Chronic pain management
Chronic pain is pain that persists beyond the normal healing time for most injuries and illnesses. Chronic pain lasts at least 3 months and in many cases has become a disorder in itself, rather than a symptom of an underlying illness or injury. Chronic pain can also be due to ongoing conditions such as arthritis or neuropathic pain.
Chronic pain is a common problem, affecting about one in 5 people in Australia. It is one of the most common reasons for people to see their doctor, with back pain, headaches and joint pain being the most common complaints. While it can affect people of all ages, it is most common in those older than 65 years, affecting one in 3 people in this age group.
Chronic pain can affect your ability to carry out your daily tasks and can impact on your general wellbeing. While our understanding of chronic pain is constantly improving, there is still much to learn about its causes and how best to treat it. A cure is not always possible, but treatments are available to help manage the pain so that you can get back to your usual activities.
Chronic pain symptoms
Chronic simply means pain that it is persistent. Chronic pain can vary in nature - it may be throbbing, burning, aching or stabbing in quality. It can also vary in severity and may be worse at times of increased stress or physical exertion.
Most people with chronic pain also have other symptoms that trouble them. These can include:
- problems sleeping;
- depressed mood or anxious mood;
- other sensory symptoms, such as pins and needles; and
- reduced appetite.
Most people with chronic pain have symptoms that last several months to years. People with chronic pain may also feel frustrated and poorly understood by both medical professionals and their families and friends. Many feel like they are not being heard or believed. Chronic pain has the potential to impact all areas of your life, including work, relationships and overall wellbeing.
Causes of chronic pain
Chronic pain can begin after you’ve had an illness or injury (such as a sporting injury, injury from a car accident or an accident at home or work). Nerve pain (neuropathic pain) - which arises from an injury or illness affecting the nerves themselves - can also cause ongoing pain.
Osteoarthritis, rheumatoid arthritis, fibromyalgia, and migraine are other examples of conditions that can cause ongoing pain. Sometimes chronic pain develops without an obvious cause.
Cancer pain is another cause of ongoing pain, but this is treated differently from other types of chronic pain.
Several factors can increase your risk of developing chronic pain, including increasing age, general health, family history, type of work you do and previous episodes of short-lived pain.
What causes pain to persist?
Several mechanisms are thought to be involved in the development of chronic pain.
- The nerves that sense pain and carry pain signals (including nerves in the spinal cord and the brain) can become oversensitive. This can cause you to feel pain even when there is no physical reason for it.
- Changes in the levels of certain neurotransmitters (chemical messengers that transmit signals between nerves, such as serotonin, noradrenaline and dopamine) also seem to play a role in the development of chronic pain.
- Muscle spasm can also contribute to the pain.
Also, pain is not just a physical sensation - it’s also an emotional response. Learning and memory are involved with feeling pain. So your reaction to pain is influenced by your past experiences, the cause of pain and other personal factors.
Is chronic pain always severe?
While chronic pain can be draining, it is not always severe. Chronic pain simply means that it has been affecting you for a prolonged amount of time. You may have times when your pain is worse, which can happen for no obvious reason or when you are stressed or busy.
Over time, your brain’s response to pain signals may become less specific, meaning that the pain can spread to more than one area. The pain can also change in nature over time, so it feels different from the pain you had originally.
It’s not surprising that having chronic pain can have a significant impact on every aspect of your life. It can affect your work, social life and activities of daily living, sometimes stopping you from doing these things altogether. Your relationships may also suffer.
It’s not uncommon for people with chronic pain to misuse or abuse medicines. In fact, up to 30 per cent of people with chronic pain treated with opioids will misuse or abuse these medicines. Chronic pain also puts you at increased risk of mental health problems such as anxiety and depression.
But what’s important to remember is that chronic pain is better managed now than ever before. Newer treatments and strategies to relieve pain and help you manage pain mean that outcomes are improving for people with chronic pain.
Tests and diagnosis
Firstly, it is very important that you see your doctor for an assessment of your pain to make sure there is not a serious underlying cause that needs specific treatment. Your doctor will ask about your pain and health in general and perform a physical examination.
Tests such as X-rays or blood tests may be recommended, but results are often normal in people with chronic pain. Special tests may be recommended if neuropathic pain is suspected.
Your doctor may suggest you keep a pain diary describing the pain, when you experience it, when it is better or worse, and what brings it on or makes it better. This can help your doctor to understand the pain, its possible causes and how best to treat it.
Who treats chronic pain?
A variety of healthcare professionals are involved in treating chronic pain, including:
- general practitioners (GPs);
- specialist pain doctors;
- specialist nurses;
- occupational therapists;
- psychologists; and
- social workers.
There are also specialist pain clinics, often in hospitals, where many of these health professionals work together as a team.
Treating chronic pain
Chronic pain should always be treated - you shouldn’t wait for it to get better on its own. There are a variety of treatments available to help you manage your pain and get back to your usual activities. A combination of treatments (including physical activity, psychological treatments and medicines) is generally the best approach.
Any chronic pain that is due to an ongoing inflammatory or degenerative condition (such as arthritis) will need specific treatment for their underlying condition as well as pain management.
Chronic pain treatment will be different for everyone - your doctor will probably draw up a personal management plan for you.
