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Tuesday, March 29, 2011

"Pain Management": Overview for Friends and Family of the "Chronic Pain Patient"

Chronic pain, as defined by the medical community: Painful symptoms which persist long after the underlying pathology/injury has been treated; or continuous pain of which the underlying pathology is unidentifiable or untreatable, leading to chronic, long term pain.

Initially, when a patient presents with complaints of acute or chronic pain, the ideal goal of the physician is to provide a diagnosis, and identify the cause of the pain. This is often difficult; pain may be a symptom of virtually any condition or injury, and is not always physically identifiable with radiology and scanning technology. However, there are plenty of conditions or injuries with which sources of pain may be identified; such as spinal mutations, rheumatic and connective tissue conditions (arthritis), fractures, herniations, and inflammation etc. In many of these cases, a curative treatment may be possible, including surgical procedures, permanent nerve blocks, short term drug regimens (antibiotics, corticosteroids, NSAIDS, analgesics) and physical techniques such as osteopathic manipulative treatment, excersize and occupational therapy.

During the interventional treatment phase of a painful condition, a good physician will manage the suffering, i.e. painful symptoms, caused by the condition - This is approached pharmacologically, with any one of a variety of medications including NSAIDs, acetaminophen, tricyclic antidepressants, anticonvulsants, local anaesthetics and opioid analgesics. Opioids offer superior relief from the emotional and physical manifestations of pain through both their antinociceptive properties, and their ability to alter the brain's interpretation of pain. Managing the suffering caused by injury or illness promotes a higher spirit, better function, and faster healing.

It is unfortunate that pain, depending on the pathology, may or may not resolve whether or not the original cause has been treated.

Additionally, many conditions such as spinal stenosis, severe arthritis, types of neuralgia or neuropathies, are recurring, life long conditions which can not be 'cured' with interventional approaches.

In a perfect world, the physiological and emotional elements of pain could perhaps be 'managed' with strength and will power alone. "Pain builds character" according to some, of traditional values. Unfortunately our world is far from perfect, and even more unfortunately, living and simply coping with pain alone, only works to a limited degree, a very limited degree. There comes a point where rather than building character, the suffering experienced due to pain will systematically diminish one's character, leading to long term depression, physical disability, and worse, neurological 'hypersensitivity' (central sensitization), caused by an over-excitation of nerve signals which communicate pain, the process of nociception. Long term excess nociceptive activity can cause severe depression, an inhibition of dopaminergic activity within the nucleus accumbens leading to anhedonia, and severe hyperalgesia.

When interventional approaches such as surgery and other aggressive treatments have failed to resolve the pain, and when a chronic condition which is not 'cureable' is the source of continuous suffering, management of the distressing effects of the pain, and relate symptoms, is often the only approach left from a medical standpoint, and in many cases, may be only way to provide such a patient with a decent quality of life. Everyone has the right to freedom from pain; whether mild, moderate, or severe, the psychological & emotional effects of chronic, untreated pain are extremely serious. When pain has made such an impact on a subjects life that sleep, emotions, and basic functions have been effected, then often the concept of a long-term dependence to opioids is a preferable alternative, and at worst, a necessarry evil.

Once it has been established that the pain is not 'curable' and must simply be managed; and that medical treatment should emphasize a supportive or palliative approach, focusing on treating the physical and emotional devastation induced by chronic refractory pain...

Clinical management of pain takes on a multidisciplinary approach, applying a wide range of possible specialists, depending on the goals of the patient and the medical team.
The American Board of Medical Specialties now includes a number of specialist fields with an optional subspecialty in 'pain medicine', which is acquired through a comprehensive fellowship training. Boards with a pain medicine subspecialty include: Anaesthesiology, Palliative Care & Hospice, Physical Medicine & Rehabilitation (i.e. Physiatry), Neurology, and Psychiatry, both of which are certified by the same specialty board.

There also exists a newer group known as the American Board of Pain Medicine. The legitimacy of this particular board is ambiguous, as it is currently not endorsed by the American Board of Medical Specialties, the primary board which oversees the specialty boards. The emergence of this board of Pain Medicine comes with a growing notion within the medical field in which pain, classically known as a symptom, may in itself be considered a disease in its own right. This philosophy is controversial, however, there are currently known illnesses marked by hyperactivity of the nervous system, in which this philosophy may hold ground. Fibromyalgia is one such condition, marked by chronic widespread pain believed to be of neuropathic origin, yet with no identifiable pathology. The pain of these conditions may be of somatic, or psychosomatic origin, yet there is little doubt that such pain is genuine, whether psychosomatic, somatic, pathologically visible or non.

A pain management plan may include physical, behavioral & cognitive therapy, often provided through Psychiatrists, therapists, or Physiatrists. Addressing chronic pain from a behavioral and psychological component may be of benefit to the overall function, self image, and attitude of the patient. A neurologist or psychiatrist may address elements of depression, psychological manifestations of the pain, or the pain itself, through a pharmacological approach, while an anaesthesiologist or palliative care specialist may provide a more aggressive approach of the pain through the pharmacological approach. Any medical specialist with a fellowship training and subspecialty of pain medicine, may provide supporitve treatment for those suffering chronic pain.

A primary care physician or family doctor may play a role in a pain care plan, often the centerpiece of treatment, by maintaining a patients overall health. Family physicians are also qualified to provide pharmacological support for pain, including a regular regimen of opioids, etc. Many family or primary care physicians are comfortable and willing to provide this type of care, as the pharmacological properties of opioids are quite straightforward, and widely understood, from centuries of use as one of the world's most fundemental tools in medicine. With complex issues however, and with advancing states of pain and tolerance requiring large doses of schedule II opioids, many family physicians will prefer to consult with specialists, often handing over the analgesic component of care to a comprehensively trained pain specialist.

The ideal approach will include all of the elements previously mentioned, A balance of psychiatric, behavioral, pharmacological, dietary & lifestyle measures aimed at providing the best possible quality of life for those suffering intractable chronic pain.

Chronic pain is often continuous, lasting around the clock, or may appear intermittently at an unexpected time. Pain may be mild, moderate, moderately severe, or severe. Pain may come on rapidly, or gradually, and may be experienced as dull, sharp, throbbing, deep, aching, tingling, burning, stabbing, itching, or electric-like; these words are often used to describe the quality of the pain, and serve as a valuable diagnostic tool in determining the origin and nature of the pain, such as neuropathic, musculoskeletal, rheumatic, vascular, visceral, etc, thus allowing a specific targeted pharmacological approach.

An opioid is selected based on several elements of the pain, such as frequency, intensity, severity, onset rate, duration, anatomical area, and physical/biological characteristics of the patient. Opiates, opiate derivatives, and opioid drugs, all work in a similar manner and target the brain and spinal cord. They relieve pain by acting on opioid receptor sites, which when activated by an opioid, decrease the flow of pain signals to the brain, and blunting the the brain's emotional/physiological response to the pain, thereby altering the way in which the pain is interpreted. Opioids induce a slight sense of well being and increased mood, by promoting the release of dopamine within the nucleus accumbens, the brain's 'pleasure centers'. This contributes the drug's ability to alter pain perception.


  1. Excellent article, but it takes medical training to read. I was Hospital Corps, worked ambulance for a decade, held other medical field jobs; I've always been a reader. I’ve been a Chronic Pain Patient (CPP) for 28 yrs. You say some family practitioners are comfortable with providing high-dose opiate therapy, but that’s seldom true now. The DEA finds such doctors easy targets, & older ones have property & savings that can be stolen via "civil forfeiture," which is added to agency coffers. The corporate MSM provides great coverage of high-profile "Pill Mill Doctor" busts, which looks good on resumes of judges with political aspirations or on promotion recommendations of cops. There are few physicians remaining in the U.S. willing to take a chance. If the DEA chooses to bust a doctor, he CANNOT WIN. As Siobhan Reynolds, former CP treatment activist (her non-profit corporation for pain treatment advocacy was destroyed & she was reduced to penury by a vindictive DOJ prosecutor - for advocating) wrote: "To be accused is to be destroyed." Even a huge financial institution like Arthur Anderson, while they won, was destroyed financially.

    Every time these clinics are busted, patient records are stolen by the DEA & are NEVER returned, & patients then have no medical records to take to a new doctor, IF they can find one, & that's a really BIG "if". Because of the reduction of pain-treating doctors, such busts usually turn thousands of patients onto the street, desperately looking for care. Patients even looking for treatment of their diabetes or heart conditions have hard to impossible times finding help. Doctors are afraid. The DEA considers patients who travel long distances for a doctor, Drug-Seeking Behavior, by the way, but they leave patients no other choice. Often such abandoned patients die by their own hands, start buying from street dealers, or OD on NSAIDs. Sometimes they turn to alcohol, or anything they can get that MIGHT help. Around twenty thousand people die of NSAID poisoning annually, & that number is increasing. Almost all CPPs are under-treated, & many are UN-treated & unable to find treatment anywhere.



    We are poor because we've been unable to work for years, sometimes decades. Every time we lose treatment, we get more & more debilitated. When we finally do find treatment, IF we do, it takes more opiates, because we are more damaged. The really heartbreaking thing is, WE CAN BE HEALED! Sometimes, with good, uninterrupted treatment, the nerves are allowed to rest from the 24/7/365 firing that destroys many & physically alters others which then transmit pain even without a stimulus, and recruit other nerves, enlarging the painful area. Treated correctly & steadily, the nerves begin to heal. Dr. Frank Fischer found that some of his patients were cutting back on their pain meds, often without realizing it, because the nerves had begun to heal & they no longer needed as much. For me, this is always where something happens & I lose my treatment. By the time I find another informed & willing doctor, I am more damaged than I was, & each time it takes longer to recover.

    I was recently told by my current doctor that he’s going back to school & will be getting out of pain management; the DEA is making it too dangerous and expensive. A doctor doesn't have to break laws to be arrested and tried; the DEA & DOJ can make ANY doctor who treats CP look like a "Pill Mill doc". They can twist the law, falsify evidence, blackmail witnesses (often the doctors former patients)... & now around 800 doctors have been sent to prison for following the Medical Standard of Care. The rest are leaving the field in droves. I don't know if I'll survive this next loss of my doctor. I'm not even sure I wish to. The loss of care & the long climb back up has cost me everything, each time. I've been homeless, unable to rest, almost unable to move... How many times should we be forced to go through this?


  3. Some really useful slides here. I've been looking for something like this to help with a research piece I've been working on.
    the pain clinic

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