Pain Basics II

By James N. Dillard, M.D.

So how do you know what to choose? Well, that’s the big question. For most serious pain sufferers, they will need one or more medications from the five classes above, and often they will need significant correction of what medications they are on. So they need a good doctor who knows how to prescribe these well. Some may need an injection or two, to help get their pain under control, if they haven’t already tried this yet.

Next, they need to manage their stress and general life upsets, because we know that uncontrolled stress can make any chronic pain much worse. Often a good psychologist, nurse, or social worker can be very helpful with this. You need to better manage the sources of the stress as well as your reactions to the stress.

To help manage the reactions to stress, every pain patient I see gets taught some simple relaxation techniques, usually based on controlled breath work. What do we teach every woman to do now when she is delivering a baby? That’s right – to use breath control to work with the contractions and help push the baby out. And that controlled breath work helps to take the edge off the pain, and return as sense of control to the mother during the birthing process. I believe that in that same way, every pain sufferer can be taught simple breathing routines to help them through pain flares, and bouts of anxiety about their pain.

Almost every single chronic pain patient I have ever seen has had a combination of at least some degree of anxiety, depression, and a sense that a catastrophe has occurred in their life. It’s my job to recognize this, and get them some help. This does NOT mean that chronic pain is caused by mental illness. It does mean that there is a lot of emotional fallout from being in pain, and that if the person had any tendency toward any depression or anxiety before they got pain, then those emotional tendencies can get worse. And the more depression and anxiety, the more the pain escalates. So you get good psychologists and psychiatrists involved, for support.

If you are living with chronic pain, you need to eat a good diet. In some sense, the failure of the nervous system to re-set to normal and quiet down is just a failure to heal. And healing requires healthy nutrients. I know it’s easy for me to say this, because many pain patients have a lot of trouble just accomplishing the basics in life, like washing, dressing, and getting any kind of meals.

But the wrong kinds of foods, like fast food, junk food, fried food, “trans” fats and sugary products can just increase inflammation and pain in the body. You have to try to stick with real food – vegetables, fresh fruits and light proteins like deep-water fish, and stay away from the heavy, greasy stuff. There are many good books about this anti-inflammatory/Mediterranean diet, including chapter 9 of my book. And if there is one supplement that may be helpful for chronic pain patients, it’s probably fish oil capsules. Talk with your doctor about this.

Most pain patients have trouble getting around and moving, but one of the keys to making the nervous system quiet down is to get the body moving. This can be done with physical or pool therapy, but that needs to be followed up with daily stretching and strengthening and moving, as much as you can do, in little steps. The body and the nervous system heals best in motion. I know this can be hard for pain people, but every little bit that you do can help.

Then you and your doctor can do trials of other complementary therapies, like acupuncture, massage therapy or bodywork, yoga, energy healing, etc. What I’ve seen happen so many times over the years is this: we adjust the medications just to get the bad pain under better control (hopefully averaging under 5/10 on the pain scale). You have to do this first – did you ever try to talk with somebody who has a nail sticking through his foot?

And you have to get the emotional issues under some control with medications or psychotherapy (often cognitive-behavioral is best for pain patients). You get the patient using relaxation and meditation routines several times a day, and breath work for pain flares. Then you might try some shots and physical therapy, and maybe some massage to bring the pain down further. As the pain comes down, you mobilize the person, and get them feeling like they are not so physically fragile.

Then you weave in one of more of the other complementary therapies, and you start to back down on the medication dosages as the person starts to feel better. Ultimately, you may not make it all the way to “pain free”, but usually I’ve see most people get much, much better with this “integrative” approach.

One thing I can promise you is that you do need to have a good relationship with a doctor who can help guide you through these trials of treatments and medications. You need someone you feel you can talk to; someone who will listen and empathize with what you are going through. If you don’t feel that you have a real partner in this process, then you need to talk to your doctor about this, and try to improve the relationship, or find a better partner for your therapeutic journey.

Just remember – there are more options, so keep your mind open to trying a different approach, or a different way of thinking about your pain problem.