Self-care for chronic pain
Studies have shown that people who understand the mechanism of feeling pain are able to control their pain more effectively. So, reading up about pain, how you sense it and how different treatments work can help you to feel more in control.
Although each person's management is personalised, there are a number of general things that most people can do to help manage their pain. These include the following.
- Pace yourself so that you don't try to do too much in one go and become over-tired.
- Learn to prioritise the things you need to do so that you do the most important things first.
- Try to do some exercise appropriate for your condition (your doctor or physiotherapist can advise you about this).
- Learn techniques to relax and distract you from thinking about your pain.
- Eat a healthy diet.
- If you have a problem with sleeping, talk to your doctor about what you can do to get a better night's sleep.
People with chronic pain may experience anxiety and depression, which can make the pain seem worse. It is very important to talk to your doctor if you are feeling anxious or depressed, as specific treatments are available.
A type of psychological therapy called cognitive behavioural therapy (CBT) can help in the treatment of chronic pain. It involves working with a therapist to understand your pain better and change how you perceive and react to it.
CBT can help you feel more in control. Your therapist can help you to set goals and come up with solutions for coping with pain and improving participation in everyday activities. Therapy can be individual with a therapist in person or online, or in a group setting.
Other psychological treatments that may help include:
- meditation and relaxation therapy;
- mindfulness; and
Psychological therapy is an important and effective component of chronic pain treatment. If psychological therapy is recommended for you, it doesn’t mean that your healthcare team thinks the pain is not real.
Prolonged bed rest is generally not helpful for chronic pain, and in many cases can actually make things worse. By keeping as active as you can, you can help reduce pain, improve sleep when you do rest and reduce the risk of becoming depressed.
The following physical activities may need to be started gradually so that you don’t overdo it first off.
- Aerobic exercise such as walking, cycling or swimming.
- Stretching, flexibility and strengthening exercises (e.g. Pilates and yoga).
- Hydrotherapy - exercising in a heated pool.
Physical or occupational therapy
There are several therapies that may be suggested by a physiotherapist or occupational therapist to help relieve chronic pain.
Transcutaneous electrical nerve stimulation (TENS) is a treatment that uses mild electrical currents to block pain sensations.
Posture correction therapy, heat or cold packs, massage and other techniques used by physiotherapists can also help, but they are not a long-term solution to pain management.
An occupational therapist can help by making suggestions on how to complete tasks at home or work that are difficult due to chronic pain. This may involve using special devices or making modifications in your home or work place.
Acupuncture may provide relief for some people.
Medicines for chronic pain
Pain relievers and other medicines can be used in combination with other treatments to relieve chronic pain and improve functioning. In general, painkillers should be used for short periods to control pain enough so that you can continue with your other treatments and daily activities.
It’s important to always take medicines according to the instructions and to check that the medicines are safe to take with any other medications you may be taking.
Non-opioid pain relievers
Painkillers such as paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) can be used to treat flare-ups in people with chronic pain. You can also take these medicines before activities that tend to make your pain worse.
Regular paracetamol can help with mild chronic pain but it is important not to exceed the recommended dose for paracetamol in any 24 hour period. Long-term use of NSAIDs is generally not recommended.
As with any medicine, there are side-effects associated with painkillers. NSAIDs (such as ibuprofen and naproxen) may not be suitable in people with certain health problems, such as asthma, heart disease, kidney disease or reflux.
Opioids (such as morphine, codeine and endone) are not usually recommended for treating chronic pain. Not only are these painkillers not effective for this type of pain, but they can cause side effects, some of which are dangerous. It’s also not uncommon for the body to become physically dependent on these medicines, even after just a few weeks. However, opioid medicines may occasionally be trialled for a limited time under strict supervision.
It should be noted that opioids are effective for the treatment of cancer pain and are safe to use for cancer pain when taken as directed.
Certain antidepressants and medicines used to treat epilepsy and seizures can help relieve neuropathic pain. Tricyclic antidepressants may also help some types of chronic pain other than neuropathic pain.
Medicinal cannabis (medical marijuana) has been investigated for treating chronic pain. Most studies have looked at the use of tetrahydrocannabinol (THC) or THC-rich extracts together with other treatments.
There is some evidence that medicinal cannabis can help relieve neuropathic pain to some degree, as well as improve sleep. However, there is currently no clear evidence that it improves overall quality of life or functioning.
Your doctor may be able to help you access medicinal cannabis (if you are a suitable candidate) as an unapproved drug through the Special Access Scheme or Authorised Prescriber Scheme. These are programmes that the Australian Government Department of Health is using to help the appropriate people access these medicines. However, access may still be limited in some states and territories.
There are some invasive treatments that involve the use of injections, nerve blocks or implantable devices to treat certain types of chronic pain. Your doctor or pain specialist can discuss with you the risks and benefits of these treatments and whether these options are suitable for you.
Having chronic pain can be an isolating experience. If pain regularly stops you from doing what you want, it not surprising that you may often feel upset or angry
Support groups are a welcome opportunity for many people with chronic pain to meet up. Talking to others who are facing similar challenges can be immensely helpful, and you can share common experiences and tips on coping. Talk to your doctor about local support groups or search the internet for online or community-based groups. Remember, chronic pain is common - you are not alone.
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