R.S.D. Article # 3

Pain is universal. You can trace its trail through time--from a toothache
evident in fossil remains of a human jawbone to today's drugstore shelves
packed with pain relievers. Almost half of all Americans seek treatment for
pain each year, 7 million from newly diagnosed back pain alone.

Pain is complex. Sometimes it's beneficial. A sharp stab alerts you to injury
when you burn your finger, hurt your back or break a bone. But other
pain--the day-after-day ache of arthritis or the anguish of cancer--serves no
useful purpose, and its relentlessness can become overwhelming.

Above all, pain is unique. The varieties of misery are as many as its
sufferers. Your pain is an interplay of your own particular biological,
psychological and cultural makeup.
 
 

New insight into these components is changing the concept of pain management.
Pain is no longer seen as just a companion of disease or injury. It can
become a damaging process in its own right that requires early and aggressive
treatment.

In addition, effective management increasingly focuses on your attitude as
well as medication and other therapies. You must understand the reasons for
your pain and how to control it.

By working closely with your doctor and health-care team, you can learn to
manage your pain and enjoy a more fulfilling family, work and leisure life.

Exercise, relaxation techniques, and physical, occupational and psychological
therapies play important treatment and prevention roles. And new
drug-delivery systems can keep some types of pain under continuous control.
But despite these advances, some painful conditions are still inadequately
treated.

The physical sensation
Most pain originates when special nerve endings, called nociceptors
(no-si-SEP-turs), detect an unpleasant stimulus. You have millions of
nociceptors in your skin, bones, joints, muscles and internal organs. There
may be as many as 1,300 in just one square inch of skin.

Some nociceptors sense sharp blows, others heat. One type senses pressure,
temperature and chemical changes. Nociceptors can also detect inflammation
due to injury, disease or infection. Nociceptors use nerve impulses to relay
pain messages to networks of nearby nerve cells (your peripheral nervous
system). Messages then travel along nerve pathways to your spinal cord and
brain (your central nervous system). Each cell-to-cell relay is almost
instantaneous, thanks to chemical facilitators called neurotransmitters.
These chemicals flow from one nerve cell to the next in less than a
thousandth of a second.

Some nerve pathways are faster than others. One type makes connections with
many surrounding nerve cells en route. They transmit more slowly. You feel
this type of pain as dull, aching and generalized. Another type relays
impulses almost instantaneously and signals sharp pain focused in one spot.

Scientists believe that pain signals must reach a threshold before they're
relayed. This "gate control" theory holds that specialized nerve cells in
your spinal cord act as gates that open to allow pain messages to pass,
depending on the strength and nature of the pain signal.

A message-routing section in your brain
Pain signals travel from your peripheral nerves to your spinal cord to your
thalamus, a message sorting and switching station in your brain. The thalamus
sends two types of messages. One goes to your cerebral cortex, the thinking
part of your brain, which assesses the location and severity of damage. The
second is a "stop-pain" message back to the injury site to tell local
nociceptors to stop sending any more pain messages. Once alerted, your brain
doesn't need additional warning. But sometimes, this mechanism fails and pain
persists.
 
 

Meanwhile, your cerebral cortex relays the pain message it received to your
brain's limbic center. Your limbic center produces emotions, such as sadness
or anger, in response to pain messages. Your limbic center can affect the way
your cerebral cortex perceives pain messages, and can lessen or intensify
your pain.

Your cerebral cortex also sends messages to your autonomic nervous system,
which controls vital body functions such as breathing, blood flow and pulse
rate.

Several types of neurotransmitters (proteins and hormones produced in your
brain or nervous system) can increase or decrease pain signals. A
hormone--one of the prostaglandins--speeds transmission of pain messages and
makes nerve endings more sensitive to pain. And a protein called substance P
continuously stimulates nerve endings at the injury site and within your
spinal cord, increasing pain messages.

Serotonin and norepinephrine (nor-ep-i-NEF-rin) seem to decrease pain by
causing nociceptors to release natural pain-relievers called endorphins (see
"Stimulating your body's natural painkillers").

The emotional component
Pain is not simply a matter of passing messages up and down your spinal cord.
When a pain signal reaches your brain, it passes through a filter of your
personal experience. Your emotional and psychological state at the moment,
memory of past pain experiences, outlook and stress level all affect how you
interpret a pain message and your ability to tolerate it. Your upbringing and
cultural attitude toward pain also play a role. And your age, level of
information about your pain, and even lack of sleep may have an impact.

The emotional responses of shock, fear and anxiety can increase your
perception of pain. For example, a minor pain sensation, such as a dentist's
probe, combined with anxiety can cause undue pain.

But your emotional state can also diminish major pain messages. One pain
study compared survivors of a major battle in World War II with men in the
general population of a major U.S. city, matched injury for injury. The
combat veterans required less pain relief than those in the general
population.