Levels of Evidence

Siwek J, et al. Am Fam Physician. 2002;65:251–258

Conventional Pain Outcomes

1. Maclaren JE, et al. Clin J Pain. 2006;22:392–398 [Evidence Level A]
2. Khot A, et al. Spine. 2004;29:833–836 [Evidence Level A]
3. Peloso PM, et al. J Rheumatol. 2006;33:957–967 [Evidence Level A]
4. Hollingworth W, et al. Acad Radiol. 2006;13(5):550–555 [Evidence Level B]
5. Maroon JC. Neurosurgery. 2002;51(5 Suppl):S137–S145 [Evidence Level B]
6. Fritzell P, et al. Spine. 2002;27:1131–1141. [Evidence Level A]
7. Gordon DB, Dahl JL. Pain 107 (1-2) January 2004, p. 1-4

Major research findings that substantiate the Integrative approach

Mind/Body

1. Astin JA. Clin J Pain. 2004;20(1):27–32. [Evidence Level B]
2. Kabat-Zinn J, Clin Psych Sci Pract. 2003;10(2)144-148
3. Wolsko PM et al. Use of mind body medical therapies. J Gen Int Med 19(1):43 Jan 2004
4. Grossman P, Niemann L, et al. J Psychosom Res 57(1):35-43 Jul 2004
5. Astin JA. Am Board Family Med 2003;16:131-147

Diet/Nutrition

1. McAlindon TE, et al. JAMA. 2000;283:1469–1475 [Evidence Level A]
2. Maheu E, et al. Arthritis Rheum. 1998;41:81–91 [Evidence Level A]
3. Ernst E, et al. Rheum Dis Clin North Am. 2000;26:13–27 [Evidence Level B]
4. Soeken KL. Clin J Pain. 2004;20:13–18. [Evidence Level B]
5. Covinton MB. Omega-3 fatty acids. Am Fam Phys 70(1):133-140 Jul 2004

Manual Therapies

1. Cherkin DC, et al. Ann Intern Med. 2003;138:898–906 [Evidence Level B]
2. Moyer CA, et al. Psychol Bull. 2004;130:3–18 [Evidence Level A]
3. Ernst E. Forsch Komplementarmed. 1999;6:149–151. [Evidence Level B]
4. Assendelft WJ, et al. Ann Intern Med. 2003;138:871–881 [Evidence Level A]
5. Ernst E. Clin J Pain. 2004;20:8–12 [Evidence Level B]
6. Astin JA, Ernst E. Cephalalgia. 2002;22:617–623 [Evidence Level B];

Acupuncture

1.Berman BM, et al. Ann Intern Med. 2004;141:901–910. [Evidence Level A]
2. Vickers AJ. J R Soc Med 1996;89:303-311
3. Lee A. Anesthesia & Analgesia 1999;184:1362-1369
4. Ernst E., Pittler M. Br Dent J 1998;184:443-447
5. Furlan AD et al. Cochrane Library 2005, Issue 4
6. Sator- Katzenschlager SM, Anesth Analg 98 (5): 1359-1364 May 2004
7. Vickers AJ et al. Health Technol Asses 8(48) Nov 2004, monograph
8. Melchart D et al. Cochrane Library 2005, Issue 4
9. White P. Anes Anal 2001;92(2):505-513
10. Birch S et al. Alt Comp Med 10 (3): 468-480 Jun 2004

Yoga

1. Williams KA. Pain 2005 May;115(1-2):107-17
2. Sherman KJ. Ann Intern Med 2005;143(12):849-856
3. Kakigi R. Eur J Pain 2005;9:581-589

Energy Healing

1. Astin JA. Ann Intern Med. 2000;132(11)903-910
2. Matthews DA. Southern Med J 93:1177-1186
3. Ernst E. Wien Klin Wochenschr 2003 115/7–8: 241–245

Aromatherapy

1. Cooke B. Brit J Gen Pract 2000;50(455):493-496
2. Kuriyama H. Evidence-Based CAM (Oxford) eCAM 2005 2(2):179-184
3. Wilkinson S. Palliat Med 1999;13:409-417
4. Ernst E. Cancer 2001;91(11):2181-2185

JCAHO

Commission on Accreditation of Healthcare Organizations. Pain Assessment and Management Standards. 2001. Oakbrook Terrace, Ill. [Evidence Level C]; http://www.jcaho.org

ALPS 2004 Survey, http://www.theacpa.org