain and less receptive to the brain chemicals that moderate or turn off pain. This "remodeling" of the nervous system is one reason that prominent pain researchers now believe chronic pain should be considered an actual disease of the nervous system.

Old View: Chronic pain is "all in your head."

New View: Chronic pain affects your whole body.

In the cascade of events involved in chronic pain, nerves may sprout sensitive new endings, receptors for natural compounds that alleviate pain may deaden, and pain mechanisms may be triggered by stimuli as benign as a cool breeze. Eventually, the whole body may be affected if the depression and anxiety that often accompany chronic pain cause abnormal levels of certain neurotransmitters, chemical messengers that can influence all organic systems. Therefore, a program to manage chronic pain has to work on many fronts.

Old View: If you hurt, you should "grin and bear it."

New View: Inadequately treated pain can lead to chronic pain.

Treating acute pain early and aggressively with pain killers and other therapies can slow the progression of irreversible changes in the nervous system, and also limit the creation of long–lasting pain memories that can intensify future responses to painful stimuli.

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Because of its wide-ranging effects, chronic pain must be treated in an integrative fashion. A treatment plan should address the physical and psychological changes, the emotional distress, and the social and cultural factors that affect the person’s perception of and response to pain.

Next I’ll describe an integrative program for coping with chronic pain that takes into account some of this new thinking.

Pain is undertreated: that was the conclusion of the Joint Commission on Accreditation of Healthcare Organizations, which recently issued new guidelines for monitoring and treating pain that will require hospitals and medical facilities all over the country to pay more attention to pain. This is good news for the estimated 50 million Americans who experience chronic pain, and whose daily lives are often restricted by it.

Having just reviewed the latest thinking on the causes, mechanisms, and treatment of chronic pain, it is my opinion that this new view reinforces the importance of an integrative approach to the condition, one for which conventional medicine (primarily surgery and drugs) has not had much success. Pain can affect every part of a person’s life—relationships, work, sleep, mood, sense of self-worth, and physical activity—but conventional medicine has tended to focus almost exclusively on the physical causes and effects of pain.

An integrated program that tackles the problem of pain from a variety of angles and is customized for the patient is far more appropriate, especially since we now know that people vary greatly in their perception of pain. Research shows that a multi-disciplinary approach that encompasses social and psychological influences as well as physical factors is more effective at moderating pain, reducing the need for medication, and improving the quality of life.

An integrative approach to pain management can ease suffering from such conditions as fibromyalgia, arthritis, headache, chronic low back or neck pain, abdominal pain, interstitial cystitis, and other painful disorders. The goals of my program are four-fold: to deal with the cause of the pain, if possible; to reduce the need for pain medications; to change the patient’s perception of pain; and to improve daily function despite the pain. You’ll notice I did not include "cure" in this list. In my experience, long-standing chronic pain is not usually going to disappear, but suffering can clearly be alleviated if the person experiencing the pain is taught how to manage it.

I think it’s important that treatment for chronic pain be integrative right from the start. Waiting years instead of months before offering mind-body therapies, for instance, may be misinterpreted by patients, who mistakenly assume doctors are giving up on them and relegating them to "it’s all in your head" status. Fortunately, physicians are starting to understand the value of early use of cognitive and behavioral interventions in cases of chronic pain. Margaret Caudill, MD, PhD, a prominent pain researcher and co-director of an integrative pain treatment center in Manchester, New Hampshire, reports that patients are starting to be referred to her clinic in the early months of chronic pain problems, a big improvement compared to an average of six years before referral common a decade ago.

Integrative Pain Management Program

In addition to the use of pain medications as required, I believe there are nine essential components that should be covered in any integrated pain management program:

1. Deal with the underlying source of the pain.

There may be physical avenues for pain relief that have not yet been explored by the treating physician. For instance, I might recommend that a person with rheumatoid arthritis use dietary measures that moderate inflammation. I often refer people with chronic musculoskeletal pain (such as low back or neck pain) to an osteopathic physician just to make sure there’s no mechanical basis for the pain. I may suggest biofeedback to reduce the muscle tension of temporomandibular joint syndrome (TMJ), cranial osteopathy for headache, TENS (transcutaneous electrical nerve stimulation) for low back pain, or acupuncture for reflex sympathetic dystrophy (RSD).

2. Establish a partnership between doctor and patient.

Patient and physician should feel they are working together to discover the particular program that will make the patient feel better and live more normally. Since a sense of personal control (self-efficacy) has been documented to reduce pain and improve the ability to function normally, it’s important for the patient to take an active role in his or her treatment and assume responsibility for managing the pain.

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3. Educate the patient.