People who learn from upbringing and cultural background that the normal
response to pain is great suffering and distress actually experience more
pain than people who grow up in an environment where pain is often ignored.
The common expressions "suffer in silence," "bite the bullet," "grin and bear
it," and "no pain, no gain" point to American cultural patterns that
discourage acknowledgment of pain.

Types and characteristics of pain
In general, doctors divide pain into two general categories--acute and
chronic.

Acute--Acute pain is temporary, related to the physical sensation of tissue
damage. It can last from a few seconds to several months, but generally
subsides as normal healing occurs. Examples include a burn, a fracture, an
overused muscle, or pain after surgery. Cancer pain may be long-lasting but
acute due to ongoing tissue damage.

Chronic--Chronic pain lingers long beyond the time of normal healing. Some
chronic pain is due to damage or injury to nerve fibers themselves
(neuropathic pain). Although it may begin as acute pain, neuropathic pain
often develops gradually and becomes chronic pain that's difficult to treat.
Chronic pain can result from diseases, such as shingles and diabetes, or from
trauma, surgery or amputation (phantom pain). It can also occur without a
known injury or disease. Like a gate that's blocked open, nerves continue to
send pain messages even though there is no continuing tissue damage.

Chronic pain ranges from mild to disabling and can last from a few months to
many years. Significant emotional and psychological components may develop.
The essential ingredient is that the chronic pain changes your behavior. For
example:

You experience the actual physical sensation of acute pain--the immediate,
sharp stab in arthritic finger joints as you try to open a lid. Next is the
emotional response--your anger and frustration with fumbling fingers.
Eventually, behavior changes may occur. You may avoid using aching fingers
and hands. Your hands become weak from inactivity, and you depend on others
for assistance.

Chronic pain can result in lowered self-esteem, sadness, anger and
depression. Over the long term, a sense of helplessness to control chronic
pain can lead you to develop characteristic "pain behavior." Behavioral
changes can become habitual--crutches that can undermine your ability to
effectively manage your pain (see "Caution: Pain behavior can become
addicting").

Evaluating pain
Pain is subjective, but there are ways to measure it. Doctors may use
questionnaires, have you fill out a pain-rating scale, or have you select
words that best describe your pain (see "The language of pain".)

When repeated attempts to find a cause fail, and treatments aren't effective,
you may benefit from a team approach offered by a pain clinic. A thorough
evaluation may involve specialists in anesthesiology, neurology, psychology
and psychiatry, rheumatology, physiatry and physical therapy. The goal is to
treat all facets of your pain.

Specialized tests can evaluate how your body senses nerve impulses and how
the impulses travel through your nervous system. Imaging techniques, such as
X-rays, computed tomography (CT), magnetic resonance imaging (MRI), bone
scans and ultrasound, may help detect problems in bones, muscles, joints and
soft tissue.

Treat pain early and aggressively
For many years, standard practice called for treating moderate to severe
acute pain with injections of narcotic medication "as needed." This method
often resulted in delays and widely varying levels of pain relief. Your pain
rose and fell based on the dose timing. For most people, pain relief was
effective only part of the time. Even today, pain is often undertreated.

Inadequate pain control can occur for many reasons. The choice, dose and
timing of medication are critical in obtaining effective relief. Also,
patients and their doctors may be unduly concerned about the use of narcotics
in treating acute pain. But addiction is rare when narcotics are used for
short-term relief of acute pain. It may become a problem when narcotics are
inappropriately used for chronic pain relief. Addiction is not an issue in
treatment of pain from a terminal illness.

Adequate acute pain control following surgery is important because it can
allow you to recover your strength faster and start walking earlier. This can
help you avoid problems, such as pneumonia and blood clots, due to
inactivity.

Inadequately treated acute pain can prolong recovery and make you more
susceptible to chronic pain. Continued pain messages enhance subsequent pain
responses. Peripheral pain receptors become more sensitive. And continued
pain may cause long-lasting modifications in nerve cells along spinal cord
pain pathways. These changes make established pain harder to suppress.

As pain persists, feelings of anxiety, stress, anger, helplessness and
depression can worsen. Tension and pain may initiate a downward pain spiral
that's difficult to break. Early, aggressive treatment, and working with your
doctor to prepare a pain plan, can help prevent this (see "Make a pain
plan").

Pain-relieving medications
Pain treatment often includes medications and nondrug therapies (see
"Achieving pain relief without medication"). Over-the-counter pain-relieving
(analgesic) drugs include:

NSAIDs--Nonsteroidal anti-inflammatory drugs, or NSAIDs (en-SAYDS), are used
to treat acute pain from inflammation, such as from arthritis. They relieve
pain by inhibiting production of pain-intensifying neurotransmitters
activated by tissue damage. NSAIDs include aspirin (Anacin, Bayer, Bufferin),
ibuprofen (Motrin, Advil, Nuprin), naproxen sodium (Aleve) and ketoprofen
(Orudis KT). All can cause gastrointestinal bleeding. All are also available
in prescription form.

