Major goals of pain management

August 5, 2011

There are three primary treatment goals for someone with chronic pain. These are: adjusting medication to suit one’s individual needs, training in psychological pain and stress management techniques, and increasing daily activities and improving the quality of one’s life.

The first goal is to appropriately adjust medications. Forty percent of patients with chronic pain take narcotic analgesics. They overuse their pain medications to try to give themselves some relief. Addicting medications should be discontinued. Rebound pain from taking short-acting narcotic analgesics continues a cycle of dependency on medication and escalation in use. By discontinuing narcotic analgesics, a “drug holiday” is given.

Although initially an individual may respond with an increase in pain, the body’s ability to naturally fight pain with its own endorphins will begin and the pain will actually diminish as narcotics are discontinued. Narcotic analgesics and sedative medications interfere with our own natural ability to produce pain-relieving substances (endorphins) and thereby the ability to fight pain naturally is enhanced with discontinuation. Nonaddicting, long-acting medications appropriate for the problem such as nonsteroidal anti-inflammatory agents, antidepressant agents which work centrally in the brain by stimulating endorphin production and strengthening the descending or inhibitory pain pathways by blocking the reuptake of seratonin should be prescribed. Many of these agents can be sedating and when used at bedtime, can allow an individual with chronic pain to sleep. Other medications may be useful in managing chronic pain. These include nonnarcotic analgesics such as Tramadol; the antidepressant medications; atypical antipsychotic agents such as olazapine; anticonvulsants including carbamazepine, Topiramate, gabapentin, and others; antispasticity agents such as tizanadine and Baclofen, and miscellaneous agents such as Mexiletine, topical lidocaine, substance P inhibitors such as capsaicin; and other topical agents that can be purchased over-the-counter such as topical aspirin may be useful.

The second goal of comprehensive treatment is training in psychological pain and stress management techniques. Pain is subjective and can be mediated by cognitive, emotional, and environmental influences. To understand the role of psychological techniques in management of chronic pain, one can conceptualize pain as consisting of both primary pain and secondary pain. Primary pain is the pain a person experiences from the tissue injury and damage. It is the direct result of nerve damage, scarring, and is usually irreversible. Therefore, primary pain is the least amount of pain a chronic pain sufferer can experience given ideal circumstances. Secondary pain, however, is the frequent fluctuation in chronic pain that can be experienced when an individual participates in life. This may be exacerbated by emotional and physical factors such as deconditioning, overexertion, body position, weather changes, anger, stress, and “life in general.” Simply, secondary pain is variable and is the fluctuation of pain as a person goes through his daily life.

Although primary pain can be influenced by medications, secondary pain, in general, is influenced by psychological pain and stress management techniques. These include relaxation training such as progressive muscle relaxation, guided imagery, and autogenic training, which promotes deep muscle relaxation. These techniques can be taught as preventive strategies as well as abortive strategies when the pain begins to escalate. Biofeedback is another commonly used technique. By “feeding back” certain information such as muscle tension, body temperature, heart rate, and peripheral blood flow, a person can learn to voluntarily control these bodily functions. Biofeedback is most commonly taught in conjunction with other relaxation techniques. There is no clear evidence that biofeedback is superior to relaxation training alone.

Hypnosis is a very useful technique which can promote deep, general, muscular relaxation; however, it is more effective in controlling acute pain such as dental pain, surgical and burn pain, and pain from childbirth. Chronic pain is best managed with awareness techniques that are better managed with relaxation training and biofeedback.

Stress and anxiety have a significant impact on an individual’s pain. There are a variety of stress management techniques that can be used including stress inoculation, assertiveness training, and time management.

The third goal of chronic pain management is increasing daily activity levels and improving the quality of life. Chronic pain is incurable, but not untreatable. Many patients who have chronic pain can learn to manage and control their problem and lead productive lives despite their pain. Physical rehabilitation is essential in order for someone to return to a normal life. Prolonged periods of bedrest can result in deconditioning. Decreased functional levels lead to decreased endurance, which can contribute to weakness, muscle spasms, and a vicious cycle of pain. Physical therapy assesses a patient’s motor skills, posture, and body mechanics. The physical therapist should ideally identify muscle weaknesses and provide a gradual program of muscle strengthening and endurance building. Assessment of activities of daily living and teaching one appropriate body mechanics and postures, which will avoid and correct asymmetries of the body, will improve an individual’s pain. Heat, cold, and deep myofascial release are appropriate for certain conditions. Joint mobilization, improving flexibility, and in certain individuals, joint stabilization is indicated.

An ergonomic evaluation is essential. Proper ways of sitting, standing, walking, carrying, lifting, and performing other activities of daily living can be taught by an occupational therapist. Ergonomics is “the laws of work.” Assessing someone’s workstation or home environment is essential. Proper positioning of computers, adjustment in chair and desk heights, use of head sets, and back, arm, and foot supports can improve a person’s ability to return to the work environment safely.

Chronic pain patients usually base their activity level on the amount of pain they are experiencing. However, in the case of chronic pain, pain is a fact of life. Patients need to learn to plan their activities so that it is “task contingent,” not “pain contingent.” Once a baseline level of activity is set, patients should follow a very simple rule; every day they must perform at least the same amount that they did on the day before. It does not matter on day one it took an individual 10 minutes to perform a task. If on day two the pain level is higher, as long as the task is completed it can take all day. By doing this, an individual can learn to avoid the “good day, bad day” syndrome. This keeps a person active and helps prevent that cycle of disability, pain, anxiety, and depression. Gradually, pain can be worked through and an individual can begin to establish a more normal routine.

Chronic pain can be used as a coping response; by using pain to avoid an undesirable event (visiting one’s in-laws), pain is used as a coping activity. However, over time it is reinforced. Just as in Pavlov’s dogs, every time the dog saw a food dish, he began to salivate, every time an individual thinks of going to his in-laws, his pain increases. This becomes a vicious cycle and the patient may actually lose voluntary control. The individual will then react to that and other distasteful situations by an exacerbation of pain. Therefore, pain should never be used as a coping tool.

Successful management of chronic pain requires active family participation. These are “the forgotten sufferers.” As a person becomes disabled with chronic pain, family members are forced to assume many of the responsibilities of the pain sufferer. This includes job responsibilities and family responsibilities. Families need to become involved so that successful management includes them. Family members should be educated as to the nature of the chronic problem and should be provided with treatment rationale. Families should learn to not be critical and should also be taught not to enable. Both of these can cause significant family dysfunction and may exacerbate the chronic problem.

Category: Chronic Pains