I’ve found that patients need to understand what’s going on in their bodies before they can begin to manage their health problems. For instance, patients can learn a lot about what promotes and what diminishes their pain by keeping a diary (see below). They are usually surprised to discover how much their perception of pain is affected by stress, anxiety, and other modifiable factors.

4. Use mind-body therapies to reframe the pain experience.

We all know people who, despite painful chronic conditions, live active, useful, and joyful lives. They perceive pain not as the end of the road but as an adversary to be outwitted. In their own minds, they are not passive victims dependent on others for relief of their pain, but self-directed agents who are able to modify their pain and disability through their own thoughts and actions.

The perception of pain can also be modified by mind-body techniques such as distraction, visualization, guided imagery, and self-hypnosis. Most of us already know how to distract our attention from pain or unpleasantness by busying ourselves with a hobby, going to a movie, or getting some exercise. Meanwhile, visualization and guided imagery as well as self-hypnosis are frequently taught in pain-control programs or can be learned from audiotapes. Don’t dismiss the power of positive self-talk. Saying, "I won’t let the pain stop me" is far more helpful than saying "I can’t do it" or "I’m helpless against this pain."

5. Modify behaviors to improve function.

One of the most crucial questions I ask a patient is, "What is the pain keeping you from doing that you want to do?" Once I know which activities are most important to this individual, my colleagues and I can set priorities and structure a program that builds up to an ability to perform those functions of their "normal" lives that are most important to them. The flip side to that question also needs to be asked: "What does the pain excuse you from doing that you don’t want to do?" Sometimes pain can be an unconscious way out of a dull job or an unwelcome responsibility. Acknowledging and dealing with these underlying issues can often reduce the severity and frequency of pain.

A pain diary can be used to see what triggers a person’s unique discomfort and map out ways to avoid or divert it. Monitoring activities to determine how long and how often each can be done without pain helps people learn to pace themselves and set reasonable expectations of what they are able to do. Physical therapists and bodyworkers, such as practitioners of the Alexander Technique or Feldenkrais Method, may be able to teach new ways to perform activities so as to diminish or avoid pain.

Of course, a person with chronic pain should also try to make his or her life as healthy as possible—by not smoking, avoiding alcohol, maintaining a normal weight, eating nutritious meals, and following the other guidelines from my book, Eight Weeks to Optimum Health.

6. Relieve stress.

Stress plays a pivotal role in pain perception. Some stress—that of the battlefield, for instance—can block pain signals. Other stressors—anxiety, anger, and sadness, for example—can intensify pain sensations. To break the self-perpetuating cycle of tension and pain, anyone with chronic pain should learn and practice regularly a relaxation technique such as meditation, breathing exercises, or progressive muscle relaxation.

7. Set up support systems.

Chronic pain can be extremely isolating, so it’s not surprising that people with supportive friends and family seem best able to manage it. If you’re married, it’s a good idea to involve your spouse in your program so he or she can understand your goals, your abilities and limitations, and when and how to offer support. In the absence of such affirmations, you may be able to find support from your doctor, from the staff or others enrolled with you in a pain management program, from a support group, from spiritual practices, or even from writing in a journal.

8. Increase physical activity.

Exercise is the last thing that many people with chronic pain want to do, but it has so many benefits that it cannot be ignored. Exercise makes muscles feel better, improves sleep, eases anxiety and depression, builds fitness, helps manage weight, boosts self-esteem, and can increase your sense of empowerment. People with chronic pain from arthritis, for example, may be worried that physical activity will cause damage, but under a doctor’s supervision, exercise may actually be beneficial for them. Local chapters of the arthritis foundation, for instance, offer interdisciplinary pain management programs that include exercise specifically designed for people with arthritis, lupus, or fibromyalgia.

9. Improve sleep.

An estimated 50 to 70% of pain patients suffer from disturbed sleep, which in turn may increase the perception of pain, setting up an endless negative cycle that should be treated quickly. I shy away from prescribing sleeping pills—either conventional or herbal—to avoid over reliance on them. To ease the body into sleep, I’m more likely to recommend such alternatives as white-noise machines; a more comfortable bed; relaxation or breathing techniques; elimination of caffeine, nicotine, and alcohol; and use of imagery or self-hypnosis tapes.

Pain treatment centers have sprung up all over the country since the first one was founded 40 years ago, but they vary enormously in quality and focus. I recommend looking for a program that emphasizes the importance of self-management of pain. It should address the whole person—not just the pain—with a multidisciplinary approach that includes exercise, mind-body techniques, and coping skills as well as medication. Such programs are focused on an essential goal: learning to relate to pain differently. Patients who successfully complete an integrative pain management program should suffer less, be able to do more, and feel more in control of their situation. And that may be more than enough to make life worth living again. 

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