Acetaminophen--Acetaminophen (Tylenol) is used to treat pain and control
fever, but has only a limited effect on inflammation. It doesn't cause
gastrointestinal bleeding like NSAIDs. Prolonged, high-dose use can cause
kidney and liver damage.
Drugs available only by prescription include:

Narcotics--These drugs are the most effective medication for moderate to
severe pain. They're used for cancer pain and acute pain when the cause is
known and other medications are ineffective. Narcotics also have an important
role in the treatment of pain associated with terminal illness. They're not
approved for chronic pain.

Chronic pain - Reassessing the role of morphine

Narcotics include drugs derived from opium (opiates), such as morphine and
codeine, and synthetic narcotics (opioids), such as oxycodone, methadone and
meperidine (Demerol).

Side effects can include drowsiness, nausea, constipation, mood changes, and
with prolonged use, addiction.
 

Antidepressants--These medications may offer some relief for people with
chronic pain, whether or not they also have depression. Amitriptyline
(Elavil), trazodone (Desyrel) and imipramine (Tofranil) may be used with
other analgesics. These drugs aren't addicting. They're especially useful for
neuropathic, head and cancer pain. Side effects can include drowsiness,
constipation and mouth dryness.

Anticonvulsants--Developed for epilepsy, these drugs, such as phenytoin
(Dilantin) and carbamazepine (Tegretol), can also help control chronic nerve
pain. Side effects include drowsiness and confusion.
Other drugs may be used for specific types of pain. Corticosteroid
medications may help relieve pain due to inflammation and swelling. Prolonged
use can result in widespread problems, such as bone thinning, cataracts and
increased blood pressure.

Tramadol (Ultram) is a synthetic analgesic used primarily for chronic pain,
but is also prescribed for acute pain. Side effects may include dizziness,
drowsiness, nausea, constipation and sweating.

Sumatriptan (Imitrex), now available in tablet form, may reduce pain from
migraine headache by constricting blood vessels in your brain. Because the
drug may increase blood pressure and constrict arteries to your heart, it's
not used for people with uncontrolled high blood pressure or heart disease.

Capsaicin (Zostrix), a topical cream made from an extract of red peppers, can
help relieve skin sensitivity resulting from shingles. It's also used to
treat pain from arthritis, cluster headaches, diabetic neuropathy and pain
after mastectomy. You may have an initial burning sensation where the cream
is applied. Benefits are temporary so you'll need repeated application.
Capsaicin probably relieves pain by interrupting transmission of pain
messages from nociceptors.

Managing pain
Short-lived acute pain generally responds to medication and goes away with
healing (see "Handling acute pain,"). But persistent pain can lead to
depression, inactivity, deconditioning and increased dependence on others.

Chronic pain can interfere with sleep and eating habits, exercise, social
activity and work. Breaking this cycle usually requires a coordinated
approach offered in a pain rehabilitation program. Physical, occupational and
behavioral therapies, and assistance with the psychological components of
chronic pain, are the cornerstones of successful treatment. Here are some
strategies for coping with chronic pain:
 

Relaxation techniques--Stress increases muscle tension and worsens pain.
Relaxation techniques--such as meditation and yoga--involve activities in
which you focus on something other than your pain. You can do many at home.
Listening to music, visualizing a relaxing scene, trying a new hobby or
visiting a friend may also help. These techniques can alter peripheral and
central pain processes and are especially effective for chronic headache and
muscle tension.
Biofeedback may also help by teaching you to be aware of autonomic pain
responses such as skin temperature, muscle tension, blood pressure and heart
rate, and how to modify these.

Ask your doctor about where to find help in learning relaxation and
biofeedback techniques.
 

Occupational therapy--This helps you return to ordinary tasks around your
home and work. Focusing on home responsibilities, work or volunteer
activities--perhaps for limited hours at first--is a first step in pain
rehabilitation.

Physical therapy and exercise--You may fear exercise will increase pain, but
if you start gently and increase gradually, exercise usually doesn't cause
injury or additional pain. A regular program should include stretching,
strengthening activities and aerobic exercise, such as walking, swimming or
cycling. Slow stretching can relax muscles and release tension. If you have
chronic back pain, you may get enough relief from muscle-strengthening
exercises alone, thereby avoiding surgery.

Family therapy--Chronic pain can change personalities and unravel
relationships. The person with pain feels guilt and family members become
stressed taking over additional responsibilities and new roles. The key is to
maintain your normal responsibilities and roles as much as possible.
A part of life
Pain may be universal--perhaps even unavoidable. But it doesn't have to
control your life. The keys to successful pain control are early treatment,
ongoing assessment, and clear communication between you and your doctor.
 

For more information
Stimulating your body's natural painkillers
The language of pain
Caution: Pain behavior can become addicting
When pain signals an emergency
Make a pain plan
Achieving pain relief without medication
Handling acute pain