Chronic Pain

By Alan Brandis, Ph.D.

Pain is considered to be chronic if it has remained essentially unrelieved for 6 months or longer. Chronic pain can be of many types and locations, and may or may not have specific tissue damage associated with it. This is in contrast with Acute pain, which is temporary, is related to specific tissue damage, and reduces in intensity as the damaged area heals.

Chronic pain is different from acute pain, in several ways. First of all, it is now believed that different neural pathways are traveled by chronic and acute pain. Acute pain passes through the thalamus, a kind of neural switching station in the mid-brain, and then on to the sensory cortex; while chronic pain travels through the hypothalamus, which is connected to the limbic system where emotional functioning (and emotional problems, such as depression) seems to originate. This is why antidepressant medications often help chronic pain sufferers.

Secondly, for most types of chronic pain conditions, there is a relationship between psychological state and the intensity of the pain experience. Stress, depression, or anxiety can all increase the intensity of the pain experience. Consequently, procedures that reduce stress, depression or anxiety can have the opposite effect and can reduce the intensity of the pain experience.

Typically, Chronic Pain Syndrome patients come to see a psychologist after being seen by a number of other health professionals to no avail, including internal medicine physicians, orthopedists, surgeons, orthopedic surgeons, neurosurgeons, physical therapists, chiropractors, acupuncturists, emergency room doctors (for late-night injections of powerful pain killing drugs) and others. Often, they are on a first-name basis with at least one pharmacist, as well.

Chronic Pain Syndrome tends to be self-perpetuating, because a series of accommodations or adjustments to the pain occur, and these adjustments serve to maintain the pain level. It is natural, for example, to "guard" or favor an area that is in pain - to put less weight on it, to use it less, to shift one's weight and center of gravity so as to reduce the mobility of the area. While this is going on, the body tries to immobilize the inflamed tissue (muscle or joint area) by putting extra fluid there (edema), much as a garden hose becomes stiff if the flow is stopped. Eventually, the chronic stiffness and disuse causes muscle atrophy. The body begins to deposit calcium in the tissues and around the joints, in effect to make an internal cast and mechanically immobilize the area (this is how bone spurs are formed). Therefore, the longer a pain patient does not use an area, the harder it will be to ever use it, and the more painful it will become.

Another factor which operates to prolong the Chronic Pain condition is the fact that, as painful as pain is, it has covert emotional bonuses and rewards that can come with it. For example, it does not take long to find out that family members go out of their way to accommodate the person in pain, taking over their responsibilities and letting them out of obligations. This is not a conscious or intentional manipulation, but is rather a natural result of being in pain for a long time. The longer the pain continues, the more likely it is that this kind of learning will occur.

Taking medicine for pain can also be a factor that prolongs and maintains the Chronic Pain condition. Most painkillers have powerful effects on other parts of the central nervous system, not just on the pain receptors, and they produce a feeling of euphoria (a "high") and/or they relieve anxiety. Again unconsciously, there is a powerful tendency to seek the emotional state that one gets from the drugs, but to justify taking the drug one must be in pain.

A significant percentage of Chronic Pain patients have become addicted to their pain medication. (The recent case of Rush Limbaugh is a prime example) We can tell that they are addicted because they have to increase their dose periodically in order to get the same level of relief (this is called developing a tolerance to the drug), and their pain level goes up rapidly if they discontinue the drug (this is called a withdrawal syndrome). Some patients have gotten prescriptions from several doctors at once, because no one doctor would give them as much medicine as they feel they need to get relief from the pain.

Chronic Pain patients are often very controlling of their medication, understandably, because the drug is the only thing that has brought them any feeling of relief, and it is the only thing that gives them a feeling of control over their pain level. However, it is more effective to take medication on a timed, continuous basis than it is to wait until the pain level becomes high, and then take a large dose. Once the pain level goes up, it takes much more of the drug to control the pain. Some pain patients have to be taken off of their medications gradually in a hospital setting. Most find that, once their medication usage is controlled by the clock rather than by their subjective pain level, their pain relief is better and they can use much less medication.

We usually try to get Chronic Pain patients to gradually reduce their reliance on medication and to increase their activity levels, to counteract the disuse syndrome. Naturally, it is important to work closely with a physician or psychiatrist who is familiar with Chronic Pain Syndrome if any medication adjustments are to be tried.

Since pain is a physical symptom, and it feels to the chronic pain sufferer just as painful as any acute pain they might feel, they often resent being told that they should see a psychologist. "Are you saying that the pain is all in my head?" they ask. This is NOT what we believe. However, we do believe that there are a number of things that the Chronic Pain patient can be taught, which will give them greater control over their depression and stress level, and thus their pain intensity.

Typically, a Chronic Pain evaluation consists of several approaches to discovering which factors play the largest role in maintaining the pain. We ask patients to keep a Pain Diary for a week or two, which helps us pinpoint which activities or emotional states are related to an increase in pain level. This also helps us observe how they are actually taking their medications. We may also perform psychological testing to determine any underlying causes of depression or anxiety which should be treated in addition to the Chronic Pain and which could be helping to maintain it. At least one Family Session is held to explore whether there have been unconscious payoffs within the family for being in pain.

A variety of methods are available to help the Chronic Pain patient manage their depression, anxiety and stress level, including psychotherapy, family therapy, stress reduction training, biofeedback training, hypnosis, and medication. Usually, some combination of these is applied for the best results.

AAPA has a new treatment available for some types of chronic and acute pain problems - TheraStim. It is an electronic muscle stimulator which is significantly more effective than any previous device. Follow the link to read more about it.

We advise our Chronic Pain patients that, even with successful treatment, they will probably not be completely pain-free. However, the frequency and intensity of the interruptions of their life could be significantly reduced, and their pain level could be kept to a tolerable level.

If you feel compelled to flame Dr. Brandis, READ THIS FIRST. (Listing of abstracts, journals and research that this article is based on.)