What is Chronic Pain (Longterm Pain)?
About a quarter of people in the United States live with chronic pain, making it one of the most common reasons someone might visit a doctor. Mismanagement of chronic pain and resulting dependency on painkillers are serious problems that tie into the nation’s health and well-being. Most people who visit doctors because of pain rely on their main healthcare provider for relief. As such, primary care providers need to understand chronic pain management fully. The US spends over 100 billion dollars per year managing pain and dealing with issues related to opioid misuse. This is more than the combined cost of managing cancer, diabetes, and heart disease.
Properly managing a patient’s chronic pain can dramatically improve their quality of life. Chronic pain, defined as pain lasting for more than three months, can come from various sources. Managing pain effectively often means using a mix between drug-based treatment and non-drug interventions. Studies suggest that using various methods together can reduce pain more than relying on one single method. The escalation of drug-based therapy usually follows a step-by-step approach. Chronic pain often goes hand-in-hand with undeclared and untreated depression and anxiety. Furthermore, people with chronic pain are at a higher risk of suicide. Chronic pain can affect every part of a person’s life, potentially leading to long-term disability and negative health outcomes. Because of this, being able to diagnose and manage chronic pain properly is a crucial skill for healthcare professionals.
What Causes Chronic Pain (Longterm Pain)?
Many people dealing with chronic pain often say they feel different kinds of pain at the same time. For example, someone with long-term back pain might also struggle with fibromyalgia, a condition that causes widespread body pain. Additionally, a significant number of people dealing with chronic pain also deal with serious depression and anxiety disorders. In fact, over 67% of these individuals are found to have a psychiatric disorder along with their chronic pain.
Pain can show up in various ways and takes many forms, including nerve-related pain, pain from actual tissue injury, muscle and bone pain, inflammatory pain, psychogenic pain (from psychological factors), and mechanical pain. To give you an idea, here are examples of each:
* Nerve-related pain: This pain is divided into two groups:
* Peripheral nerve pain: Examples include postherpetic neuralgia (pain after shingles) and diabetic neuropathy (nerve damage due to diabetes).
* Central nerve pain: An example would be the after-effects of a stroke.
* Pain from tissue injuries: This includes pain from actual injuries like burns, cuts, sprains as well as pain after surgery.
* Muscle and bone pain: Back pain, even radiating to a particular skin area, and muscle pain fall under this category.
* Inflammatory pain: This type of pain is usually associated with autoimmune disorders like rheumatoid arthritis, fibromyalgia, gout, or pain as a result of infection or cancer.
* Psychogenic pain: This is pain caused by psychological factors. For example, headaches or stomach pain caused by emotional, psychological, or behavioral factors.
* Mechanical pain: This pain arises from growing tumors, benign growths, fluid buildup in the belly, fractures, and pain from surgical materials left in the body.
Risk Factors and Frequency for Chronic Pain (Longterm Pain)
In the United States, over 100 million people struggle with chronic pain syndrome, and more than 20 million of these individuals experience severe pain that can be disabling. There are different types of chronic pain, each affecting a different part of the body, and the percentage varies: 11.1% have chronic regional pain, 10.1% have chronic back pain, 7.1% experience leg and foot pain, 4.1% experience arm and hand pain, and 3.5% struggle with headaches, while 3.6% have widespread pain all over their body.
Interestingly, older individuals seem to be prescribed 25% less pain medications compared to the average population. Chronic pain is not just physical — it has been linked to changes in metabolism and cognitive issues. Tragically, between 5% and 14% of people with chronic pain have attempted suicide in their lives, with about 20% having thoughts of suicide. Of the people with chronic pain who have taken their own lives, 53.6% used firearms, while 16.2% died from an opioid overdose.
- Over 100 million people in the US have chronic pain syndrome, with more than 20 million suffering from severe pain.
- Among people with chronic pain:
- 11.1% have chronic regional pain
- 10.1% have chronic back pain
- 7.1% experience leg and foot pain
- 4.1% experience arm and hand pain
- 3.5% struggle with headaches
- 3.6% experience widespread pain
- Older individuals receive 25% fewer pain medications than the average population.
- Chronic pain has been linked to changes in metabolism and cognitive issues.
- Between 5% and 14% of people with chronic pain have attempted suicide, with about 20% having suicidal thoughts.
