Chronic Pain.
What you need to know.   


Richard Harrold
Benjamin Janaway


What is Chronic Pain?

Pain is defined simply as “an unpleasant sensory or emotional experience associated with actual or potential tissue damage”. Chronic pain has many definitions but is generally deemed to be pain that lasts beyond the time at which normal healing should occur, and is usually referred to as pain persisting for greater than 3 months. Each individuals experience differs greatly, and some may suffer a lifelong problem.

One 2015 report describes attempts to clarify the definition of chronic pain and subdivide it into around seven different groups including primary chronic pain, chronic cancer pain and many others. This approach has the potential to provide a framework for establishing better the cause of chronic pain and how we may best treat them.

Treating chronic pain

Chronic pain is complex and usually coexists with depression, anxiety or sleep disorders. These conditions, in turn, are  associated with disability, relationship distress, isolation or social problems. Once again the experience is very individual and treatment must be tailored to reflect personal need.

It is well established that pain has both physical and psychological components. Often by establishing the psychological aspect of pain, that is the ‘affective component’ (medical jargon,) we can greatly alleviate the physical. It is worth remembering that the brain creates pain, and it can do that in a variety of ways. It is easy to believe how deep psychological pain can become physical.

Use of the SIGN framework ((Scottish Intercollegiate Guidelines Network) assists pain management, combining up to date research and providing a plan This guideline sets out a method for initiating a therapeutic relationship with chronic pain patients.  The plan includes taking a deep history of a patients life an experience to approach the problem from al angles, psychological, physical and social.  Treatment can be drugs, therapy and physical exercises.

Drugs

Pharmacological, or drug, therapy is the initial treatment of choice. The recommendation is to use a stepwise system based on what works.  simple painkillers, such as paracetamol and ibuprofen, and then progresses to mild and then to strong opioids such as codeine and morphine-derived medications.

Tailoring medications to suit an individual patient is one of the most difficult aspects of controlling this type of pain as medications will respond differently with each patient given differing neurobiological responses. This means what works for one patient may have no impact whatsoever on another.

Alternative medications such as antidepressants, antiepileptic medications and topical preparations are also suggested if more traditional analgesics are not successful.

Psychological and behavioural therapy

Another approach is psychological therapy. This can take many forms, including cognitive therapies. These therapies are thought to increase coping skills and develop adaptive strategies amongst patients.  These methods improve quality of life. A doctors role in initial therapy is vital given their ability to influence and not reinforce unhelpful behaviours patient.

There is mixed evidence regarding psychological therapies however overall there is shown to be a positive impact of cognitive therapies on chronic pain.

Physical therapy

Physical therapies  are showing promise in chronic lower back pain.  The use of ‘alternative therapies’, in particular acupuncture, have evidence of variable quality for use in chronic pain. It is important that patients who make use of alternative therapies ensure their practitioner is registered with the relevant professional body and that they inform their GP or healthcare professional.

Some further therapies are more self-directed, including encouraging the use of chronic pain support groups which demonstrated improved psychological health.

Conclusion

This article is just a brief  overview of a subject requiring deep consideration. oChronic pain is something which effects many of the population and is an area which we do not yet have all the answers for. We hope that the above is a good start, but would value your feedback on our work and what works for you.
If anybody is struggling with chronic pain or associated conditions, please see your GP or visit the NHS website for where best to get assistance and appropriate advice.
 
Any opinions above are the author's alone and may not represent those of the NHS or Mind and Medicine. Any comment is based on the best available evidence at the time of writing.  All data is based on externally validated studies unless expressed otherwise. Novel data is representative of sample surveyed. Online recommendation is no substitute for seeing your own doctor and should not be taken as medical advice.
 
Sources

Network SIG. SIGN 136: Management of Chronic Pain. Edinburgh: SIGN; 2013.
Treede RD, Rief W, Barke A, Aziz Q, Bennett MI, Benoliel R, et al. A classification of chronic pain for ICD-11. Pain. 2015;156(6):1003-7.
 WHO. International Statistical Classification of Diseases and Related Health Problems 10th Revision. 2010.
Eccleston C, Morley SJ, Williams AC. Psychological approaches to chronic pain management: evidence and challenges. Br J Anaesth. 2013;111(1):59-63.
 Fernandez E, Turk DC. Sensory and affective components of pain: separation and synthesis. Psychol Bull. 1992;112(2):205-17.
 Finlay KA, Elander J. Reflecting the transition from pain management services to chronic pain support group attendance: An interpretative phenomenological analysis. Br J Health Psychol. 2016;21(3):660-76.