- Of those with chronic pain who took their own lives:
- 53.6% used firearms
- 16.2% died from an opioid overdose
Signs and Symptoms of Chronic Pain (Longterm Pain)
When it comes to diagnosing and understanding chronic pain in a patient, a detailed medical history is crucial. It should include when the pain started, what it feels like (e.g., does it burn or throb?), what might have caused it, where it’s located, and how severe it is. It’s also important to know what makes the pain better or worse and whether it’s constant or off-and-on. All this information plays a big role in deciding the most effective treatment plan.
One common way to measure how severe the pain is involves using a scale of 0-10. Other symptoms to look out for include muscle spasms, changes in skin temperature, limited mobility, stiffness in the morning, weakness, changes in muscle strength or sensation, and any changes to the skin, hair, or nails.
In addition to physical symptoms, it’s also helpful to understand how the chronic pain is affecting the patient’s daily life. This can involve discussing how the pain is impacting their everyday activities, their relationships, their hobbies, and their emotional health. It’s also important to talk about any potential signs of depression, sleep quality, tolerance to exercise, productivity at work, and whether basic tasks like using the bathroom, getting dressed, bathing, walking, or eating are more difficult because of the pain.
- When did the pain start?
- What does the pain feel like (e.g., burning, throbbing)?
- What might have caused the pain?
- Where is the pain located?
- How severe is the pain?
- What makes the pain better or worse?
- Does the pain come and go?
- Are there any associated symptoms like muscle spasms, changes in skin temperature, limited mobility, stiffness, weakness, or changes in muscle strength or sensation?
- Are there any noticeable changes to the skin, hair, or nails?
After taking a detailed history, a physical exam can then confirm the details provided by the patient. This might include checking strength, flexibility, and range of motion. Observing the patient during the exam can also be very revealing, helping differentiate between true pain and fear or anticipation of pain that might influence their treatment. A thorough neurological examination is also beneficial, where the painful area is closely observed for any skin changes, temperature changes, and any indications of chronic heat or cold exposure or chronic picking. Observing for hair loss on the scalp and arms or legs could also provide insights into the patient’s condition.
Older adults are a group that frequently suffers from chronic pain but they might have difficulty communicating their pain. Accurate self-reporting is key to identifying and treating the pain effectively. However, older patients might describe their pain differently, such as using words like “sore” or “uncomfortable,” which can make diagnosing the pain more difficult.
Testing for Chronic Pain (Longterm Pain)
The Brief Pain Inventory (BPI) and the McGill Pain Questionnaire (SF-MPQ-2) are useful tools for understanding a person’s experience of pain and how it affects their day-to-day life. Another tool, the Neuropathic Pain Scale, specifically helps track the progress and response to treatment for nerve pain.
For chronic pain diagnosis, commonly used blood tests and imaging are not normally recommended. However, in certain cases where a specific cause for the pain is suspected, doctors may still order these tests. This includes situations where the prescribed medications might affect the liver and hence, liver function tests might be necessary.
Mental health conditions like major depression or generalized anxiety disorder can make pain symptoms worse and delay the diagnosis of pain disorders. These conditions often occur alongside chronic pain. Importantly, people with both chronic pain and a mental health condition tend to receive significantly more prescriptions for painkillers like opioids. Depression can lead to fatigue, sleep issues, reduced appetite, and lower activity levels, all of which can make pain symptoms worse. There’s also an increased risk of suicidal thoughts or actions in people suffering from chronic pain.
For people with chronic pain, it’s recommended to also screen for depression. The Minnesota Multiphasic Personality Inventory-II (MMPI-2) and Beck Depression Scale are two of the most commonly used screening tools for this purpose, with the MMPI-2 being the more extensively utilized tool for individuals with chronic pain.
Treatment Options for Chronic Pain (Longterm Pain)
When severe pain continues even after treatment, it might be time to see a pain management specialist. Treatment can be complex due to variables such as the spread of the pain and the necessary adjustments to medication dosages. In some situations, invasive methods may be suggested to control stubborn pain.
It’s important to treat not only the physical pain, but also any additional health conditions, particularly mental health conditions. Research shows that addressing both areas can lead to better results in reducing pain and related symptoms. If a person is also experiencing depression, good pain management can improve their response to the depression treatment. Various treatment options are available to manage chronic, severe and stubborn pain, including medicines, supplemental therapies, non-drug therapies, and interventional treatments.
Many types of medication are available to manage chronic pain. Over-the-counter painkillers like nonsteroidal anti-inflammatories (NSAIDs), acetaminophen, and aspirin are commonly used. Other medications like tramadol, opioids, and specific seizure medications, such as gabapentin or pregabalin, can also help manage pain. Other possibilities include antidepressants, topical pain relievers, muscle relaxants, certain receptor antagonists and stimulants.
Response to these treatments can vary from person to person. There isn’t one single best way to treat pain, so care must be taken to understand the patient’s specific circumstances. In general, treatment is typically carried out in a gradual manner, starting with non-opioid painkillers and only moving on to opioids if necessary.
Chronic muscle and bone pain is typically managed by combining non-opioid analgesics, opioids and non-drug therapies. Acetaminophen and NSAIDs are the first choices of treatment for conditions like osteoarthritis and chronic back pain. However, NSAIDs may not be suitable for people with a history of heart or kidney disease, or for those on blood thinners or with a history of ulcers.
Painkillers like opioids are typically used as a second-choice option when the first-line treatments don’t provide enough relief. Even so, opioids must be used with care, as they can cause side effects, including increased pain sensitivity, constipation, dependence, and drowsiness. Research has shown that for chronic muscle and bone pain, opioids aren’t necessarily more helpful than non-opioid painkillers.
Opioids might be necessary if other drugs don’t work and if the pain severely affects the person’s quality of life. However, it’s important to discuss the risks, benefits and alternatives before starting treatment with opioids. High doses of opioids can lead to severe side effects such as respiratory problems. Therefore, a plan to reduce and control the use of high-dose opioids can be beneficial for patients with chronic pain.
It’s important to remember that different types of pain require different treatment approaches. For instance, neuropathic pain often requires a combination of several drugs, as less than 50% of patients achieve enough pain relief with a single drug. Topical therapies (like creams) and seizure medications are common first-line treatments for neuropathic pain.
Antidepressants, such as dual reuptake inhibitors of serotonin and norepinephrine (SNRI) or tricyclic antidepressants (TCA), are also helpful for managing neuropathic pain. Other treatments include topical pain relievers and therapies such as heat and cold, cognitive behavioral therapy, relaxation therapy, and ultrasound stimulation.
Interventional techniques are also an essential part of chronic pain treatment. These can include spinal cord stimulation, nerve ablations (procedures that destroy nerve tissue), injections, and pain management pumps. While there is limited evidence for various interventional approaches, implantable intrathecal delivery systems (which release medicine directly into the spinal cord) can be valuable for patients with stubborn pain.
Spinal cord stimulators are a good choice for patients with chronic pain who haven’t responded to other treatments. They have been shown to lead to a significant reduction in pain compared to continuous medicine therapy.
What else can Chronic Pain (Longterm Pain) be?
Pain is a signal that something’s not right in our body, but it’s not a health condition in itself. When a patient is in chronic pain, it’s critical for doctors to find out the root cause or causes, because the best way to treat the pain depends on what’s causing it.
Imagine someone comes in with severe pain in their knee. The doctor has to figure out whether this is due to severe wear and tear of the joint (also known as osteoarthritis), or a condition like rheumatoid arthritis where the body’s immune system attacks its own tissues. These conditions require different treatments: if it’s osteoarthritis, options might include injections into the joint or even replacing it entirely, while in the case of rheumatoid arthritis, gout, an infection, or an injury to the cartilage in the knee, different approaches may work better.
Sometimes, the pain isn’t localized to a specific part of the body but is more generalized. This can be the case for patients who experience extreme sensitivity to pain due to long-term use of opioid painkillers (a condition called allodynia), people with serious depression, and those with mental health conditions like bipolar disorder and schizophrenia. It may also occur because of autoimmune diseases where the body’s immune system attacks healthy cells, like lupus or psoriatic arthritis, or conditions like fibromyalgia or central pain syndromes.
The four main types of pain — neuropathic (nerve-related), musculoskeletal (affecting the muscles and bones), mechanical (related to the function of moving parts in the body), and inflammatory (caused by inflammation) — should guide the doctor in trying to find out the underlying causes.
It’s important not to underestimate any pain that persists. If left untreated, acute and moderate-level pain can turn into chronic pain, which can even change the way nerves in the body work. This can mean chronic pain becomes a health condition in itself. That’s why it’s so important to treat all pain promptly and effectively.
What to expect with Chronic Pain (Longterm Pain)
Current treatments for long-lasting or ‘chronic’ pain can help reduce pain levels by about 30%. It’s been found that a 30% drop in pain can significantly improve a patient’s ability to function normally and improve their overall quality of life. However, the long-term outlook for patients with chronic pain often involves decreased functionality and a reduced quality of life. It’s suggested that better outcomes can be achieved when existing mental health conditions are also treated alongside chronic pain.
Chronic pain not only raises patient morbidity (the rate of disease) and mortality (the death rate), it also increases the incidence of chronic diseases and obesity. Additionally, those suffering from chronic pain are at a significantly higher risk of suicide compared to the general population.
In terms of treating chronic pain, spinal cord stimulation provides adequate pain relief in roughly half the cases. However, some patients, around 20 to 40 percent, develop a tolerance to the procedure. Meaning, the effectiveness of the stimulation tends to decrease over time. Similarly, patients with chronic pain who rely on opioids often develop a tolerance to these drugs over time. When the dosage of these drugs is increased, it can also increase patients’ morbidity and mortality rates.
Therefore, prevention is key when it comes to the treatment of chronic pain. Treating acute (short-term) and subacute (somewhere between short and long-term) pain appropriately and in a timely manner may prevent the onset of chronic pain, thereby minimising the impacts on a patient’s quality of life.
Possible Complications When Diagnosed with Chronic Pain (Longterm Pain)
Chronic pain can significantly reduce a person’s quality of life and productivity. It can also result in lost income, increase the severity of other long-term health conditions, and contribute to mental health issues like depression, anxiety, and substance abuse. Moreover, people struggling with chronic pain are more likely to have suicidal thoughts or even attempt suicide.
While there are many different prescription medications available to manage chronic pain, they also come with risks. For instance, acetaminophen, a common choice for chronic pain relief, can be harmful to the liver, especially when taken in amounts greater than 4 grams a day. This is the main reason for acute liver failure in the US. It can even harm the liver at normal doses if a person has pre-existing liver disease.
Doctors also often prescribe drugs like gabapentin or pregabalin to supplement pain relief. Still, these can cause side effects such as drowsiness, swelling, mood changes, confusion, and in older patients, breathing issues. These side effects are even more severe for older patients with painful diabetic neuropathy. Combining gabapentin or pregabalin with opioid pain killers can also increase the chance of patient death.
Duloxetine, another option for pain relief, can cause mood changes, headaches, and nausea, among other side effects. This medication is not safe for patients with a history of kidney or liver disease. If a patient with these conditions is prescribed duloxetine, they need to be carefully monitored.
Opioids are potent painkillers, but they come with a high risk of addiction and overdose, which can lead to breathing problems and even death. Another less-known side effect of long-term opioid use is a condition where the patient becomes more sensitive to pain. Other ongoing risks include constipation, tolerance, nausea, upset stomach, irregular heart rhythms (particularly with methadone treatment), and hormonal imbalances, which can lead to symptoms like missed periods, impotence, enlarged breasts in men, and changes in energy and desire. The risk of an opioid overdose also increases with the dosage.
Spinal cord stimulators, devices used to control chronic pain, also have a high rate of complications, anywhere from 5% to 40%. These complications can stem from the device moving, which often requires surgery to correct. The movement of these stimulators is most common in the neck region due to its greater range of motion. The stimulator can also break in up to 9% of cases. Pockets of blood or other bodily fluids, also known as seromas, can form and may require surgical drainage.
The infection risk after having a spinal cord stimulator placed is between 2.5% and 12%. In some cases, an infection can lead to a spinal cord abscess, a severe condition. Although rare, a spinal cord stimulator can puncture the spinal cord’s protective layer, leading to a headache in up to 70% of patients. The most severe complication is a spinal epidural hematoma, bleeding in the area around the spinal cord that requires immediate surgery. The occurrence of this severe complication is less than 1%.
Preventing Chronic Pain (Longterm Pain)
Managing chronic pain most effectively involves a team of healthcare professionals, often including a general doctor and a specialist in pain management. Using a variety of treatment methods can aid in controlling pain more effectively and improve patient outcomes, while minimizing the reliance on high-risk treatments like opioids.
When it comes to medications, it’s key that the doses are increased gradually and carefully adjusted according to the patient’s level of pain. Patients who are on long-term opioids should be given medication for opioid addiction if there are worries about dependency or misuse. In addition, healthcare providers can offer treatments like injections or other procedures to patients with chronic pain who aren’t responding to medication or those who want to lessen or stop taking opioids long-term.
Addressing mental health problems like depression and anxiety is also highly important in the management of chronic pain. Older patients may express their pain differently than younger ones. After a procedure to implant a device known as a spinal cord stimulator, regular follow-up visits with a pain specialist are necessary to tweak the device’s settings for the best results. It’s also crucial that patients with chronic pain are continuously checked for severe depression and thoughts of suicide. Regular evaluation and treatment of mental health issues are key to maintaining the overall well-being of patients living with chronic